Vol. 114 No.

1 July 2012

Impact of rapid maxillary expansion in unilateral cleft lip and

palate patients after secondary alveolar bone grafting: review and
case report
Chen-Jie Yang, DDS, MDS, Xiao-Gang Pan, DDS, MDS, PhD, Yu-Fen Qian, DDS, MDS, and
Guo-Ming Wang, DDS, MDS, PhD

The purpose of this article was to analyze the effects and short-term stability of rapid maxillary expansion
performed after secondary alveolar bone grafting in unilateral cleft lip and palate (UCLP) patients. Two UCLP patients with
severe maxillary constriction who had previous bone grafting were involved in this study. A hyrax rapid expansion appliance
was placed on 4 abutment teeth and activated twice daily. An opening of the midpalatal suture was found on the
posttreatment occlusal radiographs, which was clinically confirmed by the diastema. Posteroanterior cephalometric tracing
analysis demonstrated significant increases in maxillary and dental arch width. No obvious radiographic alteration was
observed in the grafted areas. (Oral Surg Oral Med Oral Pathol Oral Radiol 2012;114:e25-e30)

Treatment for patients with cleft lip and cleft palate
deformities requires close interdisciplinary collabora-
tion. This is also known as comprehensive sequential
treatment, which includes cleft lip and cleft palate
repair, alveolar bone grafting, maxillary expansion,
prosthetic rehabilitation, and so on.
A review of the literature suggests that the growth of
the maxillary dental arch in cleft patients is inhibited
owing to congenital developmental deficiency, palatal
muscle strain, scar retraction, and a history of surgical
treatment.1-7 Thus, maxillary transverse deficiency,
constricted upper arch, and cross-bite are common
manifestations in cleft lip and palate (CLP) pa-
tients.1,7-9 The technique of rapid maxillary expansion
(RME) is commonly used as part of the sequential
treatment for CLP patients.1,7-13
In the 20th century, the conventional protocol was to
perform expansion before alveolar bone grafting. Many
thought that the grafted bone would stabilize the pre-
viously expanded maxilla and prevent collapse.1,8,10,14
However, Nicholson and Plint9 concluded in 1989 that
bone grafting after RME in cleft patients did not lead to
greater stability of expanded maxillary segments after a
mean follow-up time of 6 years 8 months. Boyne and
Sands15 proposed that autogenous particulate marrow
and cancellous bone (PMCB), obtained from the iliac
crest, as an alternative graft material. Once it is incor-
porated into the recipient site, it not only stabilizes the
Department of Orthodontics, Ninth People’s Hospital, Shanghai Jiao
Tong University School of Medicine, Shanghai Key Laboratory of
Stomatology, Shanghai, China.
Received for publication Jul 29, 2011; returned for revision Aug 9,
2011; accepted for publication Aug 12, 2011.
© 2012 Elsevier Inc. All rights reserved.
2212-4403/$ - see front matter
http://dx.doi.org/10.1016/j.tripleo.2011.08.030
maxillary arch segments, but also responds to physio-
logic and functional demands, such as bone growth,
tooth movement, and arch expansion. Unfortunately,
few studies have pursued this topic. Until recently,
some authors have proposed arch expansion after alve-
olar bone graft. Precious16 thought that arch expansion
after bone graft would create a type of distraction
osteogenesis, accompanied by appropriate palatal mu-
cosa expansion. Cavassan et al.12 described the separa-
tion of the midpalatal suture in response to RME after
secondary bone grafting in a bilateral cleft lip and
palate (BCLP) patient. In 2009, Silva Filho et al.13
reported the effects of RME on 28 CLP patients. They
found that RME could open the midpalatal suture after
secondary bone grafting, but the results were unpredict-
able. Although these studies have witnessed the possi-
bility of midpalatal suture opening in CLP patients,
other effects have not been evaluated. These include the
dentoskeletal effects of RME, the expansion pattern,
and its stability.
Therefore, the purpose of the present clinical case
report was to clarify the following: the dentoskeletal
effects of RME on unilateral cleft lip and palate
(UCLP) patients after secondary bone grafting, the ex-
pansion pattern of UCLP patients, and the short-term
stability of RME.
CASE REPORT
Two complete UCLP patients with severe maxillary con-
striction were included in the study. According to the cervical
vertebral maturation (CVM) method to identify skeletal mat-
uration, both patients presented as CVM stage 3.17,18 One
patient was a 12 year 8 month– old boy with right complete
CLP, who had secondary alveolar bone graft at the age of 11
years 10 months. The other patient was a 12 year 10 month–
old girl with left complete CLP, who had secondary alveolar
bone graft at 12 years of age. No orthodontic treatment was

