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Applying New Knowledge To The Correction
Applying New Knowledge To The Correction
ABSTRACT
Rapid palatal expansion (RPE) has been used primarily to treat dental crossbites
or for space gaining to prevent extractions with little or no attempt made to
coordinate or normalize the transverse skeletal pattern. Traditionally, maxillary
orthopedics has been performed using the dental units only as anchorage
(e.g., Hyrax or Haas appliances). Dental anchorage not only has created limited
skeletal orthopedic change, but also can cause significant adverse periodontal
outcomes and unstable side effects. There is a clear correlation between buccal
tooth movement and gingival recession and bone dehiscences. These adverse
periodontal responses with RPE indicate the importance of early treatment.
The beneficial periodontal effects of transverse skeletal correction have been a
primary focus of our research for the past 35 to 40 years. We have emphasized
the importance of correcting transverse skeletal discrepancy to: 1) prevent
periodontal problems; 2) achieve greater dental and skeletal stability; 3) improve
dentofacial esthetics by eliminating or improving buccal corridors; and 4) improve
airway resistance. When it may be critical to save the natural dentition, we do
not want to introduce adverse dental/skeletal changes for adolescent patients
and/or patients with advanced periodontal disease. New advances in skeletal
anchorage should permit orthopedic change without adverse dental changes
by applying force directly to the maxillary bone; an innovative technique to
maximize the skeletal maxillary changes in the transverse dimension is explained
in this chapter. Furthermore, diagnosis of the transverse dimension—the use of
cone-beam computed tomography (CBCT) for 3D evaluation of skeletal changes,
the benefits of the skeletal transverse changes of the whole maxillofacial complex
and its periodontal response, the changes in airway and non-surgical RPE with
bone-anchored appliances utilizing temporary anchorage devices (TADs)—is
described and discussed.
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INTRODUCTION
Diagnosis in orthodontics must be performed with respect to all
three planes of space. These include the sagittal, vertical and transverse
planes in both the dental and skeletal dimensions. While our specialty
always has been focused on profile views and a diagnosis on the sagittal
plane, the vertical and transverse dimensions also are of critical impor-
tance. When Broadbent (1931) introduced cephalometric radiography
at Case Western, the frontal postero-anterior cephalometric radiograph
was included; however, its use in orthodontics was limited to asymmetric
types of cases.
It is essential to examine and quantify the degree of discrepancy
of the radiographic films to determine the skeletal pattern in these three
planes. It has been shown that clinical inspection of transverse maxillary
deficiency is inadequate for diagnostic value (Crosby et al., 1992; Flick-
inger et al., 1995) and can mislead the clinician. Likewise, a panoramic
film is not sufficient for a complete orthodontic diagnosis. At present,
the new technology, digital dentistry (Blasi et al., 2016) and three-dimen-
sional (3D) radiographs (e.g., cone-beam computed tomography [CBCT])
allow the orthodontist to evaluate the patient in 1:1 proportions and
in three dimensions. However, visualizing these beautiful images is not
enough and there is a need to quantify the skeletal and dental compo-
nents for a proper diagnosis. For example, two different cases could have
the same amount of dental overjet when measured and quantitated us-
ing a lateral cephalogram; however, one case could be a Class I skeletal
pattern and the other a Class II skeletal pattern. The same might occur
for two different cases with different dental overjets and the same Class
II skeletal relationship (Fig. 1). Therefore, a skeletal diagnosis must be
performed regardless of any dental compensation, since measuring teeth
is not diagnostic for the skeletal component. The purpose of this chapter
is to emphasize the importance of a 3D diagnosis and the impact of the
transverse dimension in our treatment outcomes.
