A New Protocol for Maxillary Protraction in Cleft Patients:

Repetitive Weekly Protocol of Alternate Rapid

Maxillary Expansions and Constrictions
ERIC JEIN-WEIN LIOU, D.D.S., M.S.
WEN-CHING TSAI, D.D.S.

Objective: It was hypothesized that, through a repetitive weekly protocol of

Alternate Rapid Maxillary Expansions and Constrictions (Alt-RAMEC), the max-
illa in cleft patients could be protracted more effectively than with a single
course of rapid maxillary expansion (RME).
Methods: Twenty-six consecutive unilateral cleft lip and palate patients at
the age of mixed dentition were included in this prospective clinical study. The
rapid maxillary expansion group included the first 16 consecutive patients un-
dergoing 1 week of rapid maxillary expansion (1 mm/day) followed by 5
months, 3 weeks of maxillary protraction. The Alternate Rapid Maxillary Ex-
pansions and Constrictions group included the next 10 consecutive patients
undergoing 9 weeks of Alternate Rapid Maxillary Expansions and Constrictions
followed by 3 months, 3 weeks of maxillary protraction. Daily activation of the
weekly expansion or constriction was 1.0 mm. Two-hinged expanders and in-
traoral maxillary protraction springs were used in both groups. Treatment re-
sults were evaluated cephalometrically.
Results: The amount of maxillary anterior displacement by the 2-hinged ex-
pander in the Alternate Rapid Maxillary Expansions and Constrictions group
was 3.0 ! 0.9 mm at A point, significantly greater than the 1.6 ! 1.0 mm in the
rapid maxillary expansion group. The amount of maxillary advancement with
intraoral protraction springs in the Alternate Rapid Maxillary Expansions and
Constrictions group was 2.9 ! 1.9 mm at A point, significantly greater than the
0.9 ! 1.1 mm in the rapid maxillary expansion group. The overall amount of
maxillary advancement in the Alternate Rapid Maxillary Expansions and Con-
strictions group was 5.8 ! 2.3 mm at A point. This result remained stable,
without significant relapse after 2 years.
Conclusions: Maxillary protraction using the 2-hinged expander, a repetitive
weekly protocol of Alternate Rapid Maxillary Expansions and Constrictions,
and intraoral protraction springs is most effective, with stable results at 2-year
follow-up.

KEY WORDS: cleft, maxillary protraction, maxillary rapid expansion

The combined use of rapid maxillary expansion (RME) and
a facemask is a contemporary technique for maxillary protrac-
tion in cleft patients (Haas, 1970; McNamara, 1987; Turley,
1988). RME is used to facilitate facemask protraction. It is
assumed that circumaxillary sutures are disarticulated after ex-
pansion (Haas, 1970; McNamara, 1987; Turley, 1988).
However, it remains controversial as to what width the ex-
pansion should reach to disarticulate the circumaxillary su-
tures. Some report that 5 mm of expansion are enough (Alcan
Dr. Eric Jein-Wein Liou is Assistant Professor and Director, Department of
Orthodontics and Craniofacial Dentistry, Chang Gung Memorial Hospital, Tai-
pei, Taiwan. Dr. Wen-Ching Tsai is Attending Staff, Department of Orthodon-
tics, Chang Gung Memorial Hospital, Kaohsiung, Taiwan.
Submitted July 2003; Accepted March 2004.
Address correspondence to: Eric JW Liou, 199 Tung-Hwa North Road, Tai-
pei, 105, Taiwan. E-mail lioueric@ms19.hinet.net.
et al., 2000), whereas others report that at least 12 to 15 mm
(Haas, 1980, 2000) are necessary. It seems that a greater
amount of expansion will disarticulate the circumaxillary su-
tures more effectively. However, to expand the maxilla beyond
15 mm (Haas, 2000) is neither clinically practical nor accept-
able to patients. It is difficult to accommodate a jackscrew
longer than 15 mm across the palate without irritating palatal
mucosa. After such expansion, the expanded maxillary dental
arch may be too wide to coordinate transversely with the man-
dibular dental arch. It is usually not necessary to increase the
maxillary transverse dimension when the maxilla has been re-
positioned anteriorly. The goal of rapid maxillary expansion
should be to displace maxilla anteriorly and to disarticulate the
circumaxillary sutures, rather than to expand the maxilla trans-
versely.
To disarticulate the circumaxillary sutures without overex-

