RAPID MAXILLARY

EXPANSION IN ORTHODONTICS

PRESENTED BY

Dr. Farah Mehjabeen

PG II Year
 CONTENTS

Introduction
Historical background
Anatomy
Etiology
Indication & contra indication of R.M.E
Screw used in R.M.E
Jack screw schedules
How much to expand
RME in primary and early mixed dentition; and late mixed dentition
S.A.M.E (surgically assissted maxillary expansion)
Effect of R.M.E on the maxillary and mandibular complex
Effect of age & R.M.E
Hazards of R.M.E
Retention and relapse tendencies
Conclusion
Bibliography

INTRODUCTION

Growth ceases first in the transverse dimension. The constricted maxilla dentally or skeletally
always poses a problem for an orthodontist . So diagnosing and treating this problem first is
an integral part in orthodontics .

Maxillary expansion treatments have been used for more than a century to correct maxillary
transverse deficiency. Three expansion treatment modalities include Slow Maxillary
Expansion (SME),Rapid maxillary expansion(RME) and Surgically assisted Maxillary
Expansion.

The maxilla and upper teeth positions are governed by the musculature surrounding them, in
patients showing constricted maxillary arch it is mandatory to deal with by applying an
orthopedic forces across the maxilla to expand it.

Orthopedic expansion is produced by applying a lateral force against the posterior maxillary
dentition, producing a seperation of the midpalatal suture.

Expansion of the maxillary arch to correct transverse skeletal and dental discrepancies and to
reduce intra-arch crowding is an accepted method of treatment that was first outlined by
Angel in 1860 and popularized by Haas 100 years later(in late 1970s).
Rapid maxillary expansion History

In 1860, E.C. ANGELL placed a screw appliance between the maxillary premolars of a girl
aged 14 ½ years and widened her arch one quarter inch in two weeks. He is considered the
father of rapid maxillary expansion.

Rapid maxillary expansion History

FARRAR (1888) AND CLARK C. GODARD (1893) also discussed the feasibility of
lateral expansion with mid palatal suture opening.
WRIGHT in 1912 reported a 6.5 mm widening of nasal cavity with rapid maxillary
expansion.
In late 1940’s GRABER advocated RME for the treatment of cleft lip and palate
patients
During early 1970’s, Hass started using rapid maxillary expansion extensively.
HAAS (1980) evaluated the stability of maxillary expansion achieved with rapid
palatal expansion.

Mid palatal suture

LATHAM (1971) believed that growth at the midpalatal suture ceases at the age of 3 years.

By means of implants, BJÖRK AND SKIELLER (1974) found that growth at the suture
might be occurring as late as 13 years of age.

PERSSON AND THILANDER (1977) in a study on cadavers found that 5% of the suture
was obliterated by age 25 years, yet the variation was such that a 15-year-old cadaver had an
ossified suture, while a 27-year-old cadaver had an unossified suture.

EPKER AND WOLFORD (1980) stated that in patients over the age of 16 years, attempted
orthopedic rapid maxillary expansion is frequently associated with significant difficulties due
to fusion of various craniofacial sutures. Most important effect is produced by zygomatic
buttress which resist lateral movements of two maxillae.

Midpalatal suture is formed by the junction of the three opposing pairs of bones namely
premaxillae, maxillae and the palatines
ANATOMY

The morphology of the mid palatal suture has been studied by MELSEN (1975).

First stage :

Covering the infantile period. The suture is very broad and Y shaped.

And binds vomer with palatine process

Second stage :

Juvenile period, the suture is found to be more wavy.

(T shape with interpalatal section serpentine course)

Third stage :

Adolescent period, the suture is characterized by a more tortuous course with increasing inter
digitations
Etiology:
Bishara and Staley AJODO 1987

Buccolingual discrepancies could be either genetic or environmental.

Graber, Harvold, Cheirici, stated that many constricted maxillary dental arches are the
result of abnormal function.

All patients considered for RME should be examined for nasal obstruction and, if obstruction
is found, they should be referred to an otolaryngologist before orthodontic treatment for
examination and treatment of the problem.

