Skeletal and dental changes after maxillary expansion

in the mixed dentition

M(ige Sandlk(~,oOlu, DDS, PhD, a and Serpil Hazar, DDS, PhD b
lzmir, Turkey
The purpose of this study was to compare skeletal and dental aspects of three different expansion
methods in the mixed dentition period in sagittal, vertical, and transversal planes, treatment
periods, complications, and relapse tendencies in early periods. Patients with unilateral or bilateral
posterior crossbites in the mixed dentition were studied. They were divided into three groups of 10
patients in each group. The first group received treatment with removable plates for semirapid
maxillary expansion; the second group with quad-helix appliances for slow maxillary expansion; and
the third group with conventional fixed hyrax appliances for rapid maxillary expansion (RME).
Lateral and posteroanterior cephalometdc films, occlusal films, and dental casts were taken before
and after expansion, and after retention with the same appliances. Cephalometric and dental cast
analyses were made. Both skeletal and dental changes were observed after all three expansion
methods. (Am J Orthod Dentofac Orthop 1997;111:321-7)

P o s t e r i o r crossbite is defined as the trans-
versal discrepancy of teeth relationships, because of
the narrowing of the u p p e r dental arch compared
with the lower dental arch. 1 A m o n g 958 Turkish
children in the mixed dentition, in the region of
Bornova, Izmir, a 2.7% incidence of posterior cross-
bite was found. Because the prevalence of this
malocclusion is between 8% and 16% in different
investigations 2 and appears in the ages of 3, 6, 8, 10,
and 12 years, 3 one has to consider an early treat-
ment.
Many different methods have been used to ex-
pand the contracted maxillary arches. When evalu-
ated on the basis of the frequency of the activations,
magnitude of the applied force, duration of the
treatment, and the patient's age, different mechanics
produce rapid, semirapid, and slow expansions.
The aims of this study are to use three different
expansion appliances (hyrax, removable, and quad-
helix appliance) to apply rapid, semirapid, and slow
expansions to the patients with posterior crossbite in
the mixed dentition and to evaluate the skeletal and
dental changes comparatively.
MATERIAL AND METHODS
Thirty children with unilateral and bilateral posterior
crossbites were treated. The group as a whole was divided
From the Department of Orthodontics, Faculty of Dentistry, Aegean
University.
aResearch fellow.
bProfessor.
Reprint requests to: Dr. Mtige Sandlk~lo~lu, 61 Sok. No-3/2 Bornova,
35040, Izmir Turkey.
Copyright © 1997 by the American Association of Orthodontists.
0889-5406/97/$5.00 + 0 8/1/67853
into three groups with 10 patients in each group. The first
group received treatment with removable plates (semi-
rapid expansion); the second group with quad-helix appli-
ances (slow expansion); and the third group with hyrax
appliances (rapid expansion). The mean ages at the
beginning of the treatment for each group were 6.6, 8.6,
and 8.9 years, respectively. Of the 30 children, 16 had
unilateral and 14 had bilateral crossbites.
Semirapid Expansion Group
The removable plates had a midline screw, Adams
clasps on the first permanent molars and labial arch
between the canines (Fig. 1). The parents were instructed
to activate the jackscrew a quarter turn every other day to
produce semirapid expansion. The plate was worn 24
hours a day, except during meals. The activation was
discontinued after sufficient expansion (enough to over-
correct the crossbite several millimeters) was achieved.
The same appliance was used for the retention period of
7 months.
Slow Maxillary Expansion
A prefabricated 0.38-inch quad-helix (Dentaurum)
appliance was soldered to molar bands on the maxillary
first permanent molars (Fig. 2). Before cementation of the
appliance, no activation was made. The appliance was
activated on the anterior and lateral bridges every other
week. After sufficient expansion was achieved, a passive
quad-helix appliance was left in the mouth for another 3
to 4 months and then removed.
Rapid Maxillary Expansion
A conventional fixed band and soldered wire appli-
ance was constructed, with a hyrax screw cemented in the
321
322 Sandtkqto~lu and Hazar American Journal of Orthodontics and Dentofacial Orthopedics
March 1997

Fig. 1. Removable plate. Fig. 3. Hyrax appliance.

