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Comparison of rapid versus slow maxillary expansion on patient-reported outcome measures in growing patients: a systematic review and meta-analysis



No systematic review and meta-analysis are present in the literature comparing patient-reported outcome measures (PROMs) in rapid maxillary expansion (RME) versus slow maxillary expansion (SME) in growing patients.


The objective of this systematic review was to compare PROMs in RME versus SME in growing patients.

Materials and Methods

Electronic search in PubMed (MEDLINE), Cochrane Library, Scopus, Embase, Web of Science, and OpenGrey was conducted. Only RCTs were included. Inclusion criteria were: growing patients in the mixed dentition or early permanent dentition, mild-to-moderate maxillary transverse deficiency, dental crowding, treatment with fixed expanders for rapid and slow maxillary expansion. Risk of bias was assessed using RoB 2. GRADE statement was performed. The mean of the differences (MD) and the risk ratio (RR) were used for the aggregation of data. A random effect model was applied.


Two articles with a total of 157 patients were finally included in the systematic review and meta-analysis. One article was at low risk of bias, while one was at risk of bias with some concerns. Pain presence was less, though not statistically significant, in SME patients (RR = 2.02, 95%CI from 0.55 to 7.49, P = 0.29, I2 = 95%, 2 studies, GRADE very low). Pain intensity was significantly lower in SME appliance in the first week of treatment (pooled MD = 0.86 favoring SME, 95%CI from 0.47 to 1.26, P < 0.0001, I2 = 6%, 2 studies, GRADE moderate). There were no significant differences between the two groups in difficulty in speaking, difficulty in swallowing, hypersalivation, difficulty in hygiene, and patient and parent satisfaction.


Pain intensity was significantly lower in SME compared to RME during the first week of treatment. For the following weeks, there were no differences in pain between the two protocols.


In orthodontic practice, many fixed appliances have been used in growing patients to solve a transverse discrepancy of the maxilla. Fixed jackscrew expander is one of the most used orthodontic appliances to correct this condition [1,2,3]. Rapid maxillary expansion (RME) is characterized by the application of heavy and intermittent forces in a short time frame that produce an opening of the mid-palatine suture in growing patients. RME can be typically achieved through appliances anchored to teeth or tissues (e.g., Hyrax or Haas) [4]. Slow maxillary expansion (SME) utilizes continuous low-force systems applied over a longer period of time than RME. SME can be produced using different appliances [5,6,7] (e.g., Quad helix, W arch, expanders incorporating stainless steel or nickel-titanium springs or nickel-titanium wires) or with the same jackscrew expander by using a different activation protocol of the central screw [8,9,10,11,12].

Palatal expanders are effective in expanding the maxilla together with further positive side effects for the patient, such as increasing the size of the airways in the short term [13,14,15], influencing voice quality [16, 17], and improving hearing [16, 18].

To date, not only the objective benefits of a medical and orthodontic treatment, but also the subjective considerations of the patient are counted, from a patient-centered perspective [19].

In medicine, patient-reported outcomes (PROMs) describe a person’s perception of their health through questionnaires in which patients report on their quality of life, daily functioning, symptoms, and other aspects of their health and well-being [20]. In orthodontics, the evaluation of PROMs is becoming increasingly important, not only because the patient’s psychosocial well-being improves collaboration during therapy [21] but also because the results of orthodontic treatment can be improved if the patient is informed and confident about his or her therapy [22, 23]. It has been proven that RME often produces discomfort or pain especially during the first week of treatment [24,25,26,27,28], particularly in girls [29,30,31,32], and it is often associated with an increased age of the child [30, 31]. Other studies showed no differences in gender [25, 27, 33] or age [27, 30, 33] of the patients involved in pain experience after RME treatment. Over time, appliances for SME have been proposed for the correction of maxillary transverse discrepancy. It has been reported that SME produces less tissue resistance in the circum-maxillary structures, better bone formation in the intermaxillary suture [1, 8], and less stress exerted on the midpalatal suture, causing less discomfort for the patient [21].

Rapid and slow expansion protocols have similar efficacy in the treatment of the transverse deficiency of the maxilla [4]. Therefore, given that the two expansion protocols have similar dentoskeletal effect, it is convenient to use an appliance that has minimal negative impact for the patient. For this reason, it is particularly important to evaluate the PROMs when comparing these procedures.

To date, there are few studies evaluating the outcomes reported by patients with SME [6, 21, 24, 26, 34, 35]. No systematic review evaluated PROMs after RME versus SME. Therefore, the aim of this systematic review of randomized controlled trials (RCTs) was to compare PROMs following RME or SME in growing patients.

Materials and methods

This systematic review was registered (CRD42020221970) at the International Prospective Register of Systematic Reviews (PROSPERO) on December 21, 2020.

Eligibility criteria

The criteria to select studies were based on the PICOS (Participants, Intervention, Comparison, Outcome, Study) process and are listed in Table 1. Only RCTs were considered.

Table 1 Inclusion and exclusion criteria used for study selection (PICOS)

Information sources

Electronic search was performed in PubMed (MEDLINE), Cochrane Library, Scopus, Embase, Web of Science, and OpenGrey databases. The survey covered the period from inception to the last access on November 1st, 2021. A manual search was also performed in the references of eligibility studies to find additional relevant articles. No place, language, or publication date restrictions were utilized. Some of the most used registers were included in the databases that were investigated (International Clinical Trials Registry Platform and are included in the Cochrane Library database).