121
122 Cleft Palate–Craniofacial Journal, March 2005, Vol. 42 No. 2

TABLE 1 Intragroup and Intergroup Differences After

Maxillary Expansion or Alt-RAMEC at T1-T2 (NT " Tip of
Nasal Bone, ANS " Anterior Nasal Spine, A " A Point, U1 "
Tip of Maxillary Central Incisor, B " B Point, POG "
Pogonion, L1 " Tip of Mandibular Central Incisor)

Measurements (mm), T1-T2

Alt-RAMEC RME versus
RME (Mean ! SD) (Mean ! SD) Alt-RAMEC

NT H† 0.3 ! 0.6‡ 1.1 ! 0.9** *

V "0.2 ! 1.1 "0.1 ! 0.9 ns
ANS H 1.4 ! 0.9*** 2.6 ! 1.0*** **
V 0.4 ! 1.2 0.0 ! 1.2 ns
A H 1.6 ! 1.0*** 3.0 ! 0.9*** **
V 0.4 ! 0.8 0.1 ! 1.0 ns
U1 H 2.5 ! 2.2*** 3.7 ! 1.5*** ns
V 0.7 ! 1.0** 0.8 ! 0.8* ns
B H "2.5 ! 2.4*** "0.9 ! 1.8 ns
V 2.9 ! 1.5*** 3.2 ! 1.5*** ns
POG H "3.4 ! 2.8*** "1.3 ! 1.9 *
V 3.2 ! 1.4*** 3.2 ! 1.4*** ns
L1 H "2.3 ! 2.1*** "0.1 ! 1.1 **
V 3.2 ! 1.5*** 3.0 ! 1.6*** ns
† H # horizontal movement; V # vertical movement.
‡ Positive value indicates forward or downward movement; negative value indicates back-
ward or upward movement.
* p $ .05; ** p $ .01, *** p $ .001; ns # nonsignificant.

This is similar to simple tooth extraction, in which the tooth

is repeatedly rocked buccally and lingually until it is disartic-
ulated from the alveolar socket.
It was postulated that the repetitive weekly protocol of Alt-
RAMEC displaces the maxilla more anteriorly and disarticu-
lates the circumaxillary sutures more effectively than a single
course of RME. The maxilla, therefore, could be protracted
more effectively. The purpose of this prospective study was to
test this hypothesis by comparing the cephalometric results in

TABLE 2 Intragroup and Intergroup Differences During the

Period of Protraction With the Intraoral Maxillary Protraction
Springs (T2-T3) (NT " Tip of Nasal Bone, ANS " Anterior
Nasal Spine, A " A Point, U1 " Tip of Maxillary Central
Incisor, B " B Point, POG " Pogonion, L1 " Tip of
Mandibular Central Incisor)

Measurements (mm), T2-T3

Alt-RAMEC RME versus
RME (Mean ! SD) (Mean ! SD) Alt-RAMEC

NT H† 0.2 ! 0.7‡ 0.9 ! 1.3 ns

V 0.2 ! 0.9 "0.1 ! 1.2 ns
ANS H 0.6 ! 1.2* 2.2 ! 2.5* *
V 0.2 ! 1.0 "0.2 ! 2.1 ns
A H 0.9 ! 1.1** 2.9 ! 1.9*** ***
FIGURE 1 The 2-hinged rapid maxillary expander (A), and the intraoral V 0.2 ! 1.0 0.2 ! 1.5 ns
maxillary protraction spring (B, C). U1 H 1.9 ! 2.7* 3.4 ! 4.0* ns
V "0.1 ! 0.9 "1.6 ! 2.1* *
B H "0.9 ! 3.4 "2.2 ! 2.8* ns
pansion of the maxilla, one alternative is to perform a repeti- V 0.2 ! 2.0 1.3 ! 2.5 ns
POG H "0.6 ! 4.1 "0.6 ! 4.1 ns
tive weekly protocol of Alternate Rapid Maxillary Expansions V 0.2 ! 1.8 1.1 ! 2.5 ns
and Constrictions (Alt-RAMEC). For example, to disarticulate L1 H "2.1 ! 2.8** "4.1 ! 2.4*** ns
circumaxillary sutures through 28 mm of maxillary expansion, V "0.9 ! 1.6* "0.2 ! 2.6 ns
one could alternately perform 7 mm of expansion, 7 mm of † H # horizontal movement; V # vertical movement.
‡ Positive value indicates forward or downward movement; negative value indicates back-
constriction, 7 mm of expansion, and 7 mm of constriction. ward or upward movement.
One could even go beyond 28 mm of maxillary expansion. * p $ .05; ** p $ .01; *** p $ .001; ns # nonsignificant.
 Liou and Tsai, MAXILLARY PROTRACTION IN CLEFT PATIENTS 123

