Effectiveness of adjunctive interventions in patients undergoing rapid maxillary expansion: An umbrella review

Abstract

Background

Rapid maxillary expansion is widely used to correct transverse maxillary deficiency; however, its biological limitations have led to the use of adjunctive interventions, with inconsistent evidence regarding their effectiveness.

Objective

This umbrella review aimed to evaluate the effectiveness of adjunctive interventions, including low-level laser therapy, platelet-rich plasma, and erbium-doped yttrium aluminum garnet laser-assisted osteoperforations, in patients undergoing rapid maxillary expansion and identify the best available evidence among conflicting systematic reviews.

Methods

Only systematic reviews and/or meta-analyses were included, while primary clinical studies (randomized controlled trials and non-randomized controlled trials) were excluded. The methodological quality of each review was evaluated utilizing the A Measurement Tool to Assess Systematic Reviews-2. The Jadad decision algorithm was employed to determine the best available evidence among the conflicting reviews.

Results

Five systematic reviews met the inclusion criteria. Low-level laser therapy demonstrated a significant improvement in osteodensity after 2 months; however, no significant differences were observed at 1 and 3 months. Evidence regarding osteoperforations and platelet-rich plasma remained limited and inconclusive.

Conclusion

Based on the currently available data, low-level laser therapy offers limited benefits for transverse maxillary expansion, with minimal effects on bone consolidation appearing after 3 months. The effectiveness of osteoperforations with rapid maxillary expansion is uncertain, and evidence for platelet-rich plasma as an adjunct therapy is lacking.

Keywords

Rapid maxillary expansion systematic reviews low-level laser therapy

Introduction

Maxillary constriction is a frequently encountered orthodontic issue that must be urgently addressed to correct multiple types of malocclusion.^1,2 This condition typically occurs due to insufficient development of the maxilla in the transverse direction.³ Several dilemmas can arise from transverse maxillary constriction, including occlusal disharmony, esthetic concerns, and impeded jaw growth.⁴ Furthermore, maxillary constriction is associated with nasal airway resistance, mouth breathing, and obstructive sleep apnea.⁵ Skeletal maxillary expansion is the most commonly employed technique to enhance transverse dimensions of the maxilla.^6,7 Based on the magnitude of the applied force, the frequency of the activations, and patient age, three different protocols of maxillary expansion can be considered: rapid maxillary expansion, semi-rapid maxillary expansion, and slow maxillary expansion.^8,9

Rapid maxillary expansion (RME) has been extensively used as a typical and reliable orthopedic and orthodontic procedure for correcting transverse maxillary deformities.^10–12 By applying intermittent and strong forces over a short span of time, RME appliances stimulate the opening of the midpalatal suture (MPS) and increase the dimensions of the maxillary and nasal cavities. Along with the desired effect of MPS splitting, RME is unavoidably associated with complications such as perceived pain, posterior teeth tipping,^6,13,14 decrease in buccal bone thickness and marginal bone level,^15,16 soft tissue swelling,¹⁷ and gingival recession.¹⁸ Moreover, rapid relapse is a commonly encountered obstacle observed after RME due to inadequate osseous regeneration in the MPS,^18,19 requiring a long period of orthodontic retention for stabilization ranging from 3 to 4 months in conventional transverse maxillary expansion. Accelerating bone regeneration and promoting healing in the MPS region after expansion are crucial factors for achieving successful treatment outcomes, which can significantly reduce the relapse rate, shorten the retention period, and improve patient adherence.²⁰

Numerous studies have been conducted on the effectiveness of various adjunctive interventions in patients undergoing RME focused on enhancing tissue response by inducing stem cell activity and biological substrate, including laser therapy; photobiomodulation; injection of growth factors, hormones, and proteins.^19,21–25

Recently, there has been a considerable rise in the number of systematic reviews concerning this topic. However, owing to the expansive nature of the subject, decision-makers often feel overwhelmed by the numerous reviews that draw conflicting conclusions. Consequently, it is sensible to conduct a systematic review of these reviews, referred to as an umbrella review. This approach aims to summarize the evidence and clarify the varying findings presented in different reviews.

Materials and methods

Protocol and registration

Protocol registration with PROSPERO was not conducted during the initial stages owing to the nature of this umbrella review. This systematic review was developed in accordance with the Cochrane Handbook for Systematic Reviews of Interventions, 2nd edition, and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.²⁶

Eligibility criteria

The eligibility criteria were defined according to the PICOS (Population, Intervention, Comparison, Outcomes, and Study design) statement as follows:

(P) Participants

Patients of any age without restriction of ethnicity or sex who underwent RME.