Search strategy

Two search strategies using predefined fields and including a controlled vocabulary (MeSH terms) were applied to identify proper articles. The search strategy is presented in Table 2. The first (1°) was a broad search strategy. The second query string (2°) was developed for the PubMed MEDLINE database search and modified for the other databases respecting the PICOS strategy. After the completion of the search on databases, the results were merged, and all records were imported into a reference management software (EndNote® X9 Thomson Reuters, Philadelphia, PA.). Endnote® software was used to automatically remove duplicate references. After the automatic duplicate’s removal, a manual screening was done to ensure there were no further duplicates.

Table 2 Search strategy for electronic databases

Selection process

After deleting duplicates, two reviewers (AF and VR) independently analyzed the titles and abstracts of identified records. All articles that did not meet the eligibility criteria were excluded.

The full-text versions of those studies that fulfilled the inclusion criteria, and of those whose content was not clearly based on the information of the title and/or abstract, were acquired.

Then, the same reviewers separately and in double read the full text of the remaining articles applying the eligibility criteria. Any disagreement was resolved through discussion and consensus between the two reviewers, with involvement of a third review author when necessary.

Data collection process

Data from the articles assessed for eligibility were gather. Information of the included articles comprised the following: study characteristics (authors, year of publication and study design), population characteristics (sample size, gender, and age), clinical evaluation characteristics (type of PROM, type of evaluation scale), characteristics of the results (results presented in relation to the study). If necessary, the authors of the studies were contacted if there were missing elements.

Data items

The following items of the included studies were collected:

  1. 1.

    Authors and year of the article

  2. 2.

    Study design

  3. 3.

    Sample size, mean age, gender of the subjects, cervical stage

  4. 4.

    Inclusion and exclusion criteria

  5. 5.

    Type of appliance used for expansion

  6. 6.

    Anchorage teeth

  7. 7.

    Activation protocol of the appliance used for expansion

  8. 8.

    Type of PROMs evaluated

  9. 9.

    Type of questionnaire used for PROMs assessment

  10. 10.

    Duration of treatment

  11. 11.


Risk of bias assessment

The risk of bias was assessed by two authors (LF and MN) independently and in duplicate. To evaluate the risk of bias of the selected randomized clinical trials, the version 2 of the Cochrane risk-of-bias tool for randomized trials (RoB 2.0) was used [36]. Disagreements between the review authors over the risk of bias were resolved by discussion.

The following biases were analyzed for each included study:

  1. 1.

    Bias arising from the randomization process

  2. 2.

    Bias due to deviations from intended intervention

  3. 3.

    Bias due to missing outcome data

  4. 4.

    Bias in measurement of the outcome

  5. 5.

    Bias in selection of the reported result

Each included study was assigned a global ‘low,’ ‘high,’ or ‘with some concerns’ risk of bias.

Effect measures and synthesis methods

A narrative synthesis of the findings from the included studies was provided. Clinical, methodological, and statistical heterogeneity was evaluated. If the included studies were sufficiently homogeneous, they were submitted to a quantitative synthesis (meta-analysis) using the Review Manager (RevMan) 5.4.1 software. A random effect model was applied. The mean of the differences (MD) between treatments was reported for the aggregation of continuous data. The outcome effect measure for binary outcomes was expressed as risk ratio. Inverse of variance method and a 95% confidence interval (95% CI) were calculated.

Heterogeneity was assessed through chi-square test (in which a P value < 0.1 indicated a statistically significant heterogeneity) and through the inconsistency index (I2). Values above 50% represented substantial heterogeneity.

The results of the meta-analysis were reported with a forest plot.

If possible, a subgroup analysis by age (children versus adolescents) was planned. A subgroup analysis was also planned based on different activation protocols for the expanders. Another subgroup analysis was planned to include only studies with low risk of bias.

Reporting bias assessment

Risk of bias of included studies were reported graphically with the risk of bias traffic light plot of ROB2 assessments created using robvis [37]. Funnel plot and Egger’s test were proposed to investigate the presence of publication bias if at least 10 studies were included in the meta-analysis.

Certainty assessment

The certainty of evidence was assessed by the Grading of Recommendations Assessment, Development and Evaluation (GRADE) [38, 39]. The following parameters were assessed by two reviewers (LF and MN): RoB [40], inconsistency (heterogeneity) [41], indirectness [42], imprecision [43] and publication bias [44]. The quality of evidence was classified into four levels: high, moderate, low, and very low.


Study selection

The full PRISMA 2020 statement flowchart is displayed in Fig. 1.

Fig. 1
figure 1

PRISMA 2020 statement flowchart

26,505 total articles were found on the six electronic databases. After removing duplicates, 6477 records remained. After reading the title and abstract, 17 articles remained to be assessed for eligibility. Of these, 15 more were excluded by analyzing the full text. The motivation of their exclusion is reported in Table 3.

Table 3 Excluded articles and motivation for exclusion

Articles that did not have PROMs as their outcome were excluded by reading the abstract. If it was not clear from the abstract, the full text was retrieved. Many excluded articles were not RCTs. Some articles did not have a group with a slow expansion protocol. A study [27] was excluded because all expanders were activated with a rapid activation protocol, included the memory screw expander which was activated 6 quarter-turns a day.

Two articles were finally included in this systematic review and meta-analysis [24, 35].

Study characteristics

Type of study and location

Characteristics of included articles are presented in Table 4. The two included studies (Ugolini et al. [24]; Nieri et al. [35]) were multicenter RCTs and were performed both within University Departments of Orthodontics. They were both conducted in Italy and published from 2020 to 2021. They both analyzed growing patients who required expansion of the maxilla.

Table 4 Characteristics of included studies

Characteristics of the participants

In the study by Ugolini et al. [24], the inclusion criteria were a transversal maxillary deficiency, with an intermolar width < 30 mm, with or without crossbite. In the study by Nieri et al. [35], it was not specified if patients had a crossbite, and the inclusion criterion was a posterior interarch discrepancy of at least 3 mm.