TRANSVERSE SKELETAL PATTERN AND DIAGNOSIS
Traditionally, the transverse dimension has been addressed in cas-
es of dental crossbites, tapered arches and skeletal asymmetries without
an appropriate skeletal diagnosis. It is critically important to diferentiate
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Figure 1. Two different cases with the same Class II skeletal relationship and
different dental overjet. A-B: Patient with excessive overjet and a 7º ANB Class
II skeletal discrepancy. C-D: A different patient with no dental overjet and a 7º
ANB Class II skeletal pattern. Note that dental compensation hides a skeletal
discrepancy on the sagittal plane.
and quantitate between the width of the maxilla and the width of the
mandible, and it is essential that both jaws be measured to make a
skeletal diagnosis (Vanarsdall, 1999). Measuring only the upper jaw has no
value. Undiagnosed transverse discrepancy leads to adverse periodontal
response, improper occlusal function, unstable dental correction and
less-than-optimal dentofacial esthetics (Vanarsdall et al., 2017).
The presence or absence of clinical posterior dental crossbite
does not indicate the absence of a transverse skeletal discrepancy or
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PERIODONTAL IMPLICATION
Orthodontics is the most conservative and predictable treatment to improve
many of the local etiologic factors that contribute to periodontal susceptibility
and breakdown (Vanarsdall et al., 2017).
It is important intrinsically as a clinician to identify the peri-
odontally susceptible patient (Vanarsdall et al., 2017). When examining
the patient clinically, evaluation of the gingival tissues—specifically bio-
type—is critical to be able to provide optimal treatment. A patient with
thin biotype (thin periodontal tissues) should be evaluated carefully. The
biotype of both the soft and hard tissue has a crucial role in the outcome
of the treatment (Lindhe et al., 2008). Orthodontic movement of teeth
should be made carefully within the alveolar housing. Even though gin-
gival recession has a multi-factorial etiology (Helm and Petersen, 1989;
Offenbacher, 1996; Kornman and Van Dyke, 2008), a failure to make a
correct diagnosis could cause orthodontics to be a contributing etiologic
factor to periodontal breakdown and gingival recession (Vanarsdall et
al., 2017).
A study at the University of Pennsylvania (Saacks and Vanars-
dall, 1994) showed that buccal gingival recession is correlated directly
with maxillary transverse deficiency as measured in a group of untreat-
ed patients with a transverse discrepancy of 5 mm or greater (than the
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Correction of the Transverse Dimension
Figure 3. Case 1. Patient treated without proper diagnosis of the skeletal trans-
verse dimension. A: PA cephalometric analysis indicating a severe skeletal dis-
crepancy on the transverse plane: transverse deficiency of > 9.3 mm between
the upper and lower jaws with a narrow maxilla and a wide mandible. B: Initial
cast of the patient before treatment. C: Final cast after two years of orthodon-
tic treatment. The patient was treated with two expanders and four premolar
extractions. D: One year after treatment cast. Note evidence of recession that
starts to appear and relapse of the dental correction. E: Two years post-orth-
odontic treatment. The case was treated beyond dental camouflage which re-
sulted in further dental relapse and gingival recession.
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probing, tooth mobility and thin, friable gingival tissue). These all are
critical reasons to make the skeletal correction in the transverse dimen-
sion based on skeletal landmarks and not on dental landmarks (e.g., the
lingual of the upper teeth contacting the buccal surfaces of the lower).
ENVELOPE OF DISCREPANCY:
LIMITS FOR DENTAL EXPANSION
As stated earlier in this chapter, there are noticeable definitive
limits to dental expansion. If these boundaries are violated, there are
adverse consequences. Establishing the envelope of discrepancy and
delineating the limits of these boundaries is highly relevant and should
be made for each individual patient. Proffit and Ackerman (1982) first
introduced and developed the sagittal and vertical envelope of discrep-
ancy concept. We later added the transverse envelope of discrepancy
(Vanarsdall and Musich, 2017). Figure 6 helps simplify and visualize the
limits of the three major treatment modalities for skeletal discrepancies.