e25
ORAL AND MAXILLOFACIAL SURGERY
e26 Yang et al.
Fig. 1. Cephalometric analysis on posteroanterior films: skel-
etal and dental landmarks and measurements (the male pa-
tient).
started before secondary alveolar bone grafting. The second-
ary alveolar bone graft was performed by the same surgeon
who repaired the 2 patients’ CLP, from the Department of
Oral Maxillofacial Surgery, Cleft Lip and Palate Treatment
Center, College of Medicine, Shanghai Jiao Tong University.
The height of grafted bone for both patients attained type II
according to the Bergland standard system.
Treatment progress
To correct the maxillary constriction, RME was performed
10 months after PMCB grafting. A hyrax rapid expander
(Unitek; 3M) was placed on 4 permanent abutment teeth (2
upper premolars and 2 upper first molars). The patients were
instructed to activate the screw twice daily, once in the
morning and once in the evening (0.25 mm per turn), until 2-3
mm of overcorrection was achieved. After expansion, the
appliance was retained as a passive retainer for 6 months.
Treatment measurement
Posteroanterior (PA) cephalograms, as well as occlusal and
periapical radiographs of the grafted areas, were obtained at 3
stages: before expansion (T1), immediately after expansion
(T2), and after 6 months of retention (T3).
The PA cephalograms were analyzed for each patient at
each of the 3 stages, and serial PA cephalograms were im-
ported into the Nemotec Dental Studio 2006 software.
Figure 1 shows the skeletal and dental landmarks used in
the PA cephalogram tracing. The following cephalometric
landmarks and corresponding definitions were used18:
Medioorbitale (Mo): the most medial point of the orbital
orifice.
Lateroorbitale (Lo): the intersection of the lateral wall of
the orbit and the greater wing of the sphenoid.
Zygomatic (Zyg): the most lateral point of the zygomatic
arch.
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July 2012
Lateronasal (Ln): the most lateral point of the nasal cavity.
Upper molar (Um): the most prominent lateral point on the
buccal surface of the upper first molar.
Maxillare (Mx): the point located at the depth of the
concavity of the lateral maxillary contour, at the junction
of the maxilla and the zygomatic buttress.
Gonion (Go): the point located at the gonial angle of the
mandible.
Treatment results
A diastema of 2 mm between the maxillary central incisors
was detected after RME, which signified that the midpalatal
suture opened. Occlusal radiographs showed a radiolucent
area at the region of the midpalatal suture, confirming the
successful orthopedic expansion of the maxilla. During the
retention stage, the gap between the central incisors closed
(Figures 2 and 3).
No obvious radiographic alteration of the height of the
grafted bone was observed on the periapical radiographs
according to the Bergland grading system (Figure 4).
PA cephalometric tracing analysis suggested that after
RME in the male patient, the width of the nasal cavity
(Ln-Ln) increased 2.2 mm, the width of the maxillary basal
bone (Mx-Mx) increased 2.6 mm, and the width of the max-
illary molar (Um-Um) increased 5.4 mm. In the female pa-
tient, the increases in width were 1.6 mm, 2.6 mm, and 5.2
mm, respectively. After 6 months of retention, a small in-
crease in these 3 indicators was observed. No significant
increase in the medial orbital distance (Mo-Mo) was observed
after 6 months of retention, which means that there was no
significant growth during the retention stage. Furthermore,
frontal view of the orthopedic sutural separation on the PA
cephalometric films showed a triangular pattern of expansion,
with the base near the alveolar bone and the apex toward the
nasal area (Table I).
DISCUSSION
From the perspective of embryonic development, the
midpalatal suture is formed by fusion of the maxillary
and nasal processes. Earlier studies have demonstrated
that growth at the palatal sutures in individuals without
CLP plays an essential role in the transverse develop-
ment of the maxilla. For cleft patients, the maxillary
and nasal processes fail to fuse, which results in under-
development of the maxilla in the transverse dimen-