In both studies the cervical stage [CS] in cervical vertebral maturation [45] was considered. In one article [35], patients were all prepubertal (CS 1 or CS 2) while in the other article [24] both prepubertal and pubertal patients (CS 1–CS 3) were comprised. Moreover, Ugolini et al. [24] did not specify the dentition stage of patients while in Nieri et al. study [35] patients were in either early or intermediate mixed dentition stage. All studies involved both male and female patients. The age of patients was between 6 and 13 years in one study [24] and between 5.7 and 11.0 years of age in the other study [35].

Characteristics of the intervention and comparisons

The included studies [24, 35] compared the outcomes reported by patients after the application of a maxillary expander and after the activation of the appliance. Both studies evaluated the differences of a rapid maxillary expander versus a slow maxillary expander (Leaf expander). The Leaf expander incorporates a Ni–Ti leaf-shaped spring [7] that it is pre-activated to deliver the first 3 mm of expansion. After deactivation, the spring has to be re-activated in office after 2–3 months, by 10 quarter-turns of the screw per month (1 quarter-turn corresponds to 0.1 mm of activation). In Ugolini et al. [24] the RME group was treated by an Hyrax expander which was applied on second primary molars with lingual extensions to the first permanent molars. The expander was activated two times at chairside and then two quarter-turns per day (0.4 mm of expansion per day). In Nieri et al. [35], both the RME group and the Leaf group used a butterfly expander [46] anchored with bands on second primary molars without lingual extensions to the first permanent molars or to the deciduous canines. In the RME group, the protocol of the activation of the screw was a quarter of a turn per day (0.2 mm of expansion per day). In the study by Ugolini et al. [24], the screw of both groups was activated until overcorrection, and then, the expander remained in place for 9 months. In the Nieri et al. [35] study, the expanders were activated until the palatal cusps of the upper second primary molars approximated the buccal cusps of the lower second primary molars. Then, they were left in place and removed after 1 year from the start of treatment.

Characteristics of the outcomes

In both studies, the primary outcome was PROMs evaluation. In the study by Ugolini et al. [24], pain in the first week after screw activation was assessed; other outcomes were jaw function impairment such as difficulty in speaking, difficulty in swallowing, and hypersalivation. In Nieri et al. [35], presence of pain was assessed until the 12th week after screw activation. Difficulty in speaking, expander hygiene, and patient and parent satisfaction were also investigated as secondary outcomes.

Pain was considered as a binary outcome (presence/absence) and as a continuous outcome. Intensity of pain assessed through a Visual Analogue Scale (VAS) was included in the meta-analysis until the 4th week of activation of the screw.

Risk of bias within studies and quality of evidence

The risk of bias of the included RCTs was assessed through the version 2 of the Revised Cochrane risk-of-bias tool for randomized trials (RoB 2), and it is presented graphically in Fig. 2.

Fig. 2
figure 2

Risk of bias of included studies

Overall risk

Ugolini et al. [24], was considered at risk of bias with some concerns.

Nieri et al. [35], was considered at low risk of bias.

Ugolini et al. [24], was considered at risk of bias with some concerns because the allocation concealment was not reported. Moreover, intention-to-treat or modified intention-to-treat analyses were not applied.

Quality of evidence

The quality of evidence of included studies was assessed with GRADE. The level of certainty of evidence was moderate for most variables. Summary of Findings Table (SoF) for GRADE statement is presented in Table 5. Indirectness did not affect the level of certainty of evidence because both studies used outcomes that were in agreement with the PICOS questions of the systematic review. Fewer than 10 studies were included in the quantitative synthesis, so it was not possible to assess publication bias. However, the broad search strategy, including the gray literature, diminished the possibility of publication bias.

Table 5 Summary of Findings Table (SoF) for GRADE statement of included studies

Results of individual studies and data synthesis

Four binary outcomes (presence of pain in the first week; presence of difficulty of speaking in the first week; presence of difficulty of swallowing in the first week; and hypersalivation in the first week) and 7 continuous outcomes (VAS pain in the first, second, third, and four weeks; VAS difficulty in hygiene in the first week; patient satisfaction; and parent satisfaction) were included in the meta-analysis.

A subgroup analysis by age (children versus adolescents) was not performed due to the similar age of patients of the two studies. Subgroup analysis based on the different activation protocols of the expanders was not performed because only two studies with different activation protocols were included.

Only one study [35] was at low risk of bias and therefore a subgroup analysis was not performed.

Summary of the data

The summary results of the data are expressed in Table 6.

Table 6 Comparison between patient-related outcomes produced by RME versus SME in included studies in the systematic review


In both studies, pain was assessed as a binary outcome (presence/absence) and as a continuous outcome (intensity of pain through a numerical and visual rating scale).

In one study [24], the visual Wong–Baker scale was employed plus a numeric rating scale. Similarly, in the other study [35] a VAS plus the visual Wong–Baker scale was used. In the study conducted by Ugolini et al. [24], pain was assessed only in the first week of activation of the screw. In Nieri et al. [35], pain was evaluated in the 12 weeks from the screw activation. For the intensity of pain, the first week of treatment for one study [24] and only the first 4 weeks of treatment of the other study [35] were included in the meta-analysis. For the presence of pain in RME and SME, pain was perceived by less patients treated with SME (pooled RR = 2.02 favoring SME, 95% CI from 0.55 to 7.49, P = 0.29, 2 studies, GRADE very low). Heterogeneity was significantly high (I2 = 95%) (Fig. 3A).