J
'~=._

Po
01-
PNS,~
J
Fig. 2. Quad-helix appliance. Lengths of posterior ex-
tensions of appliances: Size 1" 12 mm; size 2:13 ram;
size 3:14 mm; size 4:15 mm.
00
midline. The appliance was activated twice a day (Fig. 3).
After sufficient expansion was obtained, the appliance was
left in the mouth as a passive unit for a period of 3 months.

Measurements
The changes effected by maxillary expansion proce-
dures were appraised by lateral and posteroanterior ceph-
alometric films and dental casts. The records were taken
before (El) and after (E2) expansion, and after the
retention period (E3).
The cephalometric radiographs were evaluated by
means of the following measurements:
1. Lateral cephalometric analysis (Fig. 4):
a. Angular variables: SNA, SNB, ANB, NL/ML, GoGn/
SN, FH/NA, NAP, SN/NL, Interincisal angle.
b. Linear variables: SN-ANS, SN-PNS, A-SNP, S-Go,
N-Gn, ANS-Gn.
2. Posteroantelior cephalometric analysis (Fig. 5):
NC(1): Maximum width of the nasal cavity.
Fig, 4. Landmarks that were used in lateral cephalo-
metric analysis.
rex-rex(2): Width of the skeletal base of the maxilla.
Distance between JL and JR points (JL and
JR points are defined as the intersection
between processus zygomaticus and proces-
sus alveolaris maxillae on the left and right
sides).
urn-urn(3): Upper molar distance. Distance between
6A and A6 points (6A and A6 points are
defined as the outermost points of the
American Journal of Orthodontics and DemoCacial Orthopedics S a n d t k f l o ~ l u and Hazar 323
Voh~me 111, No. 3

/
Fig. 5. Landmarks that were used in posteroanterior
cephalometric analysis. 1: NC-NC; 2: mx-mx; 3: urn-
urn; 4: Im-lm.

upper first permanent molars determined

perpendicularly to the occlusal plane).
lm-lm(4): Lower molar distance. 4 Distance between
6C and C6 points (6C and C6 points are
defined as the outermost points of the
lower first permanent molars determined
perpendicularly to the occlusal plane).
AG-GA(5): Distances between antegonial notches
(left and right).
3. Dental cast analysis (Fig. 6):
up-up(2): Distance between the upper first premolars.
um-um(3): Distance between the upper first molars.
uc-uc(1): Distance between the upper canines.
lm-lm(4): Distance between the lower first molars.
Overjet distance.
Overbite distance.
Error of the Method
Lateral and posteroanterior cephalometric analysis of
the five randomly selected cases from three different stages
(before and after expansion and after retention periods)
were made to estimate the error of the method. The
statistical analysis was computed with a prepared program
(MINITAB). The Student's t test was used to determine the
presence of significant difference within the data.
RESULTS
Clinical Results
Of the 30 patients, 14 had bilateral and 16 had
unilateral posterior crossbites. If any patients with
oral breathing problems were suspected at the first
examination, they were sent directly to an otolaryn-
gologist.
Fig. 6. Dental arch dimensions with reference points:
1: uc-uc; 2: up-up; 3: um-um; 4: Im-lm.
After any problems in the nasal regions were
eliminated, the expansion was started. Thirteen
patients had already had their tonsils surgically
removed.
Midline diastemas were detected in the patients
treated with the hyrax appliances approximately 5
days after the first activation and healed in another
10 days. The patients in this group did not have any
complaints concerning the fit of appliance, loss of
appliance, fracturing of appliance, or any irritations,
but mentioned difficulties in swallowing and talking
during the first few days.
Expansion continued until overexpansion was
obtained in 19.2 days for the hyrax group, 5.5
months for the plate group, and 56 days for the
quad-helix group. The variance between the treat-
ment times of the semirapid group and the slow
group can be explained partly with delinquency of
parents adjusting the appliances and lack of good
cooperation.
324 Sandlkfzo~,lu and Hazar American Journal of Orthodontics and Dentofacial Orthopedics
March 1997

Table I. Significant differences of the means between first and second tracing of cephalograms and the error of the method tested by
means of paired t test

Variable Group name Period if( SD p SE

GoGn/SN SME E3-E 3 0.8 0.6 * 0.26

- _1 RME E3-E3 1.0 0.7 * 0.32
SRME E2-E2 1.0 0.5 * 0.22
mx-mx SRME E2-Ez -0.5 0.4 * 0.16
AG-GA SRME E2-E z -0.6 0.4 * 0.2

*p < 0.05; SE." standard error of the mean; SD." standard deviation; X." means of the differences; SRME: semirapid maxillary expansion; RME: rapid maxillary
expansion; SME." slow maxillary expansion.

