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Cast Haas-type RME appliance: A case report

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Case Reports
Cast Haas-type RME appliance:
A case report
Mauro Cozzani, DMD, MScD1
Mattia Fontana, DMD1
Paolo Cozzani, DMD1
Andrea Bertelli2

Rapid maxillary expansion (RME) in the initial stages of occlusal development

has become a routine procedure in orthodontic practice. The increase of the
transverse dimensions of the maxilla in the mixed dentition can be carried
out by a rapid palatal expander that exploits primary teeth as anchorage to
minimize any negative effects on permanent teeth. This case report demonstrates
the use of a modified Haas-type RME appliance in a Caucasian girl 7 years
6 months of age with a maxillary transverse deficiency, unilateral crossbite,
dental midline deviation, and maxillary anterior dental crowding. The patient
was treated with a modified Haas-type RME appliance composed of a six-band
metal-cast structure with a partial occlusal covering that was bonded to the
primary teeth using glass-ionomer cement. Clinicians see advantages in terms
of speed of application and patient compliance by taking a single impression.
Stability and retention of the appliance improve thanks to custom-made
metal casting and the risks of decementation minimize via the use of glass-
ionomer cement. Moreover, the fabrication in inert titanium, hypoallergenic
resin, and laser soldering means patients with allergies can use it. The results
demonstrate that the expansion carried out on primary teeth is followed by
permanent molars and remains stable. Orthodontics (Chic) 2011;12:252–259.

Key words: cast Haas-type RME appliance, expansion stability of permanent

dentition, maxillary incisor alignment, mixed dentition, rapid palatal expansion

R
apid maxillary expansion (RME) in the initial stages of occlusal devel-
opment has become a routine procedure in orthodontic practice when
orthopedic expansion of the jaw is required1 (ie, in cases of maxillary
constriction). This condition often results in unilateral crossbite, which can be
accompanied by functional deviation of the mandible.2 If not treated early,
1PrivatePractice, La Spezia, skeletostructural asymmetry of the mandible may arise.3
Italy.
2Lab Technician, La Spezia, Numerous devices designed to increase the transverse dimensions of the
Italy. maxilla in young patients have been described,4,5 and the rapid palatal ex-
pander is surely among the most efficacious due to its ability to exploit ortho-
CORRESPONDENCE
Dr Mauro Cozzani pedic forces to open the median suture of the palate using dental anchorage.6
Via Fontevivo, 21N The aim of this type of treatment is to obtain maximum orthopedic effects
La Spezia (SP) without compromising the position of the teeth,7 and this can be achieved if the
19125 Italy
Email: maurocozzani@ underlying cranial structures (nasal floor and orbitary structures) are targeted for
gmail.com alteration.8

252 ORTHODONTICS   The Art and Practice of Dentofacial Enhancement

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 However, the deleterious effects of stress on the cranial base tend to in-
tensify with increasing age due to the diminishing elasticity of the bone. It
is postulated that strain can arise upon flexion of the pterigoid processes in
adulthood during rapid palatal expansion, especially in the sphenoid bone,
with the risk of involvement of anatomical zones critical for the passage of
nervous and vascular structures.9
In addition, the skeletal changes induced by RME also seem prone to partial
relapse in the long term,10,11 in particular if RME is employed after the pubertal
growth peak.12 Nevertheless, recent studies have demonstrated how expan-
sion will remain more stable if it is performed before eruption of the perma-
nent maxillary lateral incisors.13 Permanent first molars and first premolars are
often exploited for anchorage, but this unfortunately leads to buccal inclina-
tion14,15 (which tends to partially relapse after the retention phase) and buccal
tipping of the crowns of these teeth.16
In addition, forces exerted during expansion17,18 frequently lead to root re-
sorption19,20 and bone dehiscence on the buccal side, especially in patients
with scarce alveolar bone thickness. Previous studies have demonstrated how
gingival recession in teeth used for anchorage occurs three times as frequently
with respect to the other teeth.21
To avoid these undesired effects on permanent teeth, palatal expansion can
be carried out in mixed dentition22: The primary teeth may be exploited via
bands cemented onto the primary second molars and lingual wires bonded
onto the primary canines.23
However, the necessity of adapting appliances for permanent teeth for use
with their primary counterparts is not a simple procedure, particularly due to
the poor retention of the coronal anatomy of the primary molars. Further-
more, bonding of the anterior lingual wires of the palatal expander can re-
quire grooves to be made on the primary canines using a turbine-driven bur,
a process that requires a certain degree of collaboration, which is not always
possible with young children.
The aim of the present report was to present an Haas-type RME appliance
on primary teeth, requiring new construction procedures to resolve transverse
discrepancies in the first stages of mixed dentition and minimizing chair time
and compliance from young patients.