Fig. 3
figure 3

Forest plots of the outcomes included in the meta-analysis (A, presence of pain in 1st week; B, pain intensity in 1st week; C, presence of difficulty in speaking in 1st week)

Intensity of pain in the first week was significantly less in patients treated with SME (pooled MD = 0.86 favoring SME, 95% CI from 0.47 to 1.26, P < 0.0001, I2 = 6%, 2 studies, GRADE moderate) (Fig. 3B). In the second week, pain intensity was decreased in both RME and SME, with no significant differences between RME and SME (pooled MD = 0.70 favoring SME, 95% CI from − 0.24 to 1.64, P = 0.15, 1 study, GRADE moderate) (Fig. 4A).

Fig. 4
figure 4

Forest plots of the outcomes included in the meta-analysis (A, pain intensity in 2nd week; B, pain intensity in 3rd week; C, pain intensity in 4th week)

In 3rd week, pain intensity was decreased in the two groups, with no significant differences between RME and SME (pooled MD = 0.20 favoring SME, 95% CI from − 0.25 to 0.65, P = 0.39, 1 study, GRADE moderate) (Fig. 4B).

In forth week, pain intensity decreased in both RME and SME. There were no significant differences between RME and SME (pooled MD = 0.30 favoring SME, 95% CI from − 0.17 to 0.77, P = 0.21, 1 study, GRADE moderate) (Fig. 4C).

Difficulty in speaking

Both studies evaluated difficulty in speaking after the first week of beginning of treatment as a binary variable. In both RME and SME difficulty in speaking was highly prevalent (85–90%). In the meta-analysis no significant differences were found between RME and SME (pooled RR = 0.95 favoring RME, 95% CI from 0.85 to 1.06, P = 0.37, I2 = 0%, 2 studies, GRADE moderate) (Fig. 3C).

Difficulty in swallowing

Only one study [24] reported data for this PROM as a binary variable after the first week of activation of the screw. Difficulty in swallowing was very frequent in the first week, in both RME and SME (about 80%). The forest plot revealed no significant differences between the two treatment modalities (pooled RR = 0.93 favoring RME, 95% CI from 0.78 to 1.12, P = 0.46, 1 study, GRADE low) (Fig. 5A).

Fig. 5
figure 5

Forest plots of the outcomes included in the meta-analysis (A, presence of difficulty in swallowing in 1st week; B, presence of hypersalivation in 1st week; C, difficulty in hygiene in 1st week; D, patient satisfaction at 12th week; E, parent satisfaction at 12th week)


Presence of salivation (hypersalivation) was reported only by Ugolini et al. [24]. Hypersalivation was present in more than 80% on the subjects in the first week of treatment in both RME and SME. The forest plot showed that there were no differences between RME and SME (pooled RR = 1.03 favoring SME, 95% CI from 0.84 to 1.24, P = 0.80, 1 study, GRADE low) (Fig. 5B).

Difficulty in hygiene

Nieri et al. [35] reported the grading of difficulty in hygiene in the 12th weeks of treatment through the VAS. Difficulty in hygiene was relatively mild in the first week (2.7 in SME group and 3.0 in RME group). No statistically significant differences were reported between RME and SME in the first week (pooled MD = 0.30 favoring SME, 95% CI from − 1.14 to 1.74, P = 0.68, 1 study, GRADE moderate) (Fig. 5C).

Patient satisfaction

The forest plot demonstrated the absence of difference in patient satisfaction between RME and SME (pooled MD = 0.00, 95% CI from − 0.92 to 0.92, P = 1.0, 1 study, GRADE moderate) (Fig. 5D).

Parent satisfaction

Only the study by Nieri et al. [35] took this parameter into investigation. The forest plot revealed that no differences existed between RME and SME (pooled MD = 0.10 favoring RME, 95% CI from − 0.56 to 0.76, P = 0.76, 1 study, GRADE moderate) (Fig. 5E).


Summary of evidence

This systematic review aimed to compare patient-reported outcomes after RME versus SME. In orthodontics, patient satisfaction is one of the most generally measured PROMs, especially in adults [23, 47]. As for the expansion of the maxilla in growing patients, the most investigated and most reported PROMs were pain and speech [26, 48].

As for pain, in the first week there was no significant difference for the presence of pain while there was a significant difference for the intensity of pain. With reference to the presence of pain during the first week of activation of the screw, from this systematic review arose that pain was perceived more in the RME group, more than twice than in the SME group (86.8% in RME group vs. 40.7% in SME group) (Fig. 3A). The RR of 2.02, however, was not statistically significant because of the high heterogeneity between the 2 studies. It should be noted that the RR reported by Ugolini et al. [24] was 3.65, while it was only 1.15 in Nieri et al. [35] study. This difference in RR in perceived pain during the first week could have been influenced by the fact that in Ugolini et al. [24] the expansion screw in the RME group was activated 2 times per day versus 1 time per day in Nieri et al. [35] Moreover, in Ugolini et al. [24] the child’s pain response was measured 5 min after each turn while in Nieri et al. [35] pain was recorded after 1 week of treatment with RME. Other factors that could have influenced the difference in RR in perceived pain during the first week between the 2 studies, were the small difference in age of the participants of the two studies and the intensity of the forces generated by the Ni–Ti springs of the Leaf expander in the SME group. In facts, in Ugolini et al. [24] the Leaf expander generated 450 g of force while Nieri et al. [35] used a Leaf expander that produced 900 g of force.