The inner envelope illustrates the limits of camouflage with orthodontic
treatment alone; the middle envelope establishes the limits of orthodon-
tic treatment combined with orthopedics and growth modification; and
the outer circle represents the limits of the correction with orthodontics
and orthognathic surgical procedures. The numbers on the diagram are
simple guidelines and may under-/overestimate the potentials for any
given patient; nevertheless, they help place the potential of the three
major treatment options in perspective.
It is important to note that the envelopes of discrepancy for the
transverse dimension are much smaller (Fig. 6); the premolar areas are
smaller considerably than those for incisors in the anterior-posterior (AP)
plane. When violating these limits, teeth are placed in a position where
they could be traumatized and possibly lost. Clinicians need to develop an
envelope of discrepancy concept for the transverse dimension, as well as
for the sagittal and vertical dimension for every case.
Orthopedic transverse correction, utilizing growth in children,
is the most desired approach to any skeletal discrepancy when growth
potential exists (DeGeorge, 2015). The envelope of discrepancy is in-
creased greatly with orthopedics and may allow the clinician to provide
a non-extraction treatment if the transverse skeletal discrepancy is cor-
rected. In adolescents and young adults, an orthopedic correction may
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EARLY TREATMENT
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younger the patient is and the longer the LB is used, the better the re-
sponse to treatment.
Vanarsdall and associates (2004) reported a skeletal result of
the LB on the basal bone as well. The transverse dimension of the basal
structure of the mandible measured at the antegonial notch (Ag-Ag) in-
creased relative to double the control. The jaws are more responsive
to modification at an early phase of growth and development than at
future stages. Proper management of growth and development and con-
trol of habits (tongue thrust, low tongue posture) that will worsen as the
patient grows are important to avoid secondary effects (e.g., developing
an adenoid face). Furthermore, it is possible to redirect the growth in
the transverse dimension and create a better occlusal and periodontal
environment (Fig. 7).
Beginning early treatment with orthopedic appliances (e.g., RPE
and LB) permits the clinician to take advantage of muscles, eruption
and growth, coordinate the skeletal pattern and develop a broader arch
form. Early skeletal correction of the transverse dimension is valuable
for managing growth and development, long-term periodontal health,
proper occlusal function and stability (Secchi and Wadenya, 2009; De
George, 2015).
CHANGES OF OTHER SKELETAL CHARACTERISTICS
AND AIRWAYS
Changes of the basal form cannot be accomplished with wires
or brackets (Lundstrom, 1925). Orthodontics alone will move teeth only
within the basal structure of the jaws. If a skeletal discrepancy needs
to be corrected, orthopedics and/or surgery may be the treatment of
choice. Orthopedic maxillary expansion is accomplished by placing trans-
versally directed forces in the orthopedic range on the maxilla to accom-
plish transverse maxillary expansion. There is increased facial resistance
to skeletal expansion with increasing maturity and age. The higher site
of resistance is not the midpalatal suture, but the remaining maxillary
articulations (Zimring and Isaacson, 1965) increased rigidity of the fa-
cial bones (e.g., the zygomatic buttress) and other circummaxillary su-
tures. As the sutures mature, the majority of rapid orthopedic palatal
expansion occurs via dental tipping and alveolar bone bending, rather
than skeletal movement. RPE may affect structures directly or indirectly
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Figure 7. Early treatment case. The patient was treated with phase I for 20 months
with bonded tooth-tissue-borne expander (occlusal and palatal coverage) and lip
bumper (LB). A: Initial coronal CBCT cut shows buccal inclination of upper mo-
lars. B: After early phase I treatment. CBCT coronal cut reveals properly inclined
molars creating a better periodontal environment. The teeth are centered on the
alveolar process, where occlusal forces of mastication are received over the long
axis of the dentition.
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when four TADs usually are recommended for a better anchorage and
appliance design (Lee et al., 2014).
