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Masseter muscle thickness before and after the correction of unilateral

functional posterior crossbite in growing individuals: a prospective controlled
clinical trial

Article in The European Journal of Orthodontics · December 2024

DOI: 10.1093/ejo/cjae078

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European Journal of Orthodontics, 2025, 47, cjae078
https://doi.org/10.1093/ejo/cjae078
Original Article

Masseter muscle thickness before and after the correction

of unilateral functional posterior crossbite in growing
individuals: a prospective controlled clinical trial
Fara Beltrami1,*, Stavros Kiliaridis1,2, Gregory S. Antonarakis1,
Division of Orthodontics, University Clinics of Dental Medicine, University of Geneva, 1 rue Michel-Servet, 1205 Geneva, Switzerland
1

Department of Orthodontics and Dentofacial Orthopedics, University of Bern, Freiburgstrasse 7, 3010 Bern, Switzerland
2

*
Corresponding author. Division of Orthodontics, University Clinics of Dental Medicine, University of Geneva, 1 rue Michel-Servet, 1205 Geneva, Switzerland.
E-mail: [email protected]

Abstract
Objectives: To evaluate whether unilateral functional posterior crossbite in growing children creates an asymmetry in masseter muscle thick-
ness and whether this asymmetry is normalized after crossbite correction.
Materials and methods: Two groups of growing individuals were studied prospectively: (i) a treatment group: children with unilateral functional
posterior crossbite, undergoing crossbite correction with maxillary expansion; and (ii) a control group: children without transversal malocclusions
and orthodontic treatment. The thickness of the masseter muscles was measured bilaterally using ultrasonographic recordings at three time
points: pre-treatment (T0); 9 months after (T1); and 30 months after posterior crossbite correction (T2); and at equivalent time points in the con-
trol group. Differences within and between the groups were evaluated using paired and unpaired t-tests respectively.
Results: It was found that the thickness of the masseter muscles in patients with unilateral functional posterior crossbite was significantly
thinner on the crossbite side (P = .013) by 0.5 mm. At T1, the masseter muscle of the treated crossbite side was thicker than that of the previous
normal side (0.3 mm difference; P = .046) while this difference disappeared at T2 (P > .05).
Limitations: The lack of the inclusion of an untreated posterior crossbite group, and the heterogeneity in appliances used are the principal
limitations of this study.
Conclusions: The masseter muscles in untreated individuals with unilateral functional posterior crossbite are thinner in the crossbite side than
in the contralateral non-crossbite side. This muscular asymmetry however is eliminated some time after successful treatment of this malocclu-
sion, possibly due to the bilateral symmetrization of the activity of the elevator masticatory muscles.
Keywords: posterior crossbite; functional mandibular shift; masseter muscle thickness; ultrasonography; maxillary expansion

Introduction results in an increased bite force level, such as is seen in the

Posterior crossbite is defined as a malocclusion of one or more case of chewing gum training after one month [5].
teeth in the posterior region, from canine to molar, character- The sensorimotor adaptation in children with unilateral
ized by the buccal cusps of the maxillary teeth occluding lin- posterior crossbite associated with a functional mandibular
gually to the buccal cusps of the corresponding mandibular shift may lead to a reduction in the thickness of the masseter
teeth [1]. Based on epidemiological data, the prevalence of uni- muscle on the crossbite side. Based on electromyographic
lateral posterior crossbite in the mixed dentition varies any- findings, children with posterior crossbite exhibit asym-
where between 4% and 30% [2]. In cases where this unilateral metric muscle function during chewing or clenching, with the
posterior crossbite is associated with a functional shift of the masseter muscles being less active on the crossbite than the
mandible, the sensorimotor system may adapt accordingly. non-crossbite side [6]. This difference in muscle activity on
In children, the sensorimotor system must adapt to sub- the crossbite side may thus be the culprit for the anatomical
stantial morphological changes during growth and develop- changes observed. Along these same lines, it has been shown
ment. The orofacial area is particularly challenged by the that a reduced functional demand of the masseter muscle re-
growth and development of the jaws and the transition from sults in thinning of the muscle fibres [7, 8].
the primary to the permanent dentition [3]. Often, this trans- Muscle fibres size and composition would need biopsies to
formation results in drastic changes in skeletal mass, skeletal evaluate objectively, and thus alternative methods have been
shape, muscle mass, and muscle geometry. Intensive use of developed to allow for a clinical characterization of the func-
any skeletal muscle may cause changes in the muscle fibre size tional capacity of masticatory muscles. Ultrasonography has
and composition, which, in turn, will increase the strength of been introduced to visualize the cross-sectional thickness of the
the muscle and the resistance to fatigue [4]. This is also true masseter muscle and proven to be reliable and accurate [9] and
for the masticatory muscles as prolonged functional activity comparable to measurements made using magnetic resonance