On the contrary, intensity of pain in the first week was significantly less in SME group compared to RME group, with a difference of almost 1 on VAS (Fig. 3B). One study demonstrated a minimum clinically significant difference of 1 on VAS in children [49]. Therefore, during the 1st week the difference in intensity of pain between the 2 groups was nearly clinically significant. In the following weeks, pain decreased progressively, especially in RME group, from about 2.6 in the first week to 0.4 in the fourth week (Fig. 4). Over time, pain in SME group decreased as well, about 1 point on VAS. Pain was assessed every day in the first week only in the study by Ugolini et al. [24] in which pain was perceived more in both groups especially during the first 4 days. This is in accordance with previous studies in particular during RME treatment [27, 29, 31, 32, 50]. In one study [35], pain was evaluated until 12th week; it decreased quickly after 3rd week, and from the 5th week to the 12th week it was almost nil, around 0.1 on VAS. These findings support previous non-randomized studies [21, 26] that compared RME and SME appliances, in which pain was perceived mostly during the first week of treatment, in high percentage in RME groups (93.9% [26] and > 90% in the first 2 days [21]), and then decreased until the beginning of adaptation after the third day [21] or at the end of the first week [26]. Pain was perceived more during the first phase of RME activation due to an inflammatory-like reaction of a highly cellular disorganized connective tissue [51, 52]. As expansion continued, less pain was perceived due to less distraction of the midpalatal tissues followed with each progressive turn of the screw [33].

For the presence of difficulty in speaking during the first week, there was no difference between the two groups. This outcome was measured in both studies included. Difficulty in speaking was highly represented in both treatments in the first week (about 85.5% in RME group and 90% in SME group). During time, difficulty in speaking decreased progressively although it did not disappear completely even at the 12th week, reaching values of 0.2–0.4 on the VAS (Fig. 3C) [35].

A similar trend is displayed for the presence of difficulty in swallowing during the first week, and there was a high prevalence of this condition among patients in both groups (about 79% in RME group and about 85% in SME group). This outcome was measured only in one study [24]. Also for this outcome there were no significant differences between the two groups.

These findings support previous studies in which functional jaw impairment such as difficulty in speaking and difficulty in swallowing were present in expansion treatment mostly during the first week after the cementation of the appliance [21, 26]. After a short period of time, the discomfort in speaking is minimized due to a functional adaptation of the muscles and joints [26]. In children with a narrow palate, the application of the expander causes problems in distorting the /s/ sound because the expander diminishes the tongue’s functional place [53].

It must be stressed that the size and encumbrance of the appliance can be a great impediment to functional movements. Problems in speaking or swallowing are caused by the presence of a foreign body/appliance in the oral cavity [54], especially when considering fixed appliances that cannot be removed by the patient during the day, compared with removable appliance [55]. In this systematic review all included RCTs considered two types of expanders similar in their size and encumbrance in the palatal vault. In a previous non-randomized study conducted by Abed and Alhashimi [21] difficulty in swallowing was extremely different in the two RME (Hyrax) and SME (Quad Helix) appliances. The use of a Quad Helix for SME treatment increased the intraoral space and tongue movements were less restricted for food bolus movements during the second stage of swallowing [21].

The present systematic review showed that there was no difference in salivation (hypersalivation) between RME and SME. This parameter was investigated only in one study [24]. Hypersalivation was high in the first week of treatment (more than 80% in both groups) (Fig. 5B). The presence and quantity of saliva during a treatment with a palatal expander is poorly documented in the literature. Orthodontic palatal appliances cause a salivary overflow especially during the first days as the bulk of the appliance may interfere with the mobility of the tongue and cheeks [56].

Difficulty in hygiene was assessed through the VAS only in one study [35]. This outcome was maximum during the first week of treatment and decreased along with time, without ever reaching 0 point on VAS even at the 12th week [35]. According to the meta-analysis, in the first week of treatment there were no differences between the two groups (Fig. 5C). This result is plausible as the two types of expanders (Hyrax/Butterfly expander and Leaf expander) are very similar in shape and cleaning capacity.

Patient and parent satisfaction were investigated with a VAS only in the study by Nieri et al. [35] in which 0 meant ‘maximum dissatisfaction’ and 10 ‘maximum satisfaction’ with the result assessed at the end of the study. High levels of patient and parent satisfaction were present with no differences between the two groups (Fig. 5D and E).

Usually, patient satisfaction varies largely from a strong disposition to undergo orthodontic treatment (especially in adults) to a complete indifference to treatment, especially in children. Moreover, some children and adolescents had orthodontic treatment because of their parents’ desires [47]. For patients, pain and discomfort during treatment strongly affected treatment satisfaction [23, 57].


PROMs are subjective assessments that are difficult to standardize especially in children [58, 59]. Despite this, numerical rating scales and visual and color analog scales have proved to be understood and properly utilized in growing patients [60, 61]. Pain report in children through self-reports, however, must be interpreted cautiously [33]. In one study included in this systematic review, some children were quite young (< 6 years of age) [35].

A limitation of this study was that review authors were the same as for an article [35] included in this systematic review and meta-analysis.

Another limitation was that few RCTs in the literature compared RME and SME appliances by using PROMs. Of these RCTs, SME was performed only with the Leaf expander and there is lack of information about other types of SME. Additionally, one outcome variable (presence of pain in 1st week) showed high heterogeneity. There were some treatment differences in the two included studies and different modalities of screw activation, although the design of the expanders was quite similar. There were also differences regarding the characteristics of patients included in the two studies. All patients in any case needed maxillary expansion due to transverse discrepancy between the dental arches. More RCTs are needed in orthodontics that include an evaluation of PROMs.


In growing patients, the application of SME reduced pain intensity compared to RME during the first week of treatment. There were no differences in the first week of treatment for difficulty of speaking, difficulty in swallowing, hypersalivation, difficulty in hygiene, and patient and parent satisfaction between RME and SME appliances. There were no statistically significant differences in pain between the two protocols for all following weeks.