Diagnosis :

The following measurements will help clinicians estimate how much expansion is needed:

Measure the distance between the most gingival extension of the buccal grooves on the
mandibular first molars or, when the grooves have no distinct terminus on the buccal surface,
between points on the grooves located at the middle of the buccal surfaces

measure the distance between the tips of the mesiobuccal cusps of the maxillary first molars

subtract the mandibular measurement from the maxillary measurement. The average
differences in persons with normal occlusion are +1.6 mm for males and +1.2 mm for
females.

The discrepancy between the maxillary and mandibular measurements is a good estimate of
how far the maxillary molars must be expanded. One should overexpand the molars 2 to 4
mm beyond the required distance to allow for the expected postfixation relapse. The
expansion screw should provide, at least, this calculated amount of expansion.

Radiographic Analysis for RME

The evidence from a well aligned, high contrast posteroanterior cephalogram can help the
clinician in determining a patients suitability for RME. The most useful areas to examine are:

(i) The nasal air passages.

(ii) The lateral maxillomandibular relationship.

(i) The proportions of the nasal airway can be calculated with the nasal index.

= greatest width of piriform aperture × 100

height of nasal skeleton (N-ANS)

When nasal index is less than 47, it is considered narrow or leptorrhine

they are not a very good guide to nasal resistance ab’coz they depends on the shape and
contents of the nasal airway, in both hard and soft tissues.
Abnormalities of the turbinates and septa, as well as the walls and floor, reduce the lumen of
the airway.

lncreases in the thickness of the mucous membranes also increase the nasal resistance

The lateral maxillomandibular relationship can be derived from a posteroanterior

cephalogram.

To figure the physical space available for RME, measure the distance between the vertical
planes through the coronoid process and the most buccal aspect of the molars on each side.

INDICATION OF R.M.E
(JCO 1968 Apr ;DR. JAMES)

1. In subjects, demonstrating severe maxillary constriction:

RME is an appliance of choice for expansion of maxillary halves when maxillary

bases are constricted.

2. Patients who have lateral discrepancies that result in either unilateral or bilateral
posterior cross bites involving several teeth are candidates for RME.

3. Patients with Class III malocclusions-

Patients with borderline skeletal class III are candidates if they have maxillary
constriction or posterior crossbite.

4. Cleft lip and palate patients with collapsed maxillae are also RME candidates.

5. To gain arch length in patients who have moderate maxillary crowding.

6. Narrowness of the maxillary arch and nasal stenosis.

7. According to Bell, the enhanced skeletal response that accompanies RME redirects
the developing posterior teeth into normal occlusion and corrects asymmetries of
condylar position.

8. RME causes a relative reduction in the nasal airway resistance by disarticulating the
maxilla from other bone particularly Septal and palatine bone.

CONTRA INDICATIONS FOR RME

(AJO-DO 1987) BISHARA AND STANLEY

1. Patients who have single tooth in cross bite do not need RME.

2. Patients who have anterior open bite.

3. Patients with steep mandibular plane

 4. Patients who have skeletal asymmetry of the maxilla or mandible.

5. Patients with severe anteroposteior and vertical skeletal discrepancies are not good
candidates for RME.

Expansion screws:

SCREWS

Hyrax expansion screw:

For mid palatal suture separation by means of fixed appliance without the need for acrylic
plate. Metal frame work used in combination with preformed band which are soldered to the
retention arm.

Trapezoidal expansion screw:

This skeleton type is used mainly for narrow palates.

This tiny screw with trapezoidal design is for 5mm expansion.

Width- 11 mm / 14.5 mm

Fan type expansion screw: (12mm)

For sectional expansion of maxillary anteriors. Plate sections are opened up fan wise.

It is designed as to stretch the arms angularly apart by progressive actions to be exerted on

the same screw.
Telescopic or spring loaded screws:

Telescopic stainless steel expansion screw with rectangular guide pin for lateral expansion.

Telescopic expansion screw are available in minimum – medium and maximum size.

Conventional devices used for surgically assisted rapid palatal expansion and are tooth-borne
applainces.