(I) Intervention

Application of any kind of adjunctive interventions with RME treatment.

Control group of patients without the application of adjunctive interventions.

(O) Outcome measures

The effectiveness of the interventions was evaluated by measuring the stimulation of bone regeneration and healing.

(S) Study design

Only systematic reviews, with or without meta-analysis, were considered for inclusion. The design of the primary studies of the eligible systematic reviews was prospective randomized controlled trials (RCTs).

Exclusion criteria

The exclusion criteria were as follows: (a) narrative literature reviews and (b) primary studies including case reports or case series, retrospective studies, finite element analysis studies, editorials, and non-clinical studies. Moreover, studies concerning patients with cleft lip and palate or craniofacial syndromes as well as primary clinical studies, including RCTs and non-randomized clinical trials, were excluded.

Search strategy

An extensive electronic search was performed independently from inception up to February 2025 across five databases. No language or publication date limitations were applied. Bibliographies of the included and relevant systematic reviews were checked for further probable reviews. Supplementary Table 1 illustrates further details of the electronic search strategy.

Study selection and data extraction

Three reviewers were involved in the study selection process (A.M.A., A.S.B., and F.R.N.). The selection process was initiated by removing duplicate studies. Studies were subsequently screened by titles and/or abstracts. Finally, the full-text of all remaining papers was assessed using the predefined eligibility criteria. Studies that did not meet one or more of the inclusion criteria were eliminated. The two reviewers’ level of agreement was analyzed using Cohen’s kappa statistics. Discrepancies were resolved through discussions with a third author (F.R.N.). Details regarding the author, year, sample size, participants, age, groups, outcome assessment, results, and inferences were extracted from the selected articles and organized into customized tables. Data extraction was separately achieved by two researchers (A.M.A. and A.S.B.), and any disagreements were resolved by discussion with the help of a third author to reach the final decision.

Quality assessment of the included reviews

The methodological quality of the included reviews was assessed by two independent reviewers (A.M.A. and A.S.B.) using A Measurement Tool to Assess Systematic Reviews (AMSTAR-2) guidelines.²⁷ The two reviewers’ level of agreement was analyzed using Cohen’s kappa statistics. Any conflict was resolved by discussion with a third author. The AMSTAR2 checklist consists of 16 domains that assess the critical steps required for conducting a comprehensive systematic review. The categories for reporting the overall confidence of each systematic review’s results are as follows:

high confidence of the results if there was no or only one non-critical weakness;

moderate confidence if there was more than one noncritical weakness;

low confidence if there was one critical flaw with or without a noncritical weakness;

critically low confidence if there was more than one critical flaw with or without a noncritical weakness.

The online AMSTAR-2 checklist (available at https://amstar.ca/Amstar_Checklist.php) was utilized to rate the overall confidence of the findings presented in the chosen systematic reviews.

Choice of the best body of evidence

The Jadad decision algorithm is a beneficial tool that assists decision makers in choosing the most pertinent and valid reviews in cases of inconsistent information.²⁸ In this review, when an intervention was addressed by multiple systematic reviews with contradictory results, two reviewers (A.M.A. and A.S.B.) independently applied the Jadad decision algorithm to determine the most valuable body of evidence. Any disagreements between the reviewers were resolved by discussion with a third reviewer (F.R.N.) to reach a consensus.

Results

Search results

The full PRISMA flow chart of screening and selection methodology is illustrated in Figure 1.

Figure 1.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram of the included studies.

The primary electronic search of all databases yielded 871 articles. After duplicate removal, all remaining records were checked for eligibility based on their titles and abstracts. Of the 321 articles, 9 were chosen for further assessment through full-text evaluation. Subsequently, five reviews were included in this study. Excluded reviews after full-text evaluation are shown in Supplementary Table 2, along with the reasons for exclusion.

Characteristics of the selected studies

The characteristics of the systematic reviews included in this analysis are presented in Table 1. The five included systematic reviews were published between 2018 and 2023, with one included in a meta-analysis. The studies were geographically diverse, with two conducted in Brazil, two in Iran, and one in Switzerland. The adjunctive interventions addressed in these reviews comprised low-level laser therapy (LLLT), platelet-rich plasma (PRP) therapy, and osteoperforations performed using the erbium-doped yttrium aluminum garnet (Er:YAG) laser along the MPS region. Further details can be found in Table 1.