sion.2,3 Therefore, maxillary expansion is routinely per-
formed in these patients to coordinate the width
discrepancy of the upper and lower jaws.
Studies on the effects of maxillary expansion in
noncleft patients show that transverse changes include:
1) separation of the midpalatal suture; 2) tipping of the
2 maxillae and the alveolar processes; and 3) tipping or
bodily movement of the teeth.18,20-22 The goal of max-
illary expansion is to maximize skeletal movement and
to minimize dental movement. Many clinicians have
agreed that more skeletal expansion can be obtained
through RME than through slow maxillary expansion,
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Volume 114, Number 1
Fig. 2. Serial intraoral photos during rapid maxillary expan-
sion (the male patient). A, Before expansion. B, Immediately
after expansion (diastema between central incisors). C, After
6 months of retention.
because the midpalatal suture is separated more effec-
tively with RME.20-23 Furthermore, when the increase
in transverse dimension is bone deposition at the level
of the midpalatal suture, the expansion effect is more
stable. But for those cleft patients without a bone graft,
CASE REPORT
Yang et al. e27
maxillary expansion separates the maxilla and premax-
illa and enlarge the cleft width, which is likely unsta-
ble.1,9,14,24
For cleft patients, the alveolar cleft crosses through
the area of the lateral incisor, which does not interfere
with the formation of an intermaxillary suture at the
region of premaxilla. Therefore, in patients who un-
dergo bone grafting to the alveolar cleft region, it is still
possible to separate the midpalatal suture. This hypoth-
esis has been preliminarily demonstrated, but Silva
Filho et al.13 suggested that the result is unpredictable.
Therefore, the purpose of the present study was to
further explore the possibility of separating the mid-
palatal suture with an RME appliance after bone graft
in UCLP patients and to explore the dentoskeletal ef-
fects, expansion pattern, and short-term stability of
RME on UCLP patients after secondary bone grafting.
Most investigators agree that the most suitable age
for RME is before and during pubertal growth.18,20,21,23
Therefore, in the present study, the CVM method was
used to identify the stage of individual skeletal matu-
ration at the start of treatment.18 The 2 patients in the
study were both at CVM stage 3. The occlusal radio-
graphs showed that maxillary separation occurred in the
midpalatal suture in both patients, which was clinically
confirmed by the presence of a diastema. This result
was consistent with those of Cavassan et al.12 and Silva
Filho et al.,13 but in the latter study, the success rate
was 42.8%. It is hard to explain the reason for their
findings, because the present preliminary study has
only 2 patients, but we suspect that it may be associated
with the patients’ age, the expansion time after bone
graft, the expansion method, and previous surgery.
Another point of concern in the present study was the
timing of RME after bone graft and whether the expan-
sion force would destroy the integrity of the grafted
bone. Precious16 thought that expansion could be initi-
ated about 8 to 12 weeks after grafting. Silva Filho et
al.13 advocated 3 months after grafting as the minimum
time span required for bone graft healing. Expansion in
the present study was performed 10 months after bone
grafting. Through the periapical and occlusal radio-
graphs, no obvious alteration was observed in the
grafted bone area. This result agreed with those of
Cavassan et al.12 and Silva Filho et al.13 Studies on
bone resorption in patients who underwent grafting to
the alveolar cleft reported that significant bone loss
occurred between the third and 12th month postopera-
tively.25,26 However, Bergland et al.15,19,27-29 proposed
that functional stimuli, such as tooth movement and
expansion, could reduce this bone resorption. There-
fore, further studies should be conducted to evaluate
the accurate timing and effects of expansion on the
grafted bone.
ORAL AND MAXILLOFACIAL SURGERY OOOO
e28 Yang et al. July 2012