Table II. Significant differences of lateral cephalometric variables during the periods of active treatment (Ez-E1), the retention period
(E3-E2), and the whole period of observation with the same appliance ( E 3 - E 1 )

E2-E 1 E3-E2 E3-E 1

I
Variable Group name if( SD ] p k SD p if( I SD P
I
i - 1_ RME -6.9 7.3 *
SNB RME 0.7 0.9 *
SME -0.9 1.3 *
NL/ML SRME -2.2 2.9 * 1.1 1.5 *
GoGn/SN RME 2.3 1.9 ** - 1.5 1.3 *
N-Gn SRME -3.7 3.4 ** -4.7 4.1 **
RME -3.6 1.5 *** -3.8 t. 4 ***
ANS-Gn RME 3.2 2.1 *** -2.6 1.9 **
FH/NA RME 1.5 1.6 *
SN-ANS SME 0.8 0.8 * -1.5 1.4 **
SRME 1.4 1.6 *
RME -1.5 1.4 **
S-Go k RME 1 1.2 *
NAP RME 2 1.6 ** - 1.9 1.7 *
ANP RME - 1 1.6 *

*p < 0.05; **p < 0.01; ***p < 0.001.

Error of the Method During the period of retention (E3-E2), the

To estimate the method error, 45 randomly
selected lateral and posteroanterior cephalograms
from different periods were traced by the same
author (M.S.). The differences of the means be-
tween the first and second measurements of the
films and the level of significance tested by means of
t test showed significant differences in six variables
(p < 0.05) (Table I).
Lateral Cephalometric Analysis
Statistically significant changes are listed in Ta-
ble II. During the active treatment period, interin-
cisal angle, ANB, Pal-MP, SN-_I (p < 0.05), GoGn/
SN, and N-Gn and ANS-Gn distances (p < 0.01)
showed an increase, whereas SNB (p < 0.05)
and NAP (p < 0.01) showed a decrease in hyrax
group. In the same period, N-Gn (p < 0.001)
showed an increase in plate group. The S-Go,
SN-PNS, and N-Gn distances showed increases in
all groups during the whole period of expansion
treatment (E3-E1).
FH-NA, NAP, and Pal-MP angles showed a slight
relapse and the S-Go distance increased in the hyrax
group (p < 0.05).
Posteroanterior Cephalometric Analysis
Significant differences are obtained in the maxi-
mum nasal cavity width (NC-NC), maxillary basal
width (mx-mx), maxillary dental width (urn-urn) in
all groups, and the AG-GA distance only in the
hyrax group in the active treatment period (Ez-Ea)
(Table III).
During the entire period of expansion treatment
(E3-Ea), the same variables showed significant dif-
ferences in all groups.
Model Analysis
Statistically significant changes of all dental arch
dimensions can be seen in Table IV. All groups
showed significant increases in the distances of the
upper first premolars, upper first molars, upper
canines, and lower first molars in all groups.
American Journal of Orthodontics and Dentofacial Orthopedics Sandtkfzo~,lu a n d H a z a r 325
Volume 111, No. 3

T a b l e III. S i g n i f i c a n t d i f f e r e n c e s o f p o s t e r o - a n t e r i o r c e p h a l o m e t r i c d u r i n g t h e p e r i o d s o f a c t i v e t r e a t m e n t (Ez-E1) , the retention

period (E3-E2) , and the whole period of observation with the same appliance (E3-E 0

E2-E 1 E3-E2 E3-E 1

Variable Group name f( SD p 2 SD p if( ] SD P

NC SME -0.9 0.9 * -0,7 0.8 *

SRME 0.8 0.6 ** -1.4 1 **
RME -2.1 1 *** -2.1 1.6 **
mx-mx SME - 1.9 1.3 ** -1.5 0.7 ***
SRME - 1.5 2 * -2.1 2.5 *
RME - 2.7 1.2 *** 2.8 2.7 **
urn-urn SME -5.3 2.6 *** 1.1 1.2 * -4.2 1.7 ***
SRME -4 2.2 *** -4.3 2.1 ***
RME 6.2 2.6 *** -5.4 2.1 ***
lm-lm SRME 0.7 0.6 **
AG-GA SRME 1.2 1.9 * -2.9 2.8
RME - 1.8 2 *

*p < 0.05; **p < 0.01; ***p < 0.001.