Availability of data and materials

The data underlying this article will be shared to the corresponding author after reasonable request.


  1. Bishara SE, Staley RN. Maxillary expansion: clinical implications. Am J Orthod Dentofac Orthop. 1987;91(1):3–14.

    Article  Google Scholar 

  2. Haas AJ. Palatal expansion: just the beginning of dentofacial orthopedics. Am J Orthod. 1970;57(3):219–55.

    Article  PubMed  Google Scholar 

  3. McNamara JA. Maxillary transverse deficiency. Am J Orthod Dentofac Orthop. 2000;117(5):567–70.

    Article  Google Scholar 

  4. Rutili V, Mrakic G, Nieri M, Franceschi D, Pierleoni F, Giuntini V, et al. Dento-skeletal effects produced by rapid versus slow maxillary expansion using fixed jackscrew expanders: a systematic review and meta-analysis. Eur J Orthod. 2021;43(3):301–12.

    Article  PubMed  Google Scholar 

  5. Hicks EP. Slow maxillary expansion. A clinical study of the skeletal versus dental response to low-magnitude force. Am J Orthod. 1978;73(2):121–41.

    Article  PubMed  Google Scholar 

  6. Donohue VE, Marshman LA, Winchester LJ. A clinical comparison of the quadhelix appliance and the nickel titanium (tandem loop) palatal expander: a preliminary, prospective investigation. Eur J Orthod. 2004;26(4):411–20.

    Article  PubMed  Google Scholar 

  7. Lanteri C, Beretta M, Lanteri V, Gianolio A, Cherchi C, Franchi L. The leaf expander for non-compliance treatment in the mixed dentition. J Clin Orthod. 2016;50(9):552–60.

    PubMed  Google Scholar 

  8. Martina R, Cioffi I, Farella M, Leone P, Manzo P, Matarese G, et al. Transverse changes determined by rapid and slow maxillary expansion–a low-dose CT-based randomized controlled trial. Orthod Craniofac Res. 2012;15(3):159–68.

    Article  PubMed  Google Scholar 

  9. Brunetto M, Andriani Jda S, Ribeiro GL, Locks A, Correa M, Correa LR. Three-dimensional assessment of buccal alveolar bone after rapid and slow maxillary expansion: a clinical trial study. Am J Orthod Dentofacial Orthop. 2013;143(5):633–44.

    Article  PubMed  Google Scholar 

  10. Liu JL, Li HF, Yan H. Comparing the effects of fast and slow expansion on nasal cavity and maxilla structure. Hua Xi Kou Qiang Yi Xue Za Zhi. 2019;37(5):533–6.

    PubMed  Google Scholar 

  11. Ribeiro GLU, Jacob HB, Brunetto M, Pereira JS, Tanaka O, Buschang PH. A preliminary 3‐D comparison of rapid and slow maxillary expansion in children: a randomized clinical trial. Int J Paediatr Dent. 2020;30(3):349–59.

    Article  Google Scholar 

  12. Pereira JDS, Jacob HB, Locks A, Brunetto M, Ribeiro GLU. Evaluation of the rapid and slow maxillary expansion using cone-beam computed tomography: a randomized clinical trial. Dental Press J Orthod. 2017;22(2):61–8.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Izuka EN, Feres MF, Pignatari SS. Immediate impact of rapid maxillary expansion on upper airway dimensions and on the quality of life of mouth breathers. Dental Press J Orthod. 2015;20(3):43–9.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Zhao T, Hua F, He H. Rapid maxillary expansion may increase the upper airway volume of growing patients with maxillary transverse deficiency. J Evid Based Dent Pract. 2021;21(3):101579.

    Article  PubMed  Google Scholar 

  15. Almuzian M, Ju X, Almukhtar A, Ayoub A, Al-Muzian L, McDonald JP. Does rapid maxillary expansion affect nasopharyngeal airway? A prospective cone beam computerised tomography (CBCT) based study. Surgeon. 2018;16(1):1–11.

    Article  PubMed  Google Scholar 

  16. Singh H, Maurya RK, Sharma P, Kapoor P, Mittal T, Atri M. Effects of maxillary expansion on hearing and voice function in non-cleft lip palate and cleft lip palate patients with transverse maxillary deficiency: a multicentric randomized controlled trial. Braz J Otorhinolaryngol. 2021;87(3):315–25.

    Article  PubMed  Google Scholar 

  17. Macari AT, Ziade G, Khandakji M, Tamim H, Hamdan AL. Effect of rapid maxillary expansion on voice. J Voice. 2016;30(6):760.e1.

    Article  Google Scholar 

  18. Fagundes NCF, Rabello NM, Maia LC, Normando D, Mello K. Can rapid maxillary expansion cause auditory improvement in children and adolescents with hearing loss? A Syst Rev Angle Orthod. 2017;87(6):886–96.

    Article  Google Scholar 

  19. Hua F. Increasing the value of orthodontic research through the use of dental patient-reported outcomes. J Evid Based Dent Pract. 2019;19(2):99–105.

    Article  PubMed  Google Scholar 

  20. Williams K, Sansoni J, Morris D, Grootemaat P, C T. Patient-reported outcome measures: literature review. Elizabeth Street, Sydney: ACSQHC; 2016.

  21. Abed Al Jawad FH, Alhashimi NA. Evaluation of self-perceived pain and jaw function impairment in children undergoing slow and rapid maxillary expansion: a prospective clinical trial. Angle Orthod. 2021;91:725–32.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Ryan FS, Cunningham SJ. Patient-reported outcome measures and orthodontics. J Orthod. 2018;45(2):63–4.