Table 1.

Characteristics of the included studies.

Study	Design	Search limitations	Date of search	ROB tool	Age of participants (years)	No. of studies	No. of participants	Interventions	Results
Chaves et al., 2023, Brazil²¹	Systematic review and meta-analysis	No restriction of language, year	July 2021	ROB2	8 to 25	5 RCTs	127	LLLT	-Stimulation of suture opening and bone healing at MPS
Davoudi et al., 2018, Iran²²	Systematic review	No restriction of language, year	May 2017	Modified Jadad score calculation for critical appraisal	6 to 33	4 RCTs	110	LLLT	-Stimulation of suture opening and bone healing at MPS
Farzan et al., 2022, Iran¹⁹	Systematic review	No restriction of language, year	March 2021	ROB1	8.4 to 11	4 RCTs	85	LLLT	-Stimulation of suture opening and bone healing at MPS.
Santana and Marques, 2021, Brazil²⁴	Systematic review	There was no restriction of language, year, or status of publication for inclusion	June 2020	ROB2	8 to 17	6 RCTs	117	-osteoperforations produced by (Er:YAG) laser-LLLT-platelet-rich plasma (PRP)	-Stimulation of suture opening and bone healing at MPS-Skeletal and dentoalveolar parameters-BBPT, BBCL, and incidence of dehiscence and fenestrations
Skondra et al., 2018, Switzerland²⁵	Systematic review	No restriction of language, year	July 2016	ROB1	6 to 33	4 RCTs	93	LLLT	-Stimulation of suture opening and bone healing at MPS

LLLT: low-level laser therapy; RCT: randomized controlled trial; BBPT: buccal bone plate thickness; BBCL: buccal bone crest level; MPS: midpalatal suture.

Methodological quality of the included reviews

The methodological quality of the reviews demonstrated a range of confidence, from critically low to moderate. This indicates that each review had various methodological limitations. Table 2 provides an overview of the AMSTAR-2 questions along with the associated results for the reviews. Regarding the seven critical domains outlined in the AMSTAR-2 tool, most reviews did not provide a list of excluded studies and justify the exclusions (80% of the included reviews) and did not account for the risk of bias in individual studies when interpreting and discussing the results (60% of the included reviews).

Table 2.

A summary table for methodological quality of the included reviews using the AMSTAR-2 tool.

Domains	Chaves et al., 2023²¹	Davoudi et al., 2018²²	Farzan et al., 2022¹⁹	Santana and Marques, 2021²⁴	Skondra et al., 2018²⁵
1- Did the research questions and inclusion criteria for the review include the components of PICO?	Yes	Yes	Yes	Yes	Yes
2- Did the report of the review contain an explicit statement that the review methods were established prior to conduct of the review and did the report justify any significant deviations from the protocol?	Yes	Yes	Yes	Yes	Yes
3- Did the review authors explain their selection of the study designs for inclusion in the review?	Yes	No	No	No	No
4- Did the review authors use a comprehensive literature search strategy?	Yes	Yes	P yes	Yes	Yes
5- Did the review authors perform study selection in duplicate?	Yes	Yes	Yes	Yes	Yes
6- Did the review authors perform data extraction in duplicate?	Yes	Yes	Yes	Yes	Yes
7- Did the review authors provide a list of excluded studies and justify the exclusions?	No	No	No	Yes	No
8- Did the review authors describe the included studies in adequate detail?	Yes	Yes	Yes	Yes	Yes
9- Did the review authors use a satisfactory technique for assessing the risk of bias (RoB) in individual studies that were included in the review?	Yes	Yes	Yes	Yes	Yes
10- Did the review authors report on the sources of funding for the studies included in the review?	No	No	No	No	Yes
11- If meta-analysis was justified did the review authors use appropriate methods for statistical combination of results?	Yes	–	–	–	–
12- If meta-analysis was performed did the review authors assess the potential impact of RoB in individual studies on the results of the meta-analysis or other evidence synthesis?	Yes	–	–	–	–
13- Did the review authors account for RoB in individual studies when interpreting/ discussing the results of the review?	Yes	No	No	Yes	No
14- Did the review authors provide a satisfactory explanation for, and discussion of, any heterogeneity observed in the results of the review?	Yes	Yes	Yes	Yes	Yes
15- If they performed quantitative synthesis did the review authors carry out an adequate investigation of publication bias (small study bias) and discuss its likely impact on the results of the review?	Yes	–	–	–	–
16- Did the review authors report any potential sources of conflict of interest, including any funding they received for conducting the review?	Yes	Yes	Yes	No	No
Overall quality	L	Cl	CL	M	CL

RCT: randomized clinical trial; P yes: partial yes; M: moderate; L: low; CL: critically low.