Activated by : turning a nut to compress the coil

Two stage expansion screw :

Widening of the maxillary arch by palatal expansion technique often needed, two different
expansion screw appliance –

An initial one, small enough to fit in an extremely narrow arch and produce preliminary
expansion

A subsequent larger appliance with which to achieve desired arch width

Timms

1. Up to 15 yrs: 90° rotation once in the morning & once in the evening.

2. 15-20 yrs : 45° activation 4 times a day.

JACKSCREW TURN SCHEDULES

Zimmring and Isaacson (1965) recommend the following turn schedules:

Young growing patients two turns each day for the first 4 to 5 days, one turn each day for the
remainder of RME treatment:

Adult (non growing) patient – because of increased skeletal resistance, two turns each day for
the first 2 days, one turn each day for the next 5 to 7 days, and one turn every other day for
the remainder of RME treatment
Types of appliances used:

Fixed appliances

tooth borne

tooth and tissue borne

Tooth and tissue borne appliances include:

1. Haas type

2. Derichsweiler type

Tooth borne appliances include:

1. Isaacson type

2. Hyrax type

HASS TYPE EXPANDER:

AJODO 1970 March

The first type of expansion screw popularized by Haas in 1961.

It consists of bands placed on maxillary 1st premolars and molars.

A midline jackscrew is incorporated into the acrylic pads that closely contact the palatal
mucosa.

0.045inch SS wire soldered to palatal aspect of the bands.

Support wire extend along the buccal and lingual surfaces of the posterior teeth, to add
rigidity to the appliance.

Haas in 1961 stated that more bodily movement and less dental tipping is produced when
acrylic palatal coverage is added to support the appliance, thus pertaining forces to be
generated not only against the teeth but also against the underlying soft and hard palatal
tissues.
DERISCHSWEILER:( 1953)

Tags are welded & soldered to palatal aspect of bands to provide attachment for acrylic
which is extended to palatal aspect of non-bonded teeth.

Hyrax type expander

It is more commonly used type of banded RME appliances, the design of which has been
credited to Biedermann.

This type of expander is made entirely of stainless steel, and does not include palatal acrylic,
hence considered more hygienic by many practitioners.

Bands are placed on maxillary first molars and first premolars

The appliance screw is placed in the palate in close proximity to palatal contour

Buccal and lingual support wires are added for rigidity

Hyrax type expander

One of the concerns of Hyrax appliance is that it may be more flexible than the Haas
appliance producing more dental tipping and less sutural expansion

Ralph (1998) used a finite element analysis to compare the difference between Hyrax and
Haas appliance in affecting midpalatal suture, teeth and attached stuructures
He reported that average tipping effects are 2.5-3 times greater in Hyrax model compared to
Haas model, while the later showed more tooth and sutural displacement

The Hyrax model also showed more deformation and thus decreased energy available on
activation

Oliveria et al AJODO 2004 used a three dimensional assessment to compare the effects of
Haas and Hyrax appliances. They reported that Haas appliance showed a greater component
of true orthopedic movement while Hyrax caused dentoalveolar expansion.

The orthopedic movement caused by Haas appliance was signified by greater gain in
interpalatal width while dentoalveolar expansion caused by Hyrax appliance was revealed by
greater interpalatal angulation after treatment

ISSACSON:
(1971)

This is a tooth borne appliance with out any acrylic palatal covering

Mini expander soldered directly to the bands

Screw reduced in length for narrow arches

Activated by : turning a nut to compress the coil

The Bonded acrylic splint expander

Bonded appliances were designed to cover the maxillary posterior occlusal-buccal segments
so that the appliance not only serves as an expansion device but intrudes on the freeway space
through its vertical thickness

2-3 mm of acrylic is bonded to maxillary posterior teeth so that passive stretch of elevator
and retractor musculature provides an apically directed force to maxilla and mandible (
Ahlgren 1970 and Graber 1977)
The bonded Rapid maxillary expander would increase rigidity by limiting unwanted tipping
and rotation of teeth due to increased surface of acrylic bonded to teeth