FIGURE 2 Scatterplots of the horizontal movement at A point in the Alt-RAMEC and RME groups at the period of T1-T2.

two groups of patients treated with either a single course of tubes. Lower jaw movement activates the spring. It is passive
RME or a repetitive weekly protocol of Alt-RAMEC. and is at 180& when the mandible opens (Fig. 1B). When the
mandible closes, it is compressed to 100& to 120& and generates
MATERIALS AND METHODS 400 to 500 gm of horizontal and upward force (Figure 1C).

Twenty-six consecutive patients with a unilateral cleft lip TREATMENT PROTOCOLS

and palate and hypoplastic maxillae (SNA $ 82) were includ-
ed for maxillary protraction. Their ages ranged from 9 to 12
years. The RME group included the first 16 consecutive pa-
tients (eight boys and eight girls). The Alt-RAMEC group in-
cluded the next 10 consecutive patients (four boys and six
girls).
The rapid maxillary expander is a 2-hinged expander (U.S.
Patent No. 6334771 B1), shown in Figure 1A. It consists of a
jackscrew in the center, two bolts holding the screw, a body
holding the bolts at anterior, and two hinges of rotation at
posterior. Two anterior extension arms (0.045-inch stainless
steel wires) extend bilaterally and anteriorly from the body
toward the central incisors.
The maxillary protraction device is a pair of noncompliant,
tooth-borne, intraoral maxillary protraction springs (U.S. pat-
ent 6273713 B1), shown in Figures 1B and 1C. Each is a
0.036-inch %-nickel-titanium helix spring. Ball pins are used
to mount the spring on the maxillary and mandibular headgear
RME Group
The treatment protocol in the RME group was 1 week of
RME followed by 5 months, 3 weeks of maxillary protraction.
The total treatment period of expansion and protraction was 6
months. The 2-hinged expander was fabricated in such a way
that the jackscrew was oriented perpendicular to the alveolar
cleft. The anterior extension arms were sandblasted and bond-
ed to the maxillary anterior teeth. Beginning 1 day after ce-
mentation, the expander was expanded 1 mm per day for a
week.
During application of the intraoral maxillary protraction
springs, the mandibular first molars were consolidated with a
0.036-inch stainless steel mandibular lingual holding arch with
built-in lingual crown torque. The patients were seen every 3
weeks for adjusting or replacing the intraoral maxillary pro-
traction springs when the springs were distorted or broken. The

FIGURE 3 Scatterplots of A point horizontal movement in the Alt-RAMEC (A) and RME (B) groups at the period of maxillary protraction, T2-T3.
124 Cleft Palate–Craniofacial Journal, March 2005, Vol. 42 No. 2

FIGURE 4 Clinical results of maxillary protraction using the 2-hinged expander, repetitive weekly protocol of Alt-RAMEC, and intraoral protraction
springs. The lateral facial profiles before treatment (T1) (A), at the end of protraction (T3) (B), and 2 years after the protraction (T4) (C). The occlusion
at T1 (D), T3 (E), and T4 (F). The lateral cephalograms at T1 (G), T3 (H), and T4 (I).