T a b l e IV. S i g n i f i c a n t d i f f e r e n c e s o f d e n t a l a r c h d i m e n s i o n s d u r i n g t h e p e r i o d s o f a c t i v e t r e a t m e n t (E2-E1), the retention p e r i o d ( E 3-

E2), a n d t h e w h o l e p e r i o d o f o b s e r v a t i o n w i t h t h e s a m e a p p l i a n c e ( E 3 - E 1 )

E2-E 1 E3-E2 E3-E 1

[
Variable Group name k [ p

up-up SME -2.8 1.7 *** -2.4 1.9 **

SRME -4.5 2.2 *** 3.7 2.7 **
RME 6 2.1 *** -5.1 2.6 ***
urn-um SME - 5.6 2.7 *** - 5.1 3.1 ***
SRME -4.1 2.2 *** -3.6 2.1 ***
RME -5.5 3 *** -5.4 2.3 ***
uc-uc SME -4.9 3.9 ** -3.3 3.6 *
SRME -4.1 3 ** -3.7 3.2 **
RME -3.2 2 *** -3.3 2.4 **
lm-lm SME -0.6 0.7 *
SRME - 1.3 1 ** 1.4 1.2 **
O v e r jet SRME -0.5 0.5 *
RME 0.9 1.3 * - 1.5 1.5 *

*p < 0.05; **p < 0.01; ***p < 0.001.