Further more tooth supra eruption would be limited because of bonding the entire posterior
arch

Memikoglu and Iseri 1997 investigated the effects of Haas type RME and rigid acrylic
bonded RME appliances

They reported an increase in tipping of upper molars and decrease in overbite in Haas group
compared with Bonded group

Sarver and Johnston AJODO 1989 examined the effect of acrylic spint expander in 20
patients who were on average 11 years of age at the beginning of treatment. Compared to the
findings from a study by Wertz using Haas appliance, the bonded appliance showed a
decrease in inferior displacement of maxilla

Steven Asanza et al 1997 investigated the effects of Hyrax type RME and Bonded expansion
appliance and reported that increase in the vertical dimension often seen with more
conventional Hyrax may be minimized or negated with bonded appliance

RAYMOND P HOW:
(1982)

BONDED APPLIANCE.

Mid palatal Jack Screw

4 rigid 0.060 SS wire loops – bend circumferentially at cervical level to include all posterior
teeth.

Encased by collar of acrylic surrounding wire loops only. Extending from free gingival
margin to occlusal surface.

Advantage :-

Used in deciduous & severely malposed teeth

Reduced food deposition as palatal acrylic removed

JOHN L SPOLYAR:
(1984)

Spider type rigid expansion screws

Tooth borne anchorage

Screw placed anteriorly to prevent interuption to tongue functions

Arms bend inverted U shape for rigidity between mechanical devices & attached medium.

Patrick K Turley
JCO 1988 May

Patrick K Turley (1988):-

Correction of class III malocclusion with palatal expansion and custom protraction head gear

Adv:

bite opens rapidly

Anterior cross bite correction very effective.

Butterfly Expander for Use in the Mixed Dentition (JCO Oct 1999)

RPE have been shown to create undesirable side effects such as dental extrusion and
tipping. A new RPE appliance, called a ―butterfly expander‖, that is used to treat patients in
the mixed dentition was devised.

Appliance Design :

The butterfly expander follows the basic design of Hass,

with a few modifications.

• A high midpalatal jackscrew is attached to a butterfly-shaped stainless steel

framework that extends forward to the palatal surfaces of the deciduous canines.

• The appliance is soldered to bands on the second deciduous molars.

• The rigidity of the appliance and its location high in the palatal vault allow the
transverse force to be delivered closer to the center of resistance of the posterior teeth
than with conventional expander.
 The butterfly design thus minimizes posterior tipping and extrusion.

Activation :

• Activation of the screw with a complete turn (four quarter -turns) immediately after
cementation of the appliance.

• The parents should be instructed to activate the screw a quarter-turn three, times a
day (morning, afternoon, and evening).

• Active expansion takes seven to nine days, depending on the degree of maxillary
constriction.

• Transverse expansion is usually deemed sufficient when the posterior crossbite is

over corrected by 2-3 mm.

• Screw is then blocked, and the appliance is left in place as a passive retainer.

• It allows early treatment of a skeletal problem that commonly manifests itself in the
primary dentition and will not-self-correct. Because the butterfly expander is applied
to the primary molars, it will not cause root resorption of anchored premolars and
permanent molars after RPE.

A Fan-Shaped Maxillary Expander

LUCA LEVRINI JCO NOVEMBER 1999

The expander is made of stainless steel, with the spider screw as the active component.

There are three pivot points:

a posterior one - ―fan‖ opening

two anterior ones - counteract the torquing forces produced during expansion.

Four arms, two mesial and two distal, are welded to the expander and to bands on the teeth.

After adjustments, the active component had been expanded a total of 4.2mm.

Intercanine width increased more than intermolar width

COMPARSION OF TOOTH AND TISSUE BORNE

(Angle Orthod 2005;75:548–557)

This study evaluated rapid maxillary expansion (RME) dentoskeletal effects by means of
computed tomography (CT), comparing tooth tissue–borne and tooth-borne expanders.

RME produced a significant increase in all measured transverse dimensions

Tooth-borne and tooth tissue–borne expanders tended to produce similar orthopedic effects.

