Originl Article 99m Technetium-Lbeled Methylene Diphosphonte Uptke in Mxillry Bone During nd Rpid Mxillry Expnsion Z. Mirzen Art, DDS, PhD ; Htice Göklp, DDS, PhD b ; Tmer Atsever, DDS, PhD c ; Hkn Türkkhrmn, DDS, PhD d Abstrct: The purpose of this study ws to evlute bone ctivity t the midpltl suture tht hd been biomechniclly stimulted by rpid mxillry expnsion (). A rigid crylic-bonded expnsion device with mxiskeleton screw ws used for in three ptients who were in three different growth periods. The screw ws ctivted twice dy by ¼ turns. sufficient expnsion, the screw ws fixed with crylic resin, nd the sme pplince ws used s removble retention plte for three months. Single photone emission computed tomogrphy (SPECT) bone scintigrphy records were obtined before () nd t the end of () nd three months fter the retention period (). According to the scintigrphic records, the increse in bone ctivity ws highest in the nterior nd medil sections on both the left nd right sides of the mxill in ll cses. three months of retention, the bone ctivity returned to its originl level. Therefore, it my be stted tht the retention period of three months ws sufficient for bone reorgniztion. (Angle Orthod 2003;73:545 549.) Key Words: Bone scintigrphy; Rpid mxillry expnsion; Rigid crylic-bonded expnsion device INTRODUCTION Mxillry constriction is discrepncy secondry to genetic, environmentl, nd functionl fctors. Nsl irwy constriction, premture contcts, nd long-term retention of primry teeth re the min cuses of mxillry constriction. 1 3 The most importnt indiction of skeletl or dentl upper rch nrrowness is buccl crossbite. Since 1890, vrious pplinces hve been designed to chieve miniml dentolveolr but mximl skeletl effects on the width of the mxill. Mny uthors hve investigted the effects of rpid mxillry expnsion () on the crniofcil structures using rdiologicl nd histologicl methods. 4 16 Conventionl rdiogrphs re esy to obtin; however, they re not suffi Professor, Deprtment of Orthodontics, School of Dentistry, University of Ankr, Ankr, Turkey. b Assistnt Professor, Deprtment of Orthodontics, School of Dentistry, University of Ankr, Ankr, Turkey. c Associte Professor, Deprtment of Nucler Medicine, Gzi University, Ankr, Turkey. d Reserch Fellow, Deprtment of Orthodontics, School of Dentistry, University of Ankr, Ankr, Turkey. Corresponding uthor: Htice Göklp, DDS, PhD, Ankr Üniversitesi, Diş Hekimiği Fkültesi, Ortodonti Anbilim Dlı, 06500 Beşevler, Ankr, Turkey (e-mil: hticegoklp@yhoo.com). Accepted: Jnury 2003. Submitted: Jnury 2002. 2003 by The EH Angle Eduction nd Reserch Foundtion, Inc. This reserch ws pproved by the Institutionl Review Committee of Gzi University. cient to ssess the bone ctivity in the midpltl suture nd its surrounding tissues. Histologicl findings, on the other hnd, re limited to experimentl studies. Bone scintigrphy hs been widely used for the detection of bnorml vsculrity or osteogenesis in the skeletl system. 17,18 The sensitivity of this method is fr superior to tht of conventionl rdiology becuse skeletl scintigrphy identifies pthophysiologicl rther thn morphologicl bnormlities. 19,20 In this study, bone scintigrphy ws used for the evlution of biomechniclly induced bone ctivity in the surrounding tissues of the midpltl suture during nd fter rpid mxillry expnsion in three ptients who were in three different growth periods. MATERIALS AND METHODS This study includes three orthodontic ptients in three different growth periods. Ptient consent forms were obtined t the beginning of the study. All ptients hd bilterl buccl crossbites nd crowding in the upper nd lower dentl rches. Cse l ws n 11-yer-old girl in the MP3 mturtion stge ccording to hnd-wrist films. 21 She hd skeletl nd dentl Clss I mlocclusion. Cse 2 is 14.1-yer-old boy. He ws in the MP3cp mturtion stge nd hd both skeletl nd dentl Clss III mlocclusion. Cse 3 is 15.8-yer-old girl in the RU mturtion stge. 545
546 ARAT, GÖKALP, ATASEVER, TÜRKKAHRAMAN FIGURE 1. Mxillry inter-cnine, inter-pre-molr nd inter-molr widths were mesured on dentl cst. She hd skeletl Clss II nd dentl Clss I mlocclusion. Lterl cephlogrms, hnd-wrist films, dentl csts, nd single photon emission computed tomogrphy (SPECT) bone scintigrphy with 99m Technetium-Methylene Diphosphonte ( 99 m Tc-MDP) were obtined before tretment (), t the end of (), nd three months fter the retention period ws completed (). SPECT bone scintigrphy ws used to ssess bone ctivity in res surrounding the midpltl suture during the expnsion nd retention periods. Informed consent ws obtined in ll three cses. For bone scintigrphy, ptients were given n intrvenous injection