© The Author(s) 2024. Published by Oxford University Press on behalf of the European Orthodontic Society. All rights reserved. For commercial re-use,
please contact [email protected] for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via
the Permissions link on the article page on our site—for further information please contact [email protected].
2 Beltrami et al.

imaging [10]. This method has been used extensively to evaluate treatment presenting a complete unilateral functional pos-
the functional capacity of the masticatory muscles, including its terior crossbite (associated with a mandibular shift towards
use in studies looking into posterior crossbites [11, 12]. the crossbite side). Patients with the following characteristics
In previous studies, a different level of bilateral activity of the were excluded from selection: patients not within the de-
masticatory muscles has been recorded in children with unilat- sired age range, patient having a posterior crossbite without
eral crossbite [13]. This asymmetric activity is associated with functional mandibular shift or a bilateral posterior crossbite,
a functional deviation of the mandible towards the crossbite patients having undergone other orthodontic treatment or
side so that the child achieves better tooth interdigitation [14]. the use of a space maintainer, patients with craniofacial syn-
The abnormal mandibular functional displacement associated dromes and/or clefts, patients with temporomandibular dis-
with a unilateral posterior crossbite has been proposed to have orders, medically compromised patients, those with muscular
negative long-term consequences on jaw growth and occlusal pathologies or neuromuscular disorders, or those not willing
development, potentially leading to dentofacial asymmetry [15, to take part.
16], asymmetric contraction of the masticatory muscles [17, For the control group, the inclusion criteria were the
18], reduced thickness of the ipsilateral masseter muscle [19], ­following: growing patients aged between 8 and 11 years
and a different chewing pattern [20]. old, in the mixed dentition, with a Class I malocclusion but
This asymmetry in masticatory muscle activity may or may without the immediate need for orthodontic treatment, and
not be corrected following treatment of the functional pos- without the presence of a unilateral posterior crossbite or
terior crossbite. Elimination of the functional mandibular shift any other transverse malocclusion or dental or skeletal asym-
should also have an influence on the activity of the muscles; metry. Exclusion criteria were: patients having undergone
however, this would need to be shown longitudinally. other orthodontic treatment or the use of a space maintainer,
The aims of the present study were therefore to assess patients with craniofacial syndromes and/or clefts, patients
whether oral functional asymmetry in children with unilateral with temporomandibular disorders, medically compromised
posterior crossbite associated with a functional mandibular patients, those with muscular pathologies or neuromuscular
shift creates an asymmetry in masseter muscle thickness and disorders, or those not willing to take part.
whether this asymmetry is normalized after crossbite cor-
rection and elimination of the mandibular functional shift. Intervention (treatment and control group)
The null hypotheses of the present study were that no dif- In the treatment group, treatment of the unilateral posterior
ferences are seen in masseter muscle thickness in children crossbite was accomplished using a quadhelix or a Hyrax-
with unilateral posterior crossbite, between the crossbite and type expander. The choice between the two appliances was
non-crossbite sides prior to or after crossbite correction, or made based on clinical judgement, focussing on the magni-
between children with or without crossbite. tude of the transversal discrepancy, as well as the appreciation
of the tipping of the posterior teeth. A Hyrax-type expander
was generally used if the transverse discrepancy exceeded
Materials and methods
5 mm at the level of the first permanent molars and the pos-
Trial design terior teeth did not show palatal inclination. Otherwise, if the
The present longitudinal prospective controlled clinical trial transverse discrepancy was up to 5 mm, and if palatal inclin-
was approved by the local research ethics board (protocol ation of the posterior teeth was identified, a quadhelix appli-
number 2020-01227) and carried out in accordance with the ance was favoured.
Declaration of Helsinki and the principles of Good Clinical The Hyrax-type expander was activated one quarter turn
Practice. The reporting of the present study was based on the per day (0.25 mm) and the quadhelix expander was activated
STROBE guidelines [21]. Two groups made up the sample, one-molar width at every appointment until the palatal cusps
namely a treatment group of children with functional uni- of the maxillary first molars contacted the buccal cusps of
lateral posterior crossbite, and an untreated control group the mandibular first molars. Hence, all patients were pre-
without transverse malocclusions. The included children were scribed over-expansion and reached the same endpoint in the
examined at three-time points in the context of the study, transverse dimension. All expanders were maintained for 9
namely prior to treatment (T0), 9 months after transversal months following expansion, for retention. Following expan-
expansion (T1), and 2.5 years following expansion (T2). The sion, no further orthodontic treatment was to be carried out
children in the control group were examined at the same time until the end of the experimental period (2.5 years following
points but in the absence of any treatment. expansion).
The control group was to undergo no intervention (treat-
Participants, eligibility, and settings ment) during the duration of the study.
All patients were recruited from the Division of Orthodontics
of the University Clinics of Dental Medicine, University of Masseter muscle thickness measurements
Geneva, Switzerland between September 2020 and October The thickness of the masseter muscles was measured bilat-
2021. Patients and their parents were informed of the pro- erally, as described by Kiliaridis and Kälebo [9], at the three
cedures they would undergo during the clinical trial prior time points: pre-treatment (T0); 9 months after transversal
to signing an informed consent. The sample desired was 40 expansion (T1); and 2.5 years following expansion (T2). The
consecutive patients prospectively treated or followed at the control group underwent the same masseter muscle thickness
aforementioned institution, who were divided into 2 equal measurements at the same time points but in the absence of
groups of 20 patients, 1 treatment and 1 control group. any treatment. All of the measurements were undertaken by
The following eligibility criteria were used for the treat- the same operator, who had been calibrated to the senior au-
ment group: growing patients aged between 8 and 11 years thor, using an ultrasonography scanner (Sonosite M-Turbo
old, in the mixed dentition, assessed for an orthodontic Ultrasound System) with a HFL50 × 15-6 MHz linear array
Masseter muscle thickness before and after the correction of unilateral functional posterior crossbite 3