COMPARSION OF TOOTH AND TISSUE BORNE

(Angle Orthod 2005;75:548–557)

The expansion led to buccal movement of the maxillary posterior teeth,

by tipping and bodily translation.

The tooth tissue–borne expander produced a greater

change in the axial inclination of supporting teeth, especially

in the first premolars, compared with the tooth-borne expander.

Clinical Management of RME

Fitting the appliance

Cementation of Appliance

Instructions

Pain during RME

How much to expand

Fitting the Appliance

The appliance should slip onto the teeth with sufficient friction to hold it in place lf the fit is
too tight and causes pain:-

1. Check the screw by turning (either way) to ensure that no thrust is being applied
Prematurely.

2. Some metal may be removed from the fitting surface with a bur; conversely if the
appliance is too loose, it can usually be adapted closer to the teeth.

lf the appliance have been overextended this will cause pain and blanching at the gingiva.

If the metal finishes short of the gingiva,check that it is fully seated by probing through the
drainage holes

Incorrect seating may be caused by a high spot on casting and is revealed by rocking.

Cementation of Appliance

Cement with germicidal properties is taken so that it assist in maintaining oral hygiene.mixed
on glass slab

A generous film is applied to the dried internal fitting surfaces of splints. At the same time
the maxillary teeth are dried and isolated cotton wool rolls

The appliance is pressed firmly into position' the excess cement being allowed to escape via
the drainage holes and around the edges.

The cottonwool rolls then may be placed between the splints and the mandibular teeth and the
patient is instructed to bite while the cement sets

Instructions

parent and child know just what to expect especially the appearance of a median diastema
which can be very disconcerting to both patient and parent.
JACKSCREW TURN SCHEDULES

Zimmring and Isaacson (1965) recommend the following turn schedules:

Young growing patients two turns each day for the first 4 to 5 days, one turn each day for the
remainder of RME treatment:

Adult (non growing) patient – because of increased skeletal resistance, two turns each day for
the first 2 days, one turn each day for the next 5 to 7 days, and one turn every other day for
the remainder of RME treatment

Timms

1. Up to 15 yrs: 90° rotation once in the morning & once in the evening.

2. 15-20 yrs : 45° activation 4 times a day.

Pain during RME

The modality of Pain monitor and indication of excessive force build-up that may lead to
possible tissue damage.

The threshold levels of pain vary among individuals, the cause being the force buildup from
resistance to maxillary separation. Two main factors generally are responsible:

1. Rigidity of the facial skeleton'

2. Mechanical interlocking and synostosis of the midPalatal suture'

Persistent pain normally is the product of an unyielding midpalatal suture' because the tension
disperses and the pain disappears as maxillae separate.

Never should the appliance be regularly activated for a period longer than one week against
an unyielding suture in the hope of achieving maxillary separation.

When patient report episodes which indicate excessive force buidup.The following
adjustments to the schedule of rotation may be made:

Reduce the angle of rotation but increase the frequency.

Reduce the rate of expansion,which will stop accumulation of residue.

How Much To Expand

Studies by Kerbs (1964) Stockfisch (1976) and Linder Aronson et al (1979) show that
between one third to one half of the expansion was lost before stability eventually was
reached.

A general and covenient guildeline about how much to expand dictates a stop when the
maxillary palatal cusps are level with the buccal cusps of the mandibular teeth
RME in primary and early mixed dentition:

Less force is needed to open in younger children, it is relatively easy to obtain palatal
expansion.

In early mixed dentition, both the type of appliance produce both skeletal and dental changes

Because of the instability of the teeth during the expansion process, failure to wear the
appliance even for 1 day requires adjustment of the jack screw

Using bonded appliance in the mixed dentition is relatively easy and produce better results.

Many functional appliance incorporate some components to expand the maxillary arch either
intrinsic force generating mechanisms like springs or screws or buccal shields to relieve
buccal soft tissue pressure.

Rapid expansion should not be done in young children as there is a risk of distortion of facial
structures with rapid expansion and there is no evidence that rapid movement and higher
forces produce better and more stable expansion.