Appliance construction

A single alginate-impression has to be taken and sent to the lab. Two acrylic
clear resin covers (one for each side) (Pattern Resin LS, GC) are built on the pri-
mary teeth, from the second molar to the canine (Fig 1).24 Acrylic resin covers

Volume 12, Number 3, 2011 253

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Case Reports Cast Hass-type RME appliance

Fig 1  (Left)  Acrylic clear resin covers built onto the primary teeth, from the second molars to canines.

Fig 2  (Right)  Acrylic resin covers are metal cast and verified on a master cast.

Fig 3   Hooks and vestibular tubes

with 1.2 mm diameter are inserted
with laser weldings.

Fig 4   After inner titanium bioxide

shot-blasting, the appliance is ready
to be sent to the clinician.

are then metal cast. After verifying the adaptation on master cast, the metal
casting covers are finished and polished (Fig 2).
An expansion screw (Titan-hyrax screw, Dentaurum) is selected and con-
nected to the metal casting coverages by titanium connectors with laser weld-
ings and then covered by two resin pads (Orthocryl, Dentaurum).
Hooks and 1.2-mm-diameter vestibular tubes are laser welded and then
rounded off and polished (Fig 3).
The construction with biocompatible materials (inert biomedical titanium,
hypoallergenic resin, and laser welding) permits the use of this appliance in
patients with allergies. In particular, pure type I titanium bars (0.8 to 1.2 mm
diameter) and pure type IV titanium wire are used.
The strong appliance retention is guaranteed by the individual metal cast-
ings and the final inner titanium bioxide shot-blasting (Fig 4). The inner part can
be filled with a small quantity of glass-ionomer cement (Fuji Ortho, American
Orthodontics) and bonded to the primary teeth.

254 ORTHODONTICS   The Art and Practice of Dentofacial Enhancement

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Cozzani et al
Case Reports

Fig 5  A girl aged 7 years 6 months with a left lateral crossbite at the permanent first molar, the
primary first and second molars, and the permanent lateral incisor on the opposite side. The patient
presented a high-vaulted, narrow palate and slight crowding in the maxillary and mandibular anterior
sectors. The midlines did not coincide.

Case report

The treatment of a girl, aged 7 years 6 months, in the intertransitional phase

of mixed dentition is shown. She presented with a skeletal Class I, normodiver-
gent growth pattern, maxillary transverse deficiency, and mandibular deviation.
She had a Class I dental relationship, with a left lateral crossbite involving the
permanent first molar and the primary first and second molars and a crossbite
of the permanent maxillary lateral incisor on the opposite side. The midlines
appeared to not be coinciding for a lateral functional mandibular shift caused
by dental interferences; overjet and overbite were found to be within the nor-
mal limits, and a slight degree of crowding was noted in the maxillary and man-
dibular anterior sections. The patient presented an asymmetrically constricted
narrow palate (Fig 5). Functional analysis revealed no signs or symptoms of
dysfunction, and the patient was a partial mouth breather.
A modified cast Haas-type RME anchored to the primary teeth (Fig 6a) was
employed to restore the correct transverse dimension of the maxilla and pro-
vide space for the maxillary permanent lateral incisors.
Activation of the device was accomplished with a single turn of the screw
every day, each equivalent to 0.20 mm. Resolution of the left unilateral cross-
bite as well as that at the permanent right lateral incisor, was achieved after 38
turns (Fig 6b). The device was then left passively in situ for about 10 months to
allow reorganization and bone restructuring of the median palatine suture and
alveolar processes.
Correct transverse relationships at the permanent molars were obtained via
expansion forces exerted on the primary teeth: The permanent molars fol-
lowed the expansion obtained on their primary counterparts and were thus
guided into occlusion without any appliances directly applied to them.

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Case Reports Cast Hass-type RME appliance

Fig 6a   A modified cast Haas-type RME appliance anchored on primary teeth was applied; metal-
cast structure embraces six primary teeth and partially covers the occlusal surface. The device was
bonded using glass-ionomer material.

Fig 6b   After 38 single turns of a screw (0.20 mm), resolution of the crossbite at the permanent right
lateral incisor and the crowding in the anterior sector was achieved. At this point, the screw was
blocked with acrylic resin.