Effects of interventions

Effect of LLLT on opening and healing the MPS

Five systematic reviews evaluated the effects of LLLT on the opening and healing of the MPS during RME. These reviews were conducted by Chaves et al. (2023),²¹ Farzan et al. (2022),¹⁹ Santana and Marques (2021),²⁴ Davoudi et al. (2018),²² and Skondra et al. (2018).²⁵ Although all the reviews addressed the same question, the included trials and selection criteria varied among these reviews.

To determine the best available review, the Jadad algorithm was applied, which considers the publication status, methodological quality of the primary studies, language restrictions, and data analysis on individual patients. Based on these criteria, the study by Chaves et al. (2023)²¹ was selected as the best review (Figure 2).

Figure 2.

Flow diagram of the Jadad decision algorithm.

The review by Chaves et al. included five RCTs, three of which were included in the meta-analysis. The meta-analysis of the mean variation in OD values indicated that 3–5 days postoperatively, only the study by Cepera et al.²⁹ evaluated OD during this period, revealing no significant difference between the groups (P = 0.560).

One month postoperatively, no significant difference was observed in the change in OD between the photobiomodulation therapy (PMBT) and control groups (P = 0.330). Additionally, no significant heterogeneity was observed (P = 0.510, I² = 0%, Tau² = 0.00), and the leave-one-out analysis revealed no significant impact after removing individual study results.^29,30

At the 2-month postoperative mark, only Matos et al.³⁰ evaluated the OD, reporting a significant increase in OD for the control group (P < 0.001). After 3 months, no significant difference was found among the studies (P = 0.490). However, significant heterogeneity was noted (P < 0.001, I² = 97%, Tau² = 9.44), and removing data from Matos et al. significantly favored the PBMT group.

In the 4–6 month postoperative evaluation, no significant difference was observed between the studies (P = 0.390); however, significant heterogeneity was noted. The removal of Matos et al.’s data significantly favored the PBMT group.

The overall meta-analysis, which included mean changes in the OD measurements across all periods, consisted of 134 evaluations in the PBMT group and 122 evaluations in the control group, ultimately showing no significant difference between the groups (P = 0.200).

Effect of osteoperforations produced by Er:YAG laser on opening and healing the MPS

This outcome was discussed in a review by Santana and Marques,²⁴ which investigated a study with a high risk of bias. The study focused on the application of an Er:YAG laser to create osteoperforations in the suture region of patients with maxillary atresia undergoing orthopedic RME. The evaluated outcomes included both skeletal and dentoalveolar changes. The intervention group demonstrated a more significant skeletal increase in the lateronasal (+2.19 mm, P < 0.001), maxillomandibular (+3.94 mm, P < 0.001), and maxillary (+2.98 mm, P < 0.001) width compared with the control group at the conclusion of the expansion phase. Following a 3-month retention period, the rate of relapse was found to be similar between the two groups.²⁴

Effect of PRP on the opening and healing of the MPS

The outcome was addressed in a review by Santana and Marques,²⁴ which examined a study with a low risk of bias regarding the effectiveness of PRP injections in periodontal tissue. The study concluded that there were no significant differences (P > 0.05) in vertical bone loss, with mean differences ranging from −0.08 to 0.2 mm, or in buccal bone thickness, where mean differences ranged from −0.15 to 0.85 mm. This comparison was made between anchorage teeth in patients who underwent conventional RME and those who received PRP injections. Furthermore, a higher prevalence of dehiscence (3.5%) was noted in the intervention group across all supporting teeth.

Discussion

To the best of our knowledge, this umbrella review represents the first state-of-the-art appraisal of the efficacy of different adjunctive interventions in enhancing RME. The adjunctive interventions in question were LLLT, PRP therapy, and osteoperforations performed using the Er:YAG laser.

The findings of the present review suggest that the available evidence supporting these adjunctive approaches remains limited and, in some aspects, inconsistent.