5 year old who had expansion at the rate of ½ mm /day (2 turns/ day of the jackscrew)

After activation over a 10 day period, nasal hump and paranasal swelling developed after the
child complained of discomfort related to the expansion.

RME in late mixed dentition:

With increasing age, the midpalatal suture becomes more and more tightly interdigitated.

Sutural expansion requires placing a relatively heavy force directed across the suture to move
the halves of maxilla apart.

A fixed jack screw appliance (bonded or banded) is required, and as many teeth as possible
should be included in the anchorage unit.

A bonded appliance that covers the occlusal surface of the posterior teeth is a better choice
for a child with long face tendency producing less mandibular rotation than a banded
appliance
SURGICAL ASSISSTED MAXILLARY EXPANSION

Indications for SAME

JCO 1995 Dec EFTHIMIA K. BASDRA

Surgically-assisted maxillary expansion can be considered as part of the overall treatment

plan for a mature patient with a constricted maxillary arch for the following.

1. To widen the arch and to correct a posterior crossbite .

2. Necessity for a large amount (>7mm) of expansion, or preference to avoid the

potential increased risk of segmental osteotomies

3. To widen the arch following maxillary collapse associated with a cleft palate

4. Extremely thin, delicate gingival tissue or presence of significant buccal gingival

recession in the canine-bicuspid region of the maxilla;

5. Significant nasal stenosis

The 3 principal areas of vertical and horizontal maxillary support are nasomaxillary,
zygomaticomaxillary and pterygomaxillary buttress .

Brown first described SAME in 1938, performed only a midpalatal osteotomy

Kennedy and colleagues reported the most effective is lateral maxillary osteotomy .

While other authors have recommended sectioning of all maxillary bony articulation.

The recent studies show that the midpaltal suture followed by pterygomaxillary articulation
were primary areas of resistance .

Technique of SAME

A paramedian incision is made under local anesthesia

After the mucoperiosteum is released, the midpalatal suture is separated with a midline cut,
about 3mm deep but not reaching the foramen incisive.

The mucosal and bony cuts should not overlap

Two bony cuts, each about 4mm long, are then made on each side of the lateral maxillary
buttress above the root apices and parallel to the occlusal plane.

After the osteotomy, the maxillary segments are not fully detached, but can be separated by
rapid expansion with appliance.

The expansion appliance should be cemented in place before surgery and activated three or
four quarter-turns by the surgeon after the bony cuts are made.

The rest of the expansion is achieved in daily increments for about two weeks after surgery.
Overcorrection of about 2.5mm per side (5mm total) is usually advisable

Effects of RME:

EFFECT OF R.M.E. ON THE MAXILLARY AND MANDIBULAR COMPLEX

(AJODO 1987 BISHARA AND STANLEY)

Rapid maxillary expansion occurs when the force applied to the teeth and the maxillary
alveolar processes exceeds the limits needed for orthodontic tooth movement.

The applied pressure acts as an orthopedic force that opens the midpalatal suture.

The appliance compresses the periodontal ligament, bends the alveolar processes, tips the
anchor teeth, and gradually opens the midpalatal suture.

Viewed occlusally

Inoue found that the palatine processes of the maxillae separated nonparallel— that is, in a
wedge-shaped manner. (75% to 80% of the cases observed.)

Wertz's study of three dry skulls, one adult and two in the mixed dentition, also indicated that
the shape of the anteroposterior palatal separation was nonparallel in all three skulls
The pterygoid plates of the sphenoid,although bilaterally positioned, do not have a
midsagittal suture that allows them to be displaced laterally.

The pyramidal processes of the palatine bones interlock with the pterygoid plates . This
confining effect of the pterygoid plates of the sphenoid minimizes dramatically the ability of
the palatine bones to separate at the midsagittal plane.

Alveolar processes

Alveolar processes. Because bone is resilient, lateral bending of the alveolar processes occurs
early during RME

Most of the applied forces tend to dissipate within 5 to 6 weeks. After stabilization is
terminated, any residual forces in the displaced tissues will act on the alveolar processes
causing them to rebound.