of 0.4 mci/kg (15 MBq/kg) of 99m Tc-MDP. Imging ws performed three hours fter injection of the rdiophrmceuticl. The effective rdition dose equivlents were 2 3 msv for ech exmintion. SPECT imges of the skull were obtined with dul-heded gmm cmer (GE Optim, Milwukee, Wis) using low-energy, high-resolution collimtor. Sixty-four 30-second views were cquired over 360 rottion in 64 64 mtrix. Two pixel sized trnsxil, coronl, nd sgittl slices were generted. Coronl slices were used for quntittive evlution. Twenty pixel sized circulr regions of interest (ROI) were defined on the nterior, medil, nd posterior slices of the right nd left sides of the mxill. Bckground bone ctivity ws defined from the right frontl region. Thus, the bone ctivity index (BAI) ws defined in nterior, medil, nd posterior mxillry slices by dividing mxillry ctivity counts by bckground ctivity counts. Mxillry intercnine, interpremolr, nd intermolr widths were mesured on dentl cst s indicted in Figure 1. Ptients were treted with tissue- nd tooth-borne rigid crylic-bonded pplince. A mxiskeleton jckscrew ws embedded in crylic between the first premolrs, s close s possible to the plte, with the resin covering the occlusl nd fcil surfces of the mxillry posterior permnent teeth. The occlusl resin ws trimmed thin enough FIGURE 2. Occlusl view of the tissue nd teeth-borne rigid crylic bonded rpid mxillry expnsion device with mxi-skeleton TABLE 1. Cse 1,, nd Intermolr Width of Cse 1 29.92 39.55 39.46 29.13 39.20 39.87 Intermolr 36.04 47.68 48.05 indictes before rpid mxillry expnsion ();, end of ;, fter three months of retention. TABLE 2. Cse 2,, nd Intermolr Width of Cse 2 23.28 35.07 32.53 28.24 39.38 37.72 Intermolr 30.74 41.92 41.42 indictes before rpid mxillry expnsion ();, end of ;, fter three months of retention. to preserve the freewy spce while still llowing mximum bilterl occlusl contct (Figure 2). The pplince ws ctivted by turning the screw ¼ turn twice dy. The ctivtion continued until the buccl crossbite ws eliminted. The durtion of the ctivtion period ws two to three weeks, depending on the severity of the mxillry constriction. sufficient expnsion ws chieved, the screw ws fixed with crylic resin. The sme pplince ws used s removble retention device full-time for three months. RESULTS Dentl cst mesurements Sufficient expnsion ws ttined in the upper dentl rch nd the buccl crossbite ws eliminted in ll three cses. Chnges of mxillry intercnine, interpremolr, nd intermolr widths (mm) re presented in Tbles 1 through 3.
99m TECHNETIUM-LABELED BONE DURING AND AFTER 547 TABLE 3. Cse 3,, nd Intermolr Width of Cse 3 27.50 31.79 32.34 32.45 39.00 39.36 Intermolr 38.18 42.90 42.91 indictes before rpid mxillry expnsion ();, end of ;, fter three months of retention. TABLE 4. Bone Activity Index of the Right nd Left Mxillry Region in Cse 1 nd Rpid Mxillry Expnsion () nd the Period of Three Months TABLE 6. Bone Activity Index of the Right nd Left Mxillry Region in Cse 3 nd Rpid Mxillry Expnsion () nd the Period of Three Months Right Side of the Mxill Left Side of the Mxill 2.46 2.20 2.26 3.80 3.86 3.32 2.89 2.47 2.07 2.37 2.29 3.71 3.99 3.70 2.94 2.66 2.33 Right Side of the Mxill Left Side of the Mxill 2.58 2.66 2.56 4.41 4.38 3.82 3.08 2.56 2.95 2.93 2.67 5.07 4.83 4.03 3.10 2.76 2.55 TABLE 5. Bone Activity Index of the Right nd Left Mxillry Region in Cse 2 nd Rpid Mxillry Expnsion () nd the Period of Three Months Right Side of the Mxill Left Side of the Mxillr 2.41 2.31 1.97 3.46 3.40 3.04 2.85 2.72 2.86 2.48 2.38 2.01 3.69 3.29 2.88 3.16 2.64 In the first nd second cses (ptients who were in MP3 nd in MP3 cp mturtion periods, respectively), the intermolr width ws incresed 11.64 nd 11.18 mm, respectively. In the third cse (RU mturtion stge), the interpremolr width ws incresed 6.55 mm nd the intermolr width ws incresed 4.72 mm. The mount of expnsion ws stble in ll the cses during the retention period (), but the intercnine nd interpremolr width tended to decrese in the second cse. However, the mount of expnsion in ll three regions (nterior, medil, nd posterior) of the first nd second cses ws much higher thn in the third cse. In other words, considering interpremolr nd intermolr width, the mount of expnsion in the first nd second cses ws lmost twice s much s the expnsion chieved in the third cse. Bone scintigrphy Scintigrphic records reveled n increse in the BAI during expnsion in ll slices nd ll three cses (Tbles 4 through 6; Figures 3,b; 4,b; nd 5,b). The incresed BAI FIGURE 3. () Anterior, medil nd posterior SPECT views of cse I. (b) Bone ctivity index of the right nd left mxill in ll slices of cse I.