We have reported and compared the treatment response of pa-
tients with similar transverse skeletal severity, gender and age with the
most effective orthopedic tooth-tissue-borne expander versus bone-
anchored maxillary expander on changes of the basal bone and molar
teeth of consecutively treated patients (Vanarsdall et al., 2017). Two
groups were evaluated after expansion and compared with CBCT data: a
group of eleven patients (11.3 to 17 years) treated by one clinician only
with bone-anchored expander (TAD type); and a group of 24 patients
(7.8 to 12.8 years; Christie et al., 2010) treated with a bonded tooth-
tissue-born expander (bonded type). T-test statistical analysis demon-
strated a statistically significant difference (p < 0.05) between the mean
of maxillary basal bone change at the first molars of both groups. The
percentage of the mean screw expansion associated with the width of
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the palatal expansion at the first molar was calculated as follows: 40.65%
on the bonded RPE group and 65.04% on the TAD RPE. The large differ-
ence in the efficiency of the expansion was due to the direct effects of the
expansion upon the palate itself and not the surrounding molars of the
maxillary arch where the bonded tooth-tissue-borne RPE device general-
ly retains. This analysis also is supported strongly by the large inter-molar
tipping angle effect of the bonded RPE compared with the TAD group
before and after expansion. The bonded RPE group resulted in a mean
of 11.7 SD +/- 3.05° difference versus the near absence of any mean ef-
fect 0.2 SD +/- 3.47° difference in the case of the TAD treatment group. A
T-test exhibited a highly significant difference (p < 0.00001) between the
two groups. Furthermore, both groups exhibited midline suture opening
in a parallel fashion (Fig. 9C). This was different from the earlier type of
expanders, which have been reported to cause openings of the midpala-
tal suture in a triangular shape with extended opening on the anterior
maxilla area (Garib et al., 2008; Woller et al., 2014; Figs. 9D-E and 10A-
B). Expansion efficacy was exhibited in both significant skeletal changes.
However, the bone-anchored devices obtained 25% more skeletal bas-
al change (Mx-Mx) without dental compensation than did the bonded
tooth-tissue-borne RPE. Greater maxillary orthopedic expansion was
seen with the bone-anchored versus the bonded tooth-tissue-borne ex-
pander and a highly statistically significant difference in molar tipping an-
gulation. With the Hass appliance, therefore, 20% of basal bone change
from the jack screw activation can be achieved, 41% with the bonded RPE
and 65% with the TAD RPE (Fig. 10C-E; Vanarsdall et al., 2017). It is impor-
tant to know what an appliance will provide for the skeletal correction.
Lin and coworkers (2015) reported similar results. They evalu-
ated and compared the effects of a Hyrax expander and a bone-borne
expander (similar to our design). The Hyrax group had more buccal tip-
ping of the dentition and alveolar process with significant adverse buc-
cal dehiscence in the first premolar area. They also concluded that the
bone-borne expanders produced greater orthopedic changes and fewer
dentoalveolar tipping compared to the Hyrax expander group.
Although there have been demonstrated benefits of skeletally an-
chored RPE, potential adverse effects may exist. These include reversible
microfractures at the level of the nasal bone or cracked nose that could
be seen clinically as a bump on the nose; damage to the surrounding
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Figure 10. A-B: Hyrax appliance used on a mixed dentition case. The CBCT axial
cut reveals a triangular shape expansion more prominent on the anterior part
of the maxilla. From Woller et al., 2014. Reprinted with permission of Dental
Press Publishing. C-E: There is a need to select the proper rapid palatal expander
(RPE) that will provide the skeletal correction needed for the skeletal age of the
patient. C: Haas-type appliance provides 20% of basal change. D: Bonded tooth-
tissue-borne expander, 41% of basal change. E: Bone-borne, 65% basal change
of the mean jackscrew opening at the level of the first permanent molars. From
Vanarsdall et al., 2017. Reprinted with permission of Elsevier.
tissues due to a failed TAD and/or pain if the RPE impinges on palatal
tissues.