Therefore, one can appreciate the need for overcorrection of the constricted dental arches to
compensate for the subsequent up righting of the buccal segment.

Maxillary anterior teeth

From the patient's point of view, one of the most spectacular changes accompanying RME is
the opening of a diastema between the maxillary central incisors

But the amount of separation between the central incisors should not be used as an indication
of the amount of suture separation.
If a diastema is present before treatment, the original space is either maintained or slightly
reduced. The mesial tipping of the crowns is thought to be caused by the elastic recoil of the
transseptal fibers.

Once the crowns contact, the continued pull of the fibers causes the roots to converge toward
their original axial inclinations. This cycle generally takes about 4 months.

The maxillary central incisors tend to be extruded relative to the S-N plane and in 76% of the
cases they upright or tip lingually.

This movement helps to close the diastema and also to shorten arch length. The lingual
tipping of the incisors is thought to be caused by the stretched circumoral musculature.

Maxillary posterior teeth

Hicks found that With the initial alveolar bending and compression of the periodontal
ligament, there is a definite change in the long axis of the posterior teeth the angulation
between the right and left molars increased from 1° to 24° during expansion.

Not all of the change, however, is caused by alveolar bending, but is partly due to tipping of
the teeth in the alveolar bone. This tipping is usually accompanied by some extrusion.

Palatal mucoperiosteum, periodontal tissues, and root resorption.

Cotton suggested that the post expansion angular changes of the maxillary first molars may
be related to the stretched fibers of the attached palatal mucosa.

Maguerza and Shapiro attempted to relieve the stretch of the mucoperiosteum after "slow"
expansion by making incisions along the palate down to the cortical bone, 3 mm away from
the teeth. The incisions did not effectively reduce the relapse tendency.

Whether such incisions might be effective with RME expansion or whether the incision
wound itself causes contraction is yet to be determined

Other investigators, reported marked buccal root resorption of the anchor teeth during RME
and fixed retention. These defects tended to gradually repair.

Effects of RME on the mandible

It is generally agreed that with RME there is a concomitant tendency for the mandible to
swing downward and backward.

There is some disagreement regarding the magnitude and the permanency of the change.

The fairly consistent opening of the mandibular plane during RME is probably explained by
the disruption of occlusion caused by extrusion and tipping of maxillary posterior teeth along
with alveolar bending.

RME should not be performed on persons with steep mandibular planes and/or open bite
tendencies
SOFT TISSUE EFFECT

Because of their relative rigidity, skeletal tissues offer the immediate resistance to the
expansion force. But another equally important factor is the soft-tissue complex that invests
these skeletal structures.

The muscles of mastication, the facial muscles, and the investing fascia are relatively elastic
and can be stretched as the expansion force is applied.

But the ability of the stretched muscles, ligaments, and fascia to permanently adapt to the
new environment is a matter that deserves further investigation.

Orthodontists are acutely aware of the limitations imposed by the soft tissues when teeth are
moved

Effects of RME on adjacent facial structures.

Kudlick, in a study on a human dry skull that simulated in vivo response of RME,
concluded the following:

(1) all craniofacial bones directly articulating with the maxilla were displaced except the
sphenoid bone,

(2) the cranial base angle remained constant,

(3) displacement of the maxillary halves was asymmetric, and

(4) the sphenoid bone, not the zygomatic arch, was the main buttress against maxillary
expansion.

EFFECTS OF AGE & R.M.E

Growth Ceases first In Transverse dimension

Growth at the midpalatal suture was thought to cease at the age of 3 years.

By means of implants, Bjork and Skiellent found that growth at the suture might be occurring
as late as 13 years of age

Wertz

He divided his sample into 3 age groups: under 12, 12 to 18, and over 18 years.

He found that after expansion and during fixed retention there was little relapse in any of the
three groups (-0.5, -0.6 and 0.5mm, respectively).

On the other hand, each age group behaved differently from the time of appliance removal to
the end of retention. The group under 12 years of age had a further increase of approximately
10%, and the over 18 years group had a relapse of approximately 63%.