transducer. The participants were seated in an upright position treat analysis was planned in the case of dropouts. The sig-
with their heads in a natural position. To avoid tissue compres- nificance level was set at P < .05. With regard to differences
sion, a generous amount of gel was used under the probe. The in the three time points (T0, T1, T2) for each side within each
transducer was oriented perpendicularly to the ramus, scan- group, ANOVA tests were used, followed by post hoc Tukey
ning the masseter obliquely in order to measure the maximum HSD tests. Statistical tests were carried out using SPSS (ver-
thickness of the muscle. In order to achieve this, the angle of sion 29.0; IBM, Chicago, USA).
the transducer was altered until the best echo of the man-
dibular ramus was achieved. The site of measurement was at Error of the measurement
the thickest part of the masseter muscle close to the level of the The error of the measurement in the ultrasonographic thick-
occlusal plane, halfway between the zygomatic arch and gonial ness of the masseter muscles was calculated by means of the
angle, approximately in the middle of the mediolateral distance two measurements of 20 repeat recordings of imaging and
of the ramus (Fig. 1). The imaging and the measurements of measurements of the thickness of this muscle using Dahlberg’s
the masseter were performed bilaterally, under contracted con- formula [22] to assess random error and paired-sample t-tests
ditions, by asking the participants to clench maximally in the to assess systematic error [23]. Results showed that no signifi-
intercuspal position. The imaging and the measurements were cant systematic error was found, and the random error was
performed twice and extracted directly from the image at the found to not exceed 0.3 mm.
time of scanning. The final muscle thickness recorded was Moreover, intra- and inter-rater reliability tests were car-
obtained from the mean of the two measurements. ried out using intraclass correlation coefficients (ICC) based
on 20 recordings. The intra-rater reliability was found to be
Sample size calculation excellent, ICC = 0.969 (95% CI = 0.931; 0.986), while the
A sample size calculation was performed, for the changes inter-rater reliability (with the two raters being the principal
in masseter muscle thickness on the crossbite side, using an operator and the senior author) was found to be very good,
alpha significance level of 0.01 and a beta of 99% for a two- ICC = 0.839 (95% CI = 0.589; 0.936).
sided t-test. Based on previous data [19], considering that
masseter muscle thickness on the crossbite side before treat-
ment was found to be 11.7 ± 1.6 mm and after treatment Results
was found to be 14 ± 1.6 mm, a minimum of 17 patients in The total sample (Fig. 2) consisted of 40 patients, 28 fe-
both groups were required to reveal statistically significant males and 22 males. The treatment group was made up of
differences. In order to account for any possible dropouts, 20 20 growing individuals (10 male and 10 female) with uni-
eligible patients in each group were planned to be included in lateral functional posterior crossbite, with a mean initial
the present study. age of 8.9 ± 0.8 years, while the control group consisted of
20 growing patients (12 male and 8 female) without trans-
Statistical methods versal malocclusions, with a mean initial age of 9.6 ± 0.9
Normality of the data distribution was first evaluated by years. In the treatment group, 10 patients were treated with a
visual inspection with histograms followed by the Shapiro– quadhelix appliance (duration of appliance activation = 75 ±
Wilk test evaluating the null hypothesis that the data were 16 days) while 10 patients were treated with a Hyrax-type ap-
normally distributed. Visual inspection and the Shapiro–Wilk pliance (duration of appliance activation = 28 ± 13 days). All
test (P > .05) confirmed that the data were normally distrib- treatments resulted in successful correction of the crossbite
uted and parametric tests were thus used. Paired t-tests were and elimination of the mandibular functional shift. The treat-
used to evaluate possible differences in the thickness of the ment results remained stable throughout the study period.
masseter muscle between the crossbite side and the normal Although the control group was intended to be an un-
side in the treatment group. The same tests were used to treated control group, two of the included patients went on
evaluate possible differences in the thickness of the left and to begin removable orthodontic first-phase treatment in this
right masseter muscles in the control group. An intention to group. One patient received a maxillary plate with spurs to
resolve a night-time thumb-sucking habit, and one received a
maxillary plate with an anterior bite block to reduce a poten-
tially traumatic deepbite.
All patients in whom eligibility for the present trial was
confirmed accepted to take part in the study. Two patients
were however lost to follow-up in the treatment group (one
due to relocation and one for medical reasons) while one pa-
tient was lost to follow-up in the control group (due to re-
location). The two patients in the control group that began
treatment, did so towards the end of the follow-up just prior
to T2 and data from these children were thus included. All
initially included patients were analysed using an intention-
to-treat analysis.
Bilateral asymmetry in masseter muscle thickness was
found in the treatment group at T0. It was found that the
Figure 1. Ultrasound image of the masseter muscle showing the
thickness of the masseter muscles on the crossbite side was
measured thickness of the muscle (vertical line), with the upper line significantly thinner than on the contralateral normal side
demarcating the subcutaneous fascia and the lower line demarcating the (P = .013), with masseter thickness on the crossbite side being
mandibular ramus. 9.3 ± 0.14 mm and on the contralateral normal side being
4 Beltrami et al.