Skeletal anchorage should permit orthopedic change without
the adverse dental changes by applying force directly to the maxillary
bone. Its use is indicated for moderate to severe skeletal discrepancies,
skeletal mature individuals and patients with missing teeth and/or peri-
odontal involved cases (Vanarsdall et al., 2017). Orthopedic expansion
can be accomplished in adolescents, even in young adults, with skeletally
anchored devices (Fig. 11). Future research is needed to determine the
skeletal age limitation of bone-borne RPEs; nevertheless, it is clear that
the envelope of treatment has evolved to include older patients (Fig. 12).
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Figure 11. A 25-year-old female with history of orthodontic treatment. The pa-
tient was treated with upper premolar extractions only to relieve crowding due
to a narrow maxilla. A: Three TADs used per side to maximize the skeletal change
of the maxillary expansion. B: Rapid palatal expander bone-borne Haas type with
acrylic for better support and distribution of forces of expansion. C-D: 3D CBCT
confirms purely skeletal expansion with separation of the palatal suture in a par-
allel fashion in an adult patient.
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LONG-TERM STABILITY
In our view, RPE has less to do with gaining arch perimeter and
extraction/non-extraction treatment and more to do with the skeletal
correction of the transverse dimension.
It generally is accepted by orthodontists that mechanically
pushing or pulling the teeth to expand the dental arches is not a stable
correction. One of the biggest problems in orthodontics is arch form.
Clinicians want to keep that arch form because if it is modified, it can
relapse to the original configuration; however, it is important to realize
that if it is corrected orthopedically, it does not relapse.
Stability of RPE depends partially on the histological activity at
the site of the separated suture. Ten Cate and colleagues (1977) described
a single layer of active osteoblasts that continued to lay down new bone
at the bony margins of the suture. The uniting layers consisted of a large
fiber bundle running across the borders of the suture. The response to
expansion was osteogenesis and fibrillogenesis, followed by the sutural
connective tissue fibroblasts to remodel, which led to regeneration of the
suture (Revelo and Fishman, 1994).
With growth, the skeletal transverse correction with RPE and
LB do not reverse (Vanarsdall et al., 2004; DeGeorge, 2015). In a young
patient, when inducing tooth movement (orthopedics, LB) by muscles,
eruption and growth, the dentoaveolar widening that occurs provides
a broad arch form that is not determined mechanically by the brackets
and arch wires. Before any bracket system is used, the wider, natural or
broader arch form is established. Other treatment options that do not
influence the growth and change of the apical skeletal base (orthopedics/
surgery) are limited to maintain the original arch form of the malocclusion.
In these treated cases, satisfactory mandibular alignment may exist in
less than 30% of the cases long term (Little et al., 1981).
Relapse tendencies after RPE have been reported in the past, but
many of the studies are based on intermolar width dental measurements
(Mew, 1983). Much of the relapse may be due to expansion achieved
with means of dentoalveolar tipping, rather than palatal suture opening.
Therefore, it is important to maximize skeletal expansion and minimize
dental tipping for long-term stability of the correction.
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CONCLUSIONS
The benefits of correcting a transverse skeletal deficiency include:
1. Improved periodontal health;
2. Dental and skeletal stability of the correction;
3. Dentofacial esthetics—improving buccal corridors;
and
4. Improved airway resistance.
Its diagnosis must be based on skeletal and not dental components. The
earlier the patient is treated, the better the response to treatment. It is
important to assure skeletal expansion regarding the appliance selection.
With the new skeletally-anchored expanders, the envelope of treatment
definitely has changed to include mature patients and avoid certain surgi-
cal procedures (e.g., SARPE). Further research is needed to delineate the
limits of such expanders.
ACKNOWLEDGEMENTS
The authors would like to thank Dr. Normand S. Boucher for sup-
porting the research with CBCT data.
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