Regarding LLLT, the systematic reviews included in the assessment show a lack of reliable evidence supporting its efficacy. All of the reviews specifically highlighted this issue, and the discordant conclusions likely stem from the conflicting results of the primary studies. To identify the best available review, the Jadad algorithm was applied. This algorithm takes into account publication status, methodological quality of the primary studies, language restrictions, and individual patient data analysis. Based on these criteria, the study by Chaves et al. (2023) was selected as the best review.

Among the evaluated interventions, LLLT demonstrated a short-term improvement in OD, particularly after 2 months of follow-up; however, this effect was not maintained over longer observation periods. This finding is consistent with previous studies reporting transient biological effects of LLLT on bone tissue.

The short-term improvement in OD may be attributed to the biostimulatory effects of LLLT, including enhanced osteoblastic proliferation, increased angiogenesis, and stimulation of mitochondrial activity, all of which contribute to early bone formation. However, the lack of sustained effects suggests that these biological responses may be temporary and highly dependent on treatment parameters such as wavelength, energy density, and frequency of application.

Indeed, variability in laser protocols represents a major source of heterogeneity across studies. Differences in irradiation parameters and treatment regimens have been shown to significantly influence the clinical outcomes, which may explain the conflicting findings reported in the literature.

Photobiomodulation has various effects on bone tissue, which depend on several parameters applied to patients. These parameters include the type of laser used, amount of energy irradiated, duration of application, frequency, energy density, power, power density, and wavelength. When applied correctly, these factors can stimulate bone cells and enhance their osteoblastic activity in the affected area.³¹

Currently, numerous emitting devices are available on the market, featuring various parameters. Furthermore, methodological differences in the irradiation protocols, evaluation methods, radiographic standardization, and study analyses complicate the comparisons of results, making it challenging to identify the ideal properties for clinical applications. Recent findings, such as those by Ferreira et al. and Cepera et al.,²⁹ indicate a shift in applied dosimetry, using energy densities of 35 and 10 J/cm², respectively. This contrasts with previous studies by Angeletti et al. and Saito et al., which employed higher energy densities of 126 and 140 J/cm², respectively, in their irradiation protocols.²¹

Additionally, factors such as the type of laser used (low power versus defocused high power) and the type of gas producing the radiation can affect the outcomes and protocols used. The effects of LLLT on bone tissue have been studied across various medical and dental fields, with wavelengths ranging from 660 to 1064 nm.³² However, diode lasers with wavelengths between 780 and 950 nm can penetrate deeper into tissue. Notably, wavelengths in the 904 to 980 nm range have demonstrated positive bio-stimulatory effects on bone regeneration.²¹

Defocused high-power diode laser was not utilized in the study by Matos et al.³⁰; however, previous studies have demonstrated the successful application of a defocused high-power diode laser for healing and stabilizing bone in sites affected by peri-implantitis and periodontitis.³³

It is important to emphasize that PBMT demonstrated a significant benefit over the 6-month evaluation period. However, this finding should be interpreted with caution due to the variability among studies, and further research is needed to increase the sample size. Furthermore, upon excluding the study by Matos et al., the clinical benefit appears even greater, which raises additional concerns about the protocol used in the study.

The energy densities employed in the studies included in this meta-analysis varied from 10 to 140 J/cm².^29,30,34,35 Some research suggests that energy densities as low as 5 J/cm² can already have a stimulating effect on bone tissue.³² This finding contradicts those of other studies indicating that energy densities exceeding 16 J/cm² may be necessary for optimal results.³⁶ Consequently, no standardized energy density requirement exists for effective bone healing. Angeletti et al. reported greater bone density at different postoperative intervals in the PBMT group receiving 140 J/cm², compared with the study by Cepera et al,²⁹ who utilized 10 J/cm² and noted significantly higher bone density in the PBMT group 3 months after RME.

In addition to LLLT, osteoperforations have been proposed as a minimally invasive approach to enhance bone remodeling through the regional acceleratory phenomenon.³⁷ This biological mechanism is characterized by a transient increase in bone turnover and reduced bone density, which may facilitate orthodontic tooth movement and skeletal adaptation. Experimental and clinical studies have demonstrated that micro-osteoperforations can stimulate localized inflammatory responses, increase cytokine activity, and accelerate bone remodeling processes.^37,38

However, despite this strong biological rationale, the clinical evidence supporting the effectiveness of osteoperforations in the context of RME remains inconsistent. Some studies have reported a potential benefit in accelerating bone response and reducing treatment duration, while others have found no significant differences compared with conventional approaches.^39–41 This discrepancy may be attributed to variations in the perforation depth, number of perforations, anatomical site, and patient-related factors.