Regarding intragroup comparisons between time intervals

in the patients without crossbite, ANOVA results showed that
there were significant differences in masseter muscle thick-
ness on both left (df = 2; F = 7.28; P < .001) and right sides
(df = 2; F = 3.70; P = .028) depending on time. Post hoc tests
revealed differences only between T0 and T2 on the left
(mean increase 0.122 mm; 95% CI = 0.045, 0.198; P < .001),
and right (mean increase 0.087 mm; 95% CI = 0.011, 0.163;
P = .021) sides.
Concerning changes in masseter muscle thickness differ-
ences between the crossbite and contralateral normal side in
the treatment group, these were significantly different from
T0 to T1 (P = .002) and T0 to T2 (P = .004) but not from
T1 to T2 (Table 2). No significant different changes between
time points were found in the control group with regard to
side differences.

Discussion
The results of the present longitudinal prospective controlled
clinical trial suggest that the thickness of the masseter muscle
in growing individuals with functional unilateral posterior
crossbite, although asymmetric prior to crossbite correc-
tion, shows no difference between the two sides some years
after successful treatment of the crossbite. Interestingly, how-
ever, there was a difference at T1 with the former crossbite
side being thicker, perhaps due to the fact that the muscular
re-adaptation had not yet entirely taken place. At T2, no more
differences were found between the former crossbite and the
normal sides.
Our findings agree with those of previous studies. Kiliaridis
et al. [19] found in their cross-sectional study, that masseter
muscles in untreated individuals with unilateral posterior
crossbite are thinner on the crossbite side than on the non-
crossbite side and such an asymmetry in the thickness of the
masseter muscle could not be detected some years after the
Figure 2. Flow diagram for the identification and selection of studies.
successful correction of the crossbite. A possible explanation
for the restoration of muscular symmetry after unilateral func-
9.8 ± 0.13 mm (Table 1). No statistically significant differ- tional posterior crossbite correction may lie in the reason why
ence was found in the thickness of the masseter muscles be- the muscular asymmetry is present in the first place. The differ-
tween the left (9.7 ± 0.15 mm) and the right (9.6 ± 0.15 mm) ence in thickness of the masticatory muscles before treatment
sides in the control group (P = .794). may be related to the mandibular functional shift towards the
At T1, a statistically significant difference was found for crossbite side to avoid cuspal interference, leading to asym-
the thickness of the masseter muscle between the former metric muscular activity. The prolonged asymmetric masti-
crossbite side (10.3 ± 0.12 mm) and the contralateral normal catory muscle activity may work as an asymmetric training
side (10.1 ± 0.11 mm) in the treatment group (P = .046), stimulation resulting in differences in thickness. When the
but not between the left (10.1 ± 0.16 mm) and the right posterior crossbite is corrected, however, the functional man-