    Article  PubMed  Google Scholar 

  23. Bradley E, Shelton A, Hodge T, Morris D, Bekker H, Fletcher S, et al. Patient-reported experience and outcomes from orthodontic treatment. J Orthod. 2020;47(2):107–15.

    Article  PubMed  Google Scholar 

  24. Ugolini A, Cossellu G, Farronato M, Silvestrini-Biavati A, Lanteri V. A multicenter, prospective, randomized trial of pain and discomfort during maxillary expansion: leaf expander versus hyrax expander. Int J Paediatr Dent. 2020;30(4):421–8.

    Article  PubMed  Google Scholar 

  25. Önçağ G, Dindaroğlu F, Doğan S. Perception of pain during rapid palatal expansion. Turk J Orthod. 2011;24:111–22.

    Article  Google Scholar 

  26. De Felippe NL, Da Silveira AC, Viana G, Smith B. Influence of palatal expanders on oral comfort, speech, and mastication. Am J Orthod Dentofac Orthop. 2010;137(1):48–53.

    Article  Google Scholar 

  27. Halicioglu K, Kiki A, Yayuz I. Subjective symptoms of RME patients treated with three different screw activation protocols: a randomised clinical trial. Aust Orthod J. 2012;28(2):225–31.

    PubMed  Google Scholar 

  28. Serritella E, Migliaccio S, Musone L, Impellizzeri A, Stefano AAD, Galluccio G. Perceived pain during rapid maxillary expansion (RME): Trends, anatomical distinctions, and age and gender correlations. Pain Res Manag. 2021;2021:1–8.

    Article  Google Scholar 

  29. Gecgelen M, Aksoy A, Kirdemir P, Doguc DK, Cesur G, Koskan O, et al. Evaluation of stress and pain during rapid maxillary expansion treatments. J Oral Rehabil. 2012;39(10):767–75.

    Article  PubMed  Google Scholar 

  30. Baldini A, Nota A, Santariello C, Assi V, Ballanti F, Cozza P. Influence of activation protocol on perceived pain during rapid maxillary expansion. Angle Orthod. 2015;85(6):1015–20.

    Article  PubMed  PubMed Central  Google Scholar 

  31. Feldmann I, Bazargani F. Pain and discomfort during the first week of rapid maxillary expansion (RME) using two different RME appliances: a randomized controlled trial. Angle Orthod. 2017;87(3):391–6.

    Article  PubMed  Google Scholar 

  32. de Araújo MC, Bocato JR, Berger SB, Oltramari PVP, de Castro AC, Conti F, et al. Perceived pain during rapid maxillary expansion in children with different expanders. Angle Orthod. 2021;91:484–9.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Needleman HL, Hoang CD, Allred E, Hertzberg J, Berde C. Reports of pain by children undergoing rapid palatal expansion. Pediatr Dent. 2000;22(3):221–6.

    PubMed  Google Scholar 

  34. McNally MR, Spary DJ, Rock WP. A randomized controlled trial comparing the quadhelix and the expansion arch for the correction of crossbite. J Orthod. 2005;32(1):29–35.

    Article  PubMed  Google Scholar 

  35. Nieri M, Paoloni V, Lione R, Barone V, Marino Merlo M, Giuntini V, et al. Comparison between two screws for maxillary expansion: a multicenter randomized controlled trial on patient’s reported outcome measures. Eur J Orthod. 2021;43(3):293–300.

    Article  PubMed  Google Scholar 

  36. Sterne JAC, Savović J, Page MJ, Elbers RG, Blencowe NS, Boutron I, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ. 2019.

  37. McGuinness LA, Higgins JPT. Risk-of-bias VISualization (robvis): an R package and Shiny web app for visualizing risk-of-bias assessments. Res Synth Methods. 2021;12(1):55–61.

    Article  PubMed  Google Scholar 

  38. Quilodrán C, Kirmayr M, Valente B, Pérez-Bracchiglione J, Garegnani L, Franco JVA. The GRADE approach, Part 2: evidence to decision frameworksoutlining decision-making in health. Medwave. 2021;21(4):e8182.

    Article  PubMed  Google Scholar 

  39. Kirmayr M, Quilodrán C, Valente B, Loezar C, Garegnani L, Franco JVA. The GRADE approach, part 1: how to assess the certainty of the evidence. Medwave. 2021;21(2):e8109.

    Article  PubMed  Google Scholar 

  40. Guyatt GH, Oxman AD, Vist G, Kunz R, Brozek J, Alonso-Coello P, et al. GRADE guidelines: 4. Rating the quality of evidence–study limitations (risk of bias). J Clin Epidemiol. 2011;64(4):407–15.

    Article  PubMed  Google Scholar 

  41. Guyatt GH, Oxman AD, Kunz R, Woodcock J, Brozek J, Helfand M, et al. GRADE guidelines: 7. Rating the quality of evidence–inconsistency. J Clin Epidemiol. 2011;64(12):1294–302.

    Article  PubMed  Google Scholar 

  42. Guyatt GH, Oxman AD, Kunz R, Woodcock J, Brozek J, Helfand M, et al. GRADE guidelines: 8. Rating the quality of evidence–indirectness. J Clin Epidemiol. 2011;64(12):1303–10.

    Article  PubMed  Google Scholar 

  43. Guyatt GH, Oxman AD, Kunz R, Brozek J, Alonso-Coello P, Rind D, et al. GRADE guidelines 6. Rating the quality of evidence—imprecision. J Clin Epidemiol. 2011;64(12):1283–93.