Fig. 3. Maxillary occlusal radiographs (the male patient). A, Before expansion. B, Immediately after expansion (opening of the
midpalatal suture). C, After 6 months of retention.

Fig. 4. Periapical radiographs (the male patient). A, Before expansion. B, Immediately after expansion. C, After 6 months of retention.

Table I. PA cephalometric measurements (mm) during rapid maxillary expansion

Patient A (male) Patient B (female)
Measurement T1 T2 T3 T1 T2 T3
Lo-Lo 99.8 99.9 100.3 94.6 94.7 95.8
Mo-Mo 25.2 25.3 25.7 25.2 25.3 25.6
Ln-Ln 31.0 33.2 33.3 30.2 31.8 32.6
Mx-Mx 72.9 75.5 76.3 65.7 68.3 69.7
Um-Um 57.4 62.8 63.9 53.9 59.1 60.5
Zyg-Zyg 136.8 136.8 138.6 138.2 138.4 141.2
Go-Go 102.7 102.7 102.8 102.2 102.4 103.3
T1, Before expansion; T2, immediately after expansion; T3, after 6 months of retention.

PA cephalometric analysis showed that after RME, increased. A frontal view of the orthopedic sutural
the nasal cavity width, the maxillary basal width, and separation showed a triangular pattern of expansion,
the distance between the maxillary molars significantly with the base near the alveolar bone and the apex
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Volume 114, Number 1
toward the nasal area. These results are the same as
those reported for noncleft patients.18,20-21,23 This indi-
cated that, in cleft patients, the main resistance to
midpalatal suture opening is probably not in the suture
itself, but in the surrounding structures, particularly the
sphenoid and zygomatic bones.22,29,30 PA cephalo-
grams also showed that after RME, nasal width signif-
icantly increased and the nasal septum became more
straight, which would reduce the nasal airway resis-
tance and provide beneficial dentoskeletal changes dur-
ing growth periods.29,31
In the present study, we found that skeletal changes
accounted for approximately one-half of the increased
arch width. After 6 months of retention, this rate
changed minimally. Although the result is satisfying,
the long-term stability is still unknown. A review of the
literature indicates that insufficient retention periods
have resulted in substantial, even total, skeletal re-
lapse.9,11,14,24,32,33 Retention periods of 3-6 months are
normally recommended to allow reorganization and
stabilization of rapidly expanded maxillary sutures.
Therefore, the retention periods in our study lasted 6
months, and the short-term result was stable. But for
cleft patients, reorganization of the separated palatal
suture is not the only factor causing relapse; palatal scar
contraction and rotation of bone segments may be im-
portant factors affecting long-term stability of the ex-
pansion. Successfully separating the midpalatal suture
in clefts after bone grafting still indicates growth at the
level of the midpalatal suture, thus the expansion ef-
fects may be more stable.
Posttreatment long-term stability of the teeth and
maxillary segments is an extremely important aspect of
treatment in cleft patients. Therefore, searching for
more favorable and effective methods to achieve stable
treatment results is the goal we should be striving for.
Although this is a preliminary study, the findings are
optimistic and support the idea that PMCB obtained
from the iliac crest would respond well to physiologic
and functional demands.12,13,15
CONCLUSIONS
● For adolescent patients with unilateral complete cleft
lip and palate, rapid maxillary expansion after sec-
ondary bone grafting can open the midpalatal suture
and will likely provide greater stability of RME.
● No obvious radiographic alteration was observed in
the grafted areas on periapical radiographs.
● Significant increases in maxillary width and dental
arch width were obtained after RME. A triangular
expansion pattern with the base near the alveolar
bone and the apex toward the nasal area was
observed.
CASE REPORT
Yang et al. e29
Nevertheless, further investigations are necessary to
define the appropriate timing for RME after secondary
alveolar bone grafting, the possible impact of RME on
the reconstruction of the grafted bone, and long-term
stability of RME in UCLP patients .
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Reprint requests:
Dr. Yu-Fen Qian
Department of Orthodontics
Ninth People’s Hospital
Shanghai Jiao Tong University School of Medicine
Shanghai Key Laboratory of Stomatology
Shanghai 200011
China
yufenqian@yahoo.cn