(10.3 ± 0.17 mm) sides in the control group (P = .210) dibular shift and any possible asymmetric muscle activity are
(Table 1). At T2 no significant difference was found in both eliminated, which may restore muscular anatomic symmetry as
groups, both in the treatment group (10.8 ± 0.12 mm vs. expressed by its thickness in the present study.
10.7 ± 0.12 mm in the former crossbite side and contralateral Unilateral posterior crossbite with mandibular shift has
sides respectively; P = .097) and the control group (Table 1). been associated with asymmetric facial growth of the hard
Regarding intragroup comparisons between time intervals tissues, and muscular dysfunction seen through the difference
in the patients with crossbite, ANOVA results showed that between the activity of the temporalis and masseter muscles
there were significant differences in masseter muscle thick- on the crossbite and non-crossbite sides, and a significantly
ness on the crossbite side depending on time (df = 2; F = 7.79; smaller bite force in individuals with crossbite in the mixed
P < .001). Post hoc tests revealed differences between T0 dentition [24]. The successful treatment of a unilateral pos-
and T1 (mean increase 0.101 mm; 95% CI = 0.006, 0.195; terior crossbite therefore seems to have a positive effect in
P = .034), T0 and T2 (mean increase 0.151 mm; 95% CI eliminating muscular thickness asymmetries. These changes
= 0.056, 0.245; P = .034) but not T1 and T2. Intragroup com- may be related to the symmetrization of the bilateral activity
parisons between time intervals, using ANOVA for masseter of the masticatory muscles. The recordings of the thickness
muscle thickness on the non-crossbite side did not show sig- of the masseter muscles in the treated crossbite group some
nificant results. time following treatment resembled those in the non-crossbite
Table 1. Comparison of masticatory muscle thickness between the crossbite side and the contralateral side in the treatment group, and the left and right sides in the control group.

Time point Masseter muscle thickness

Crossbite side (treatment) Contralateral side (treatment) Difference Paired t-test

Mean (mm) SD (mm) Mean (mm) SD (mm) Mean (mm) SD (mm) 95% CI lower 95% CI upper

T0 9.34 0.14 9.82 0.13 –0.48 0.79 –0.85 –0.11 P = .013

T1 10.34 0.12 10.07 0.11 0.28 0.58 0.01 0.54 P = .046
T2 10.84 0.12 10.7 0.12 0.15 0.37 –0.03 0.32 P = .097

Right side (control) Left side (control) Difference Paired t-test

Mean (mm) SD (mm) Mean (mm) SD (mm) Mean (mm) SD (mm) 95% CI lower 95% CI upper

T0 9.63 0.15 9.67 0.15 –0.04 0.67 –0.36 0.28 P = .794

T1 10.12 0.16 10.27 0.17 –0.15 0.5 –0.38 0.09 P = .210
T2 10.56 0.17 10.53 0.17 0.03 0.39 –0.16 0.21 P = .775

Regarding differences, positive values in the crossbite group indicate greater muscle thickness on the crossbite side, whereas negative values indicate smaller muscle thickness on the crossbite side. For the control
group, positive values indicate greater muscle thickness on the right side, whereas negative values indicate smaller muscle thickness on the right side.