548 ARAT, GÖKALP, ATASEVER, TÜRKKAHRAMAN showed new bone formtion during in the midpltl suture on both the right nd left sides of the mxillry bone. retention period of three months, the BAI of the first nd the third cse returned lmost to the initil sttus in both the right nd left mxillry region (Figures 3b nd 5b; Tbles 4 nd 6). The BAI of the second cse did not return to the initil sttus during this period in either the right or left mxillry regions (Figure 4b; Tble 5). DISCUSSION hs been widely used for the tretment of mxillry constriction. The expnsion of the upper jw without expnding the teeth is the min objective of this method. Thus, is considered s n orthopedic pproch. Conventionl rdiogrphy is not cpble of detecting the structurl chnges of the bone during. Bone scintigrphy, however, is n pproprite method for the erly dignosis of the lesions nd ctivtion regions in the bone. 18,20 Bone scintigrphy hs been used rther scrcely in orthodontics. 22 25 It hs been used for the exmintion of symmetric condylr ctivity in unilterl condylr hyperplsi. 26,27 Pulsen 24 reported differentil condylr dptive response ttined with the Herbst pplince in retrognthic cse hving symmetric fce nd occlusion ( girl in the period of MP3cp-DP3u) with plnr bone scintigrphy. In recent study, Art et l 25 hve lso investigted the effects of functionl pplince on the temporomndibulr joint in Clss II mlocclusion using plnr bone scintigrphy. In this study, the bone ctivtion in midpltl suture during ws exmined with SPECT bone scintigrphy. To hve some ide of the role of ge in bone ctivtion nd reorgniztion, three individuls in three different growth phses were included. The cst mesurements nd scintigrphic records were evluted in the nterior, medil, nd posterior regions of the mxill. The lrgest expnsions were mesured in the first nd second cses s 11.18 nd 11.64 mm, respectively, in the posterior region. In the third cse, the lrgest expnsion ws observed in the medil region nd mesured 6.6 mm. This shows tht the rection to mxillry expnsion decreses by hlf in cses where the ptients hve completed their ctive growth. This result is lso supported by the results of recent study. 28 According to scintigrphic records, the increse in bone ctivtion is highest in the nterior nd medil sections but lest in the posterior region in ll cses. Consequently, we might presume tht the mount of expnsion nd the mount of bone ctivtion re not prllel. An evlution of the BAI with regrd to growth periods reveled tht the first cse ( girl in MP3 mturtion period) hd the highest BAI. Contrdictory to the expecttions, the BAI in the third cse ws higher thn in the second cse. CONCLUSIONS According to scintigrphic records, the increse in bone ctivtion is highest in the nterior nd medil region, but lest in the posterior region in ll cses. FIGURE 4. () Anterior, medil, nd posterior SPECT views of cse II. (b) Bone ctivity index of the right nd left mxill in ll slices of cse II. The rection to mxillry expnsion decreses by hlf in cses where ptients hve completed their ctive growth. In the retention period (-), the BAI ws very close to the initil vlue in ll sections. This my imply tht retention of three months is sufficient for bone reorgniztion. However, it would be too optimistic to stte tht the reorgniztion in the bone is insurnce ginst relpse. It should lwys be kept in mind, however, tht the musculr environment plys n importnt role in relpse.