expander and the springs were removed at the end of the sixth
month.
Alt-RAMEC Group
The treatment protocol in the Alt-RAMEC group was 9
weeks of Alt-RAMEC followed by 3 months, 3 weeks of max-
illary protraction. The total treatment period was 6 months.
The weekly sequence of Alt-RAMEC was four pairings of
expansion and constriction, followed by a final expansion.
Each expansion or constriction course was 7 days and 1 mm
per day. A 0.036-inch stainless steel mandibular lingual hold-
ing arch with built-in lingual crown torque also was used dur-
ing the period of maxillary protraction. The patients were seen
every 3 weeks for adjusting or replacing the intraoral maxillary
protraction springs when they were distorted or broken. The
expander and springs were removed at the end of the sixth
month.
CEPHALOMETRIC RECORDS AND MEASUREMENTS
For each patient in the RME group, lateral cephalometric
radiographs were taken before cementation of the expander
(T1), after one week of expansion (T2), and at the sixth month
after removal of the expander and springs (T3). For each pa-
tient in the Alt-RAMEC group, lateral cephalometric radio-
graphs were taken before cementation of the expander (T1),
immediately after the course of Alt-RAMEC (T2), at the sixth
month after removal of the expander and springs (T3), and 2
years after the protraction (T4).
Lateral cephalometric tracings of T1, T2, T3, and T4 were
superimposed on the cranial base by registering on the sella,
orienting on the sella-nasion (SN) line, and using the outline
of the cranial vault for final confirmation (Liou et al., 1998).
A horizontal reference line through the sella was then con-
structed down anteriorly 7& to the SN line, and a perpendicular
line was constructed through the sella as the vertical reference
 Liou and Tsai, MAXILLARY PROTRACTION IN CLEFT PATIENTS 125