Moreover, the invasive nature of the procedure, need for repeated interventions, and potential for patient discomfort may limit its widespread clinical applicability. Therefore, although osteoperforations are biologically plausible, current evidence does not provide sufficient support for their routine use as an adjunctive intervention during RME.

Similarly, PRP has been investigated as a potential adjunctive intervention during RME owing to its high concentration of growth factors, which are believed to enhance tissue healing and bone regeneration. PRP is known to release biologically active molecules such as platelet-derived growth factor, transforming growth factor-beta, and vascular endothelial growth factor, all of which play a key role in bone remodeling and angiogenesis.⁴²

Despite this strong biological rationale, the clinical evidence supporting the effectiveness of PRP in the context of RME remains inconsistent. Although some experimental and clinical studies have suggested a potential benefit in enhancing early bone formation and reducing relapse, other studies have reported no significant differences compared to conventional treatment. This inconsistency may be attributed to substantial variability in the PRP preparation protocols, including differences in centrifugation methods, platelet concentration, and activation techniques.⁴³

Furthermore, the timing and mode of PRP application may influence treatment outcomes, adding another layer of variability across studies. Consequently, the current body of evidence does not provide sufficient support for the routine use of PRP as an adjunctive intervention during RME. Further well-designed clinical trials with standardized protocols are required to clarify its potential role and clinical effectiveness.^44,45

Limitations

Similar to all reviews, the current review has both strengths and limitations. This review adhered to the PRISMA checklist, conducted a thorough electronic search, and employed the AMSTAR-2 tool to evaluate the quality of the selected reviews. The objective was to identify the best available evidence from various reviews that examined different methods of RME enhancement. However, the review-of-reviews approach depends on “second-hand” information, which can expose it to the interpretive biases of prior reviewers. To mitigate this issue, an objective method—Jadad decision algorithm—was used to identify the most reliable evidence. It is important to note that the quality of the included reviews varied widely, ranging from critically low to moderate. In some cases, conclusions were drawn from reviews of critically low quality.

Conclusions

Based on the currently available information and the criteria established by the Jadad decision algorithm, photobiomodulation (LLLT) provides limited clinical benefits as an adjunctive therapy for patients undergoing transverse maxillary expansion. Its impact on bone consolidation in the MPS region is minimal, becoming evident only after 3 months. Additionally, it is recommended to avoid the use of longer wavelengths and high energy densities to achieve optimal clinical outcomes. There is very low certainty regarding the effectiveness of osteoperforations along the MPS in producing transverse skeletal increases in the maxilla when associated with RME. Lastly, reliable evidence supporting the use of PRP as an adjunctive therapy for RME remains lacking.

Supplemental Material

sj-pdf-1-imr-10.1177_03000605261448026 - Supplemental material for Effectiveness of adjunctive interventions in patients undergoing rapid maxillary expansion: An umbrella review

Supplemental material, sj-pdf-1-imr-10.1177_03000605261448026 for Effectiveness of adjunctive interventions in patients undergoing rapid maxillary expansion: An umbrella review by Ahmad Marwan Alhamwi, Ahmad S Burhan and Fehmieh R Nawaya in Journal of International Medical Research

Supplemental Material

sj-pdf-2-imr-10.1177_03000605261448026 - Supplemental material for Effectiveness of adjunctive interventions in patients undergoing rapid maxillary expansion: An umbrella review

Supplemental material, sj-pdf-2-imr-10.1177_03000605261448026 for Effectiveness of adjunctive interventions in patients undergoing rapid maxillary expansion: An umbrella review by Ahmad Marwan Alhamwi, Ahmad S Burhan and Fehmieh R Nawaya in Journal of International Medical Research

Footnotes

Declaration of conflicting interests

The authors declare that they have no conflict of interest.

Ethics approval

Ethical approval was not required for this systematic review as it was not applicable.

Funding

This study was funded by Damascus University (Grant No. 501100020595).

Informed consent

For this type of study, formal informed consent is not required.

Supplemental material

Supplemental material for this article is available online.

ORCID iDs

Ahmad Marwan Alhamwi

Ahmad S Burhan

Fehmieh R Nawaya

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