99m TECHNETIUM-LABELED BONE DURING AND AFTER 549 FIGURE 5. () Anterior, medil, nd posterior SPECT views of cse III. (b) Bone ctivity index of the right nd left mxill in ll slices of cse III. REFERENCES 1. Linder-Aronson S. Nso-respirtory function nd crniofcil growth. In: McNmr J, ed. Nso-respirtory Function nd Crniofcil Growth. Monogrph 9. Ann Arbor, Mich: Center for humn growth nd development, University of Michign; 1979. 2. Proffit WR. Contemporry Orthodontics. St Louis, Mo: CV Mosby.; 1986, 0556. 3. Kutin G, Hwes RP. Posterior cross-bite in the deciduous nd mixed dentitions. Am J Orthod. 1969;56:491 504. 4. Hs AJ. Rpid expnsion of the mxillry dentl rch nd nsl cvity by opening the mid-pltl suture. Angle Orthod. 1961;31: 73 90. 5. Hs AJ. The tretment of mxillry deficiency by opening midpltl suture. Angle Orthod. 1965;35:200 217. 6. Hs AJ. Just the beginning of dentofcil orthopedics. Am J Orthod. 1970;57:219 254. 7. Krebs AA. Expnsion of the mid-pltl suture studied by mens of metllic implnts. Act Odontol Scnd. 1959;17:491 501. 8. Wertz RA. Skeletl nd dentl chnges ccompnying rpid pltl suture opening. Am J Orthod. 1970;58:41 66. 9. Bishr SE, Stley RN. Mxillry expnsion: clinicl implictions. Am J Orthod. 1987;91:3 14. 10. Grdner GE, Kronmn JH. Crnioskeletl displcements cused by rpid pltl expnsion in the rhesus monkey. Am J Orthod. 1971;59:146 155. 11. Timms DJ. A study of bsl movement with rpid mxillry expnsion. Am J Orthod. 1980;77:500 507. 12. Strnbch HK, Clell JF. The effects of splinting the mid-pltl suture on the surrounding structures. Am J Orthod. 1963;50:923 924. 13. Clell JF, Byne DI, Posen JM, Subtelny JD. Expnsion of the mid-pltl suture in the monkey. Angle Orthod. 1965;35:23 35. 14. Ten Cte AR, Freemn E, Dickinson JB. Suturl development nd its response to rpid expnsion. Am J Orthod. 1977;71:622 636. 15. Hs AJ. Long-term post tretment evlution of rpid pltl expnsion. Angle Orthod. 1980;50:189 217. 16. Storey E. Tissue response to the movement of bones. Am J Orthod. 1973;64:229 247. 17. Mtteson SR, Stb EV, Fine JT. Bone scn ppernce of benign orl pthologic conditions. Orl Surg. 1980;38:759 763. 18. Hrcke HT. Bone imging in infnts nd children: review. J Nucl Med. 1978;19:324. 19. Alexnder JM. Rdionüclide bone scnning in the dignosis of lesions of the mxillofcil region. J Orl Surg. 1976;34:249 256. 20. Higshi T, Sugimoto K, Shimur A, Shimur K, Mssmn JE. Tecnetium 99m bone imging in the evlution of cncer of the mxillofcil region. J Orl Surg. 1979;37:254 258. 21. Helm S, Siersbek-Nielson S, Skieller V, Björk A. Skeletl mturtion of the hnd in reltion to mximum pubertl growth in body height. Tndlegebldet. 1971;75:1223 1234. 22. Grci DA, Higginbothm DJ, House JE, Kpur KK. Tc-99mpolyphospte bone imging of orthodonticlly treted dog teeth. Am J Orthod. 1974;66:665 674. 23. Nicoly OF, Khlif ER, Lncour M, Hinkle G, Lnese R. 99m Tc- Medronte uptke in the temporomndibulr joints of young rts treted with mndibulr hyperpropulsor. Am J Orthod Dentofcil Orthop. 1991;100:459 464. 24. Pulsen HU, Rbol A, Sorensen SS. Bone scintigrphy of humn temporomndibulr joints during Herbst tretment; cse report. Eur J Orthod. 1998;20:369 374. 25. Art ZM, Gökçor N, Göklp H, Erdem D, Atsever T. Evlution of functionl orthognthic therpy effects on temporomndibulr joint with Scintigrphy [bstrct]. Eur J Orthod. 2000;22:570. 26. Mtteson SR, Proffit WR, Terry BC, Stb EV, Burkes EJ, Hill C. Bone scnning with 99m Technetium phosphte to ssess condylr hyperplsi. Orl Surg Orl Med Orl Pth. 1985;60:356 367. 27. Cisneros GJ, Kbn LB. Computerized skeletl scintigrphy for ssessment of mndibulr symmetry. J Orl Mxillofc Surg. 1984;42:513 520. 28. Tizino Bcetti, Lorenzo Frnchi, Christopher G, Cmeron JA, McNmr Jr. Tretment timing for rpid mxillry expnsion. Angle Orthod. 2001;71:343 350.