Fig 7   The 3-year, 2-month follow-up confirms the maxillary incisor alignment and the posterior trans-
versal stability. The patient is now in permanent dentition: Dental midlines coincide and the maxillary
canines erupted in the correct occlusion. The maxillary left first premolar rotation has not allowed a
correct occlusion of that tooth.

Expansion of the primary teeth permitted resolution of posterior crossbite

on permanent first molar and provided space for the permanent maxillary lat-
eral incisors. The lateral functional mandibular shift was corrected and dental
midlines were coincident; metal casting separated the occlusion, and no oc-
clusal grinding was necessary. The stability of the occlusion was maintained in
the permanent dentition (Fig 7). The maxillary left first premolar rotation did
not allow a correct occlusion of that tooth.

256 ORTHODONTICS   The Art and Practice of Dentofacial Enhancement

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Cozzani et al
Case Reports
Discussion

Correction of transversal discrepancies in the early mixed dentition can be ef-

fectively performed by means of a rapid palatal expander anchored onto the
primary teeth,23 and relapse can be minimized if expansion is carried out prior
to eruption of the permanent maxillary lateral incisors.13
A previously described Haas-type RME appliance for primary anchorage was
composed of two bands cemented onto the primary second molars, two an-
terior lingual wires bonded to the primary canines, and an acrylic resin palatal
pad with a central screw.23
The modified Haas-type RME appliance is made up of custom-made metal
castings (one for each side) that cover the primary first and second molars and
primary canines24,25; hooks at the primary canines for elastic traction (Class II
and asymmetrical elastics, Delaire mask26) and buccal tubes at the primary
second molars (for extraoral traction) and Class III elastics are incorporated
into the structure.
This type of appliance offers clinical advantages of ease and speed of manu-
facture and fitting. While the bands in the original device had to be adapted
to the poorly retentive coronal anatomy of the primary second molars, the pro-
cess can now be accelerated by close collaboration with the dental technician,
to whom it is sufficient to send an alginate impression. When the device comes
back from the lab, it will already be perfectly adapted to the patient’s primary
teeth, and the turbine-driven bur will not be required to create grooves for
housing the anterior wires on the canines. The clinician need only bond the
appliance to the teeth with composite material or glass-ionomer cement. This
step is very rapid and simple, minimizing chair time and the request for compli-
ance from the young patient.
The rigid metal-cast structure involving six primary teeth and using glass-
ionomer cement has the advantage of greater stability and retention than
traditional appliances (anchored to only two primary molars that have a less
convex coronal structure and to a lingual wire bonded to primary canines with
a greater risk of decementation).
The appliance may be fabricated with biocompatible materials (inert bio-
medical titanium, hypoallergenic resin, and laser welding), which allows for its
use in allergic patients.24,25
Studies demonstrate that the orthopedic forces exerted during expansion
may damage the teeth used for anchorage21–27; however, when using our device,
this potential damage is limited to the primary teeth that will soon be replaced.
Mandibular shift is a frequently occurring phenomenon in cases of unilateral
crossbite2,3; however, in this case, the partial occlusal coverage provided by
the rigid metallic structure has the advantage of separating the occlusion and
giving the muscles the opportunity to abandon the habitual shift and the man-
dible to come back to centric relation during treatment; if some interferences
remained, it will be easier to identify and eliminate them by occlusal adjust-
ment after treatment.

“ . . .relapse can be minimized if expansion is

”
carried out prior to eruption of the permanent
maxillary lateral incisors.

Volume 12, Number 3, 2011 257

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Case Reports Cast Hass-type RME appliance

Conclusion

The case presented shows that Haas-type RME appliances anchored to the pri-
mary teeth are an effective procedure to resolve posterior crossbite and maxil-
lary transverse deficiency and to provide space for maxillary permanent lateral
incisors in the mixed dentition. The modified cast-Haas type RME appliance
offers numerous advantages in terms of speed of application and patient com-
pliance because a single impression is required for construction. Metal casting
adapts perfectly to the anatomy of primary teeth, and this, in addition to the
use of glass-ionomer cement, considerably increases stability and retention of
the appliance. Partial occlusal coverage separates the occlusion in the pres-
ence of functional mandibular shift, postponing any occlusal adjustment. Fab-
rication with inert biocompatible materials extends its use to allergic patients.

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“ . . . Haas-type RME appliances anchored to the primary teeth

are an effective procedure to resolve posterior crossbite

”
and maxillary transverse deficiency and to provide space for
maxillary permanent lateral incisors in the mixed dentition.

258 ORTHODONTICS   The Art and Practice of Dentofacial Enhancement

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 Cozzani et al
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