    Article  PubMed  Google Scholar 

  44. Guyatt GH, Oxman AD, Montori V, Vist G, Kunz R, Brozek J, et al. GRADE guidelines: 5. Rating the quality of evidence–publication bias. J Clin Epidemiol. 2011;64(12):1277–82.

    Article  PubMed  Google Scholar 

  45. Baccetti T, Franchi L, McNamara JA. The cervical vertebral maturation (CVM) method for the assessment of optimal treatment timing in dentofacial orthopedics. Semin Orthod. 2005;11(3):119–29.

    Article  Google Scholar 

  46. Cozza P, Giancotti A, Petrosino A. Butterfly expander for use in the mixed dentition. J Clin Orthod. 1999;33(10):583–7.

    PubMed  Google Scholar 

  47. Pachêco-Pereira C, Pereira JR, Dick BD, Perez A, Flores-Mir C. Factors associated with patient and parent satisfaction after orthodontic treatment: a systematic review. Am J Orthod Dentofac Orthop. 2015;148(4):652–9.

    Article  Google Scholar 

  48. Feldmann I, List T, Bondemark L. Orthodontic anchoring techniques and its influence on pain, discomfort, and jaw function–a randomized controlled trial. Eur J Orthod. 2012;34(1):102–8.

    Article  PubMed  Google Scholar 

  49. Powell CV, Kelly AM, Williams A. Determining the minimum clinically significant difference in visual analog pain score for children. Ann Emerg Med. 2001;37(1):28–31.

    Article  PubMed  Google Scholar 

  50. Silveira GS, Abreu LG, Palomo JM, da Matta Cid Pinto LS, de Sousa AA, Gribel BF, et al. Mini Hyrax vs hyrax expanders in the rapid palatal expansion in adolescents with posterior crossbite: a randomized controlled clinical trial. Prog Orthod. 2021;22(1):30.

    Article  PubMed  PubMed Central  Google Scholar 

  51. Murray JM, Cleall JF. Early tissue response to rapid maxillary expansion in the midpalatal suture of the rhesus monkey. J Dent Res. 1971;50(6):1654–60.

    Article  PubMed  Google Scholar 

  52. Starnebach HK, Cleall JF. Effects of splitting the midpalatal suture on the surrounding tissues. Am J Orthod. 1964;50:923–4.

    Article  Google Scholar 

  53. Laine T. Articulatory disorders in speech as related to size of the alveolar arches. Eur J Orthod. 1986;8(3):192–7.

    Article  PubMed  Google Scholar 

  54. Sergl HG, Klages U, Zentner A. Functional and social discomfort during orthodontic treatment–effects on compliance and prediction of patients’ adaptation by personality variables. Eur J Orthod. 2000;22(3):307–15.

    Article  PubMed  Google Scholar 

  55. Sergl HG, Klages U, Zentner A. Pain and discomfort during orthodontic treatment: causative factors and effects on compliance. Am J Orthod Dentofac Orthop. 1998;114(6):684–91.

    Article  Google Scholar 

  56. Oshagh M, Momeni Danaei S, Hematiyan MR, Hajian K, Shokoohi Z. Comparison of dental arch changes and patients’ discomforts between newly designed maxillary expansion screw and slow expansion procedures. J Dent. 2012;13(3):110–9.

    Google Scholar 

  57. Feldmann I. Satisfaction with orthodontic treatment outcome. Angle Orthod. 2014;84(4):581–7.

    Article  PubMed  PubMed Central  Google Scholar 

  58. Beyer JE, Wells N. The assessment of pain in children. Pediatr Clin North Am. 1989;36(4):837–54.

    Article  PubMed  Google Scholar 

  59. LeBaron S, Zeltzer L. Assessment of acute pain and anxiety in children and adolescents by self-reports, observer reports, and a behavior checklist. J Consult Clin Psychol. 1984;52(5):729–38.

    Article  PubMed  Google Scholar 

  60. Franck LS, Greenberg CS, Stevens B. Pain assessment in infants and children. Pediatr Clin North Am. 2000;47(3):487–512.

    Article  PubMed  Google Scholar 

  61. von Baeyer CL. Children’s self-reports of pain intensity: scale selection, limitations and interpretation. Pain Res Manag. 2006;11(3):157–62.

    Article  Google Scholar 

  62. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372n71.

  63. Isrctn. Comparison of two screws for maxillary expansion in prepubertal children. 2016.

  64. Nct. Pain and discomfort during maxillary expansion. 2018.

  65. Nct. Treatment of unilateral posterior cross bite in children. 2020.

  66. Nct. Pain, discomfort, and functional impairments during rapid and slow maxillary expansion. 2021.

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We thank Dr. Adam Fuad Amir for his contribution in the selection process of this review.

Protocol of the review

The review protocol was developed according to the updated Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA 2020) statement [62].


No funding was received for this review.

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Authors and Affiliations



VR performed search strategy, article selection, and qualitative synthesis and wrote the manuscript. AF performed search strategy and article selection. MN performed data extraction, risk of bias assessment, and the quantitative synthesis and edited the manuscript. VG, DF, and FP guided the study and critically reviewed the manuscript. LF performed the concept and design of the study, data extraction, and risk of bias assessment and edited the manuscript. All authors read and approved the final manuscript.

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Correspondence to Lorenzo Franchi.

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Rutili, V., Nieri, M., Franceschi, D. et al. Comparison of rapid versus slow maxillary expansion on patient-reported outcome measures in growing patients: a systematic review and meta-analysis. Prog Orthod. 23, 47 (2022).

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  • Systematic review
  • Rapid maxillary expansion
  • Slow maxillary expansion
  • Proms
  • Pain
  • Meta-analysis