Table 2. Comparison of masticatory muscle thickness changes between time points, between the crossbite side and the contralateral side in the treatment group, and the left and right sides in the control
group.

Time point Masseter muscle thickness

Crossbite side (treatment) Contralateral side (treatment) Difference Paired t-test

Mean (mm) SD (mm) Mean (mm) SD (mm) Mean (mm) SD (mm) 95% CI lower 95% CI upper

T1–T0 1.01 0.12 0.25 0.08 0.76 0.91 0.33 1.19 P = .002
T2–T1 0.5 0.06 0.63 0.07 –0.13 0.5 –0.36 0.1 P = .255
T2–T0 1.51 0.13 0.88 0.08 0.63 0.86 0.23 1.03 P = .004
Masseter muscle thickness before and after the correction of unilateral functional posterior crossbite

Right side (control) Left side (control) Difference Paired t-test

Mean (mm) SD (mm) Mean (mm) SD (mm) Mean (mm) SD (mm) 95% CI lower 95% CI upper

T1–T0 0.5 0.06 0.6 0.08 –0.11 0.66 –0.41 0.2 P.486
T2–T1 0.44 0.08 0.27 0.05 0.17 0.53 –0.08 0.42 P.169
T2–T0 0.93 0.07 0.86 0.07 0.07 0.57 –0.2 0.33 P.617

Regarding differences, positive values in the crossbite group indicate greater change over time in muscle thickness on the crossbite side, whereas negative values indicate smaller change over time in muscle thickness
on the crossbite side. For the control group, positive values indicate greater change over time in muscle thickness on the right side, whereas negative values indicate smaller change over time in muscle thickness on
the right side.
5
6 Beltrami et al.

group, suggesting a normalization of muscle activity and use of ultrasonographic masseter muscle thickness measure-
function. Ultrasound assessment, however, does not directly ments is however an often-used an accepted method in the
allow one to determine whether a functional reorganization literature.
occurs, resulting in an achieved symmetry between the right
and left masseter muscles after treatment. Only other assess-
ments, such as electromyographic recordings, would allow Conclusions
muscle activity to be properly assessed in this context. The results of the present study found that:
In fact, previous studies have shown that following the
correction of a unilateral posterior crossbite with functional • Masseter muscles in untreated individuals with functional
shift, favourable changes are induced in the neuromuscular unilateral posterior crossbite associated with functional
control of chewing in these patients, with a resulting normal- mandibular shift, measured in maximal intercuspation,
ization [25]. Crossbite elimination induces a significant reduc- are thinner on the crossbite side than on the contralateral
tion in reverse chewing cycles, and masseter muscle activity normal side.
becomes more symmetrical, with both the kinematic and the • However, more than 2 years after the successful correc-
muscular activity outcomes resembling a control group. The tion of the functional unilateral posterior crossbite, the
amount of time that it may take for the muscles to re-adapt muscular asymmetry seems to disappear, possibly due to
and for the muscular anatomic characteristics to achieve sym- the elimination of the functional mandibular shift and
metry is important, but the exact time frame is not known. asymmetric bilateral activity of the masticatory muscles.
Cross-sectional studies that have been carried out to date
on this subject put forward valuable results and hypotheses,
with the results of such studies paving the way for longitu-
Conflict of interest
dinal prospective clinical trials such as the present one which The authors declare no conflicts of interest.
are imperative in being able to confirm a hypothesis. The pro-
spective design was the principal strength of the present trial.
Funding
Measurements were taken twice ensuring that measurement
errors could be evaluated, and these were judged to be small None declared.
and clinically irrelevant. A limitation of the present study may
be the lack of therapeutic homogeneity, in that half of the pa-
Data availability
tients were treated with a quadhelix while the other half with
a Hyrax-type expander. Nevertheless, the choice of appliance The datasets used and/or analysed for the current study will
provided that a unilateral functional posterior crossbite is cor- be made available from the corresponding author upon rea-
rected and the functional shift eliminated, may not play such sonable request.
an important role since it is the effect of the appliance that is
important and not the appliance in itself. Furthermore, the
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