No relapse was observed during the retention Many different appliances have been used to
period (E3-E2). expand the maxillary segments for more than 100
years. Among these, 6'7'8 in the past we have chosen
DISCUSSION the hyrax screw, fixed bonded appliance. The advan-
Maxillary expansion has been a must to obtain tage of this type of appliance is that no chair time is
harmonious dental and basal arches in posterior spent for the construction, except for taking an
bilateral and unilateral crossbites in the mixed den- impression. None of the patients had any complaints
tition. The purpose of this study was to compare the about the appliance.
dental and skeletal results in transversal, sagittal and Semirapid maxillary expansion has not been stud-
vertical dimensions, complications, treatment peri- ied much. The study by Mew9 seems to be the only one
ods, and relapse tendencies after retention with regarding semirapid expansion. He had added protru-
three different maxillary expansion methods. sive arch wires behind the upper incisors, whereas our
The sample was selected according to their design of the removable plate consisted of only a
dentition stage (mixed dentition) and their transver- jackscrew on the midline for expansion.
sal problem (posterior crossbite). Because no sexual Among the several quad-helix appliances, we
differences were found for all frontal cephalometric have used the one called mobile intraoral arch
variables in a previous study, s we did not separate (Dentaurum). Regarding activation of the appli-
our sample according to sex. ances, we have followed a different schedule for the
326 San&kfto~lu and Hazar
quad-helix appliance. In the literature, this appli-
ance has been activated only once at the initiation of
the expansion procedures, unless needed. 4,1°,11
These studies reported that sufficient expansion was
obtained between 30 days and 4 months, while it was
56 days on average in our study.
As for the problems during active treatment, no
complaints were noted during rapid expansion,
whereas poor fit of appliance, loss of appliance, and
fractured appliance for the removable plate group,
and loose bands and irritation of one of the poste-
rior helices for the quad-helix group were seen in
some cases. These findings are in accordance with a
previous study, m
The assessment of the method error revealed
that of the 31 variables, only 6 showed significant
differences at 5% level.
Changes in the transversal plane in slow expan-
sion revealed higher values than in sagittal and
vertical planes. This finding resembles the effect of
rapid maxillary expansion (RME) on nasal cavity
width, maxillary basal width, and maxillary dental
width.
It was not possible to compare objectively the
effects of semirapid expansion, because of the lack
of studies regarding this type of expansion.
In the evaluation of the removable plate group,
the most remarkable effect was attained in the
transversal plane. In addition, an increase in the
anterior total facial height could be a result of
rotation of the maxilla inferiorly and, specifically,
occlusal changes in the posterior dentition. Getting
a greater increase of this variable in the quad-helix
group than in the plate group could be explained
with more tipping of the posterior teeth in the latter.
More variables demonstrated statistically signifi-
cant differences in hyrax group than in those in the
other two groups. Even though the increase (6.9°) in
the interincisal angle is high, because of the standard
deviation being rather high, it cannot be claimed that
the incisors were directly affected by RME. This
finding is in accordance with the findings of Aras. 6
Wertz a2 in his investigation of RME found a
remarkable decrease in SN-1 angle and reported
that incisor angulation showed either an increase or
a decrease, independently from maxilla.
In our study, we found a decrease in this angle
(p < 0.01) as in the study by Wertz. 12 Our finding
supports the increase in the interincisal angle. It is
not likely that this movement of incisors could be a
resultant of inferior rotation of palatal plane.
Regarding changes in the transversal plane with
the hyrax appliance, the maxilla showed changes
American Journal of Orthodontics and Dentofacial Orthopedics
March 1997
mostly in this plane, compared with sagittal and
vertical planes. These findings are in accordance
with the findings of Wertz and Dreskin. a3
As for the sagittal plane, we obtained an increase
in the SNA (p < 0.05) and the ANB (p < 0.05)
angles, and a decrease in the SNB (p < 0.05) angle.
Wertz reported that point A moved slightly back-
ward in a few cases and the ANB angle mostly
showed high values. According to his research, if it is
assumed that point A does not move forward during
RME, the change in the ANB angle could be a
result of posterior rotation of point B.
It has been reported that the mandibular plane
angle usually opened after maxillary expansion pro-
c e d u r e s . l O , 12-16
In our study, the GoGnSN angle increased sig-
nificantly (p < 0.01) only in the hyrax group. Neither
posteroanterior nor dental cast variables showed
statistically significant changes in the mandible, con-
trary to the previous studies. 1°,16,17
However, mandibular variables were found to be
effected by semirapid expansion, possibly because of
the longer period of active treatment; consequently,
this may have lead to the result that the mandibular
arch is allowed more time for adaptation to the
changed occlusal forces.
For the hyrax group, it was seen that the mandib-
ular arch showed dental changes (intermolar width)
after the retention period. It is also possible to elicit
the same result previously mentioned for this group.
From an occlusal view, opening in the midpalatal
suture was observed in all patients in the hyrax
group and in half of the patients in the other two
groups. As has been reported by some au-
thors, 7'8'12'14'15A7-2° the greatest opening of the suture
was found in the anterior region, with progressively
less separation toward the posterior region.
Relapse Tendencies After Maxillary Expansion
Boysen and La Cour, 4 in their investigation with
quad-helix and removable plate, reported a relapse
in the amount of expansion in the maxillary arch,
except for deciduous second molars, after a 3-month
retention period.
Herold 2s found a lingual tilting of the molars in
all groups (quad-helix and hyrax appliances, and
removable plate) in the postretention period. In our
study, we also found a relapse in the upper intermo-
lar width and the SN-PNS distance in quad-helix
group (p < 0.05). This indicates the relapse ten-
dency in basal and dental structure of the maxilla.
Mew,2e in his study of semirapid expansion,
reported no relapse in the gained expansion in
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 111, No. 3
intermolar width. We have not found any relapse
after semirapid maxillary expansion either, as in
Mew's study.
Aras 16 reported statistically significant decrease
in the SNA angle after a 3-month retention period
in her study with the Haas-type R M E appliance.
Wertz reported that point A relapsed, maintained
stable, and moved forward in 50%, 30%, and 20% of
the cases, respectively, a2 Davis and Kronman 23 also
found forward movement at point A. In the current
study, point A presented backward movement as
characterized by the decrease in the F H - N A and
SNA angles, the A-SNP distance, and the decrease
in the NAP angle.
In the transversal plane, only the mandibular
intermolar width exhibited contraction (p < 0.01).
CONCLUSIONS
1. Equal skeletal and dental results were obtained at
the end of treatment with the quad-helix appliance.
2. The most remarkable dental and skeletal effects
were seen in the transversal plane, less in the
vertical plane, and none in the sagittal plane after
semirapid maxillary expansion.
3. RME showed significant skeletal and dental results
in all planes.
4. All the appliances demonstrated maximum effect in
the transversal plane.
The quad-helix and hyrax appliances appeared to
present a more successful treatment regimen, when
viewed from treatment periods, application methods, pa-
tient cooperation, practical usage, skeletal and dental
results, and orthodontic and medical benefits. We were
not able to evaluate potential iatrogenic consequences of
the three approaches.
Sandtkfto~,lu and Hazar 327
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