The optimal age for expansion is, therefore, before 13 to 15 years of age.
HAZARDS OF RME

Oral hygiene

Length of fixation

Dislodgement and Breakage

Tissue damage

Infection

METHOD OF RETENTION AND RELAPSE TENDENCIES

The aim of retention is to hold the expansion while all the forces generated by expansion
appliance is removed.

Hicks observed that the amount of relapse is related to the method of retention after
expansion.

He observed with no retention, the relapse can amount to 45%, as compared with 10% to
23% with fixed retention and 22% to 25% with removable retention.

Bell concluded that slow expansion is less disruptive to the sutural systems. Slow expansion
that maintained tissue integrity apparently needs 1 to 3 months of retention, which is
significantly shorter than the 3 to 6 months recommended for rapid expansion.

Mew advocates a total retention period of 1 ½ to 4 years depending on the extent of

expansion.

Short-term and long-term stability of surgically assisted rapid palatal expansion revisited

Chamberlanda S and Proffit W.R (Am J Orthod Dentofacial Orthop 2011;139:815-22)

With surgically assisted rapid palatal expansion (SARPE), the mean maximum expansion at
the first molar was 7.60 +/- 1.57 mm, and the mean relapse was 1.8 +/- 1.8 mm (24%).
Modest relapse after completion of treatment was not statistically significant for all teeth
except for the maxillary first molar A significant relationship was observed between the
amount of relapse after SARPE and the posttreatment observation. At maximum, a skeletal
expansion of 3.58mm was obtained, and this was stable.

Conclusions: Skeletal changes with SARPE were modest but stable. Relapse in dental
expansion was almost totally attributed to lingual movement of the posterior teeth; 64% of
the patients had more than 2 mm of dental changes.

Three-dimensional assessment of buccal alveolar bone after rapid and slow maxillary
expansion: A clinical trial study

Brunetto M et al (Am J Orthod Dentofacial Orthop 2013;143:633-44)

 The purposes of this study were to analyze and compare the immediate effects of rapid and
slow maxillary expansion protocols, accomplished by Haas-type palatal expanders activated
in different frequencies of activation on the positioning of the maxillary first permanent
molars and on the buccal alveolar bones of these teeth with cone-beam computerized
tomography.

Both protocols caused buccal displacement of the maxillary first permanent molars, which
had more bodily displacement in the slow maxillary expansion group, whereas more
inclination was observed in the rapid maxillary expansion group. Vertical and horizontal
bone losses were found in both groups; however, the slow maxillary expansion group had
major bone loss.

Dimensional changes of upper airway after rapid maxillary expansion: A prospective cone-
beam computed tomography study.

Chang Y et al . (Am J Orthod Dentofacial Orthop 2013;143:462-70)

These results confirm the findings of previous studies of the effect of rapid maxillary
expansion on the maxilla that at premolar and molar region equal amount of expansion is
seen. Additionally, we found that only the cross-sectional area of the upper airway at the
posterior nasal spine to basion level significantly gains a moderate increase after rapid
maxillary expansion.

Cone-beam computed tomography evaluation of dentoskeletal changes after

asymmetric rapid maxillary expansion
Baka Z.M et al, (Am J Orthod Dentofacial Orthop 2015;147:61-71)

Comparisons of the before-treatment and after-retention measurements showed that the arch
widths and buccolingual inclinations of the posterior teeth increased significantly on the
crossbite side of the maxilla and on the non-crossbite side of the mandible. Comparison of the
2 sides showed statistically significant differences in both the maxilla and the mandible .

After ARME treatment, the crossbite side of the maxilla and the non-crossbite side of the
mandible were more affected than were the opposite sides.

Conclusion

Only during the last decade ,rapid palatal expansion has got a measure of acceptance. For a
century before that the concept had been repeatedly rejected by some of most prominent
members of our specialty ,but in spite of an uncertainty as to the actual separation of the
maxilla, rapid maxillary expansion has gained a wave of popularity with both orthodontist
and rhinologist during the twentieth century.
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