line. The perpendicular and horizontal changes to the reference TABLE 3 Intragroup and Intergroup Differences for the
Overall Treatment Results (T1-T3) (NT " Tip of Nasal Bone,
lines at A point, anterior nasal spine (ANS), tip of the nasal ANS " Anterior Nasal Spine, A " A Point, U1 " Tip of
bone (NT), tip of the maxillary central incisor (U1), tip of the Maxillary Central Incisor, B " B Point, POG " Pogonion, L1 "
mandibular central incisor (L1), B point, and the pogonion Tip of Mandibular Central Incisor)
(POG) were measured.
Measurements (mm), T1-T3
Intragroup differences of each landmark at T1-T2, T2-T3,
Alt-RAMEC RME versus
or T1-T3 were analyzed with a paired t test, and the intergroup RME (Mean ! SD) (Mean ! SD) Alt-RAMEC
differences were compared with Student’s t test. In the Alt-
NT H† 0.5 ! 0.6*‡ 1.9 ! 1.3** ***
RAMEC group, changes at T1-T4 were compared to those at V 0.1 ! 0.7 "0.1 ! 0.4 ns
T1-T3 with a paired t test for maxillary stability after maxillary ANS H 2.1 ! 1.3*** 4.8 ! 2.5*** ***
protraction. V 0.6 ! 1.6 "0.2 ! 1.6 ns
A H 2.6 ! 1.5*** 5.8 ! 2.3*** ***
V 0.6 ! 1.0 0.3 ! 1.2 ns
RESULTS U1 H 4.4 ! 2.2*** 7.1 ! 4.0*** *
V 0.6 ! 0.8* "0.8 ! 2.0 *
B H "3.4 ! 2.4*** "3.1 ! 1.6*** ns
All patients in both groups tolerated the procedures well V 3.1 ! 2.2*** 4.5 ! 2.5*** ns
during treatment. Some patients in the Alt-RAMEC group, POG H "4.0 ! 2.8*** "1.9 ! 3.6 ns
though none in RME group, reported discomfort over the nasal V 3.1 ! 2.1*** 4.2 ! 2.4*** ns
L1 H "4.3 ! 2.1*** "4.2 ! 2.0*** ns
bone, suborbital region, and zygomatic key-ridges during the V 2.3 ! 1.7*** 2.8 ! 2.1** ns
rapid expansions or constrictions of the maxilla. No patients
† H # horizontal movement; V # vertical movement.
reported severe pain. ‡ Positive value indicates forward or downward movement; negative value indicates back-
At T1-T2 (Table 1), the maxillae were significantly dis- ward or upward movement.
* p $ .05; ** p $ .01; *** p $ .001; ns # nonsignificant.
placed anteriorly and the mandible were rotated inferiorly and
posteriorly in both groups. The nasal bones were significantly
displaced anteriorly in the Alt-RAMEC group, but not in the single course of RME, resulting in more effective protraction
RME group. More significant anterior displacement of the na- of the maxilla. The amount of maxillary anterior displacement
sal bones and maxillae was observed in the Alt-RAMEC group in the Alt-RAMEC group was almost twice that of the RME
than in the RME group. Anterior displacement of the maxilla group (3.0 ! 0.9 mm versus 1.6 ! 1.0 mm). The amount of
at A point ranged from 2.0 to 4.5 mm in the Alt-RAMEC maxillary advancement with maxillary protraction springs in
group, and from 0.0 to 3.5 mm in the RME group (Fig. 2). the Alt-RAMEC group was three times greater than that in the
At T2-T3 (Table 2), the maxillae were significantly protract- RME group (2.9 ! 1.9 mm versus 0.9 ! 1.1 mm).
ed by the intraoral protraction springs in both groups. The The expanders used in both groups were the 2-hinged ex-
maxillae were protracted more in the Alt-RAMEC group than pander, and all were oriented perpendicular to the alveolar
in the RME group. The maxillae in all patients in the Alt- cleft. The patients all had a unilateral cleft lip and palate and
RAMEC group were protracted anteriorly, whereas there were were of a similar age. The intraoral protraction springs in both
seven patients in the RME group whose maxillae remained at groups had a similar force magnitude, although protraction in
the same position and were not protracted anteriorly (Fig. 3). the Alt-RAMEC group was 8 weeks shorter than that of the
At T1-T3 (Table 3), the nasal bones and maxillae were all RME group. It seems apparent that the greater amount of max-
significantly protracted and the mandibles were rotated pos- illary advancement in the Alt-RAMEC group was related to
teriorly and inferiorly in both groups. The posterior and infe- the repetitive weekly protocol of Alt-RAMEC rather than the
rior rotation of the mandible was related to the counterclock- noncompliant intraoral protraction springs.
wise rotation of the maxilla and dental tipping of the maxillary The total amount of maxillary advancement was 5.8 ! 2.3
and mandibular molars (Figs. 4 and 5). The maxillary incisors mm in 6 months for the Alt-RAMEC group; the 2-year follow-
tipped anteriorly, and the mandibular incisors tipped posteri- up evaluations revealed that the advancement was stable, with-
orly. The overall advancement of the maxillae at A point was out significant relapse. The 2-hinged expander contributed 3.0
5.8 ! 2.3 mm in the Alt-RAMEC group, compared with 2.6 mm and the intraoral protraction spring contributed 2.9 mm to
! 1.5 mm in the RME group. overall maxillary advancement, in contrast with 2.4 mm in 7.7
The maxilla remained stable without significant relapse for months with a hyrax expander and facemask under a single
2 years after treatment in the Alt-RAMEC group (Table 4, course of expansion (Kim et al., 1999). The overall maxillary
Figs. 4 and 5). advancement in the Alt-RAMEC group was two to three times
greater than that with a hyrax expander and facemask. Three
DISCUSSION factors may have contributed to the greater amount of maxil-
lary advancement: the 2-hinged expander, the Alt-RAMEC,
The results of this clinical prospective study supported the and the intraoral protraction springs.
hypothesis that a repetitive weekly protocol of Alt-RAMEC The 2-hinged expander is designed to consistently displace
with a 2-hinged expander displaces the maxilla more anteriorly the maxilla anteriorly. Because of the two hinges, the expander
and may disarticulate the circumaxillary sutures better than a rotates each half of the maxilla outward and forward around
126 Cleft Palate–Craniofacial Journal, March 2005, Vol. 42 No. 2

FIGURE 5 Cephalometric superimpositions of T1-T3 (A) and T3-T4 (B) of the same patient featured in Figure 4.

the maxillary tuberosities, rather than around the posterior na- 1988) or modified protraction headgear (Nanda, 1980; Alcan
sal spine, as the hyrax expander does. This assumes a geo- et al., 2000), and heavy Class III elastics (Haas 1980), which
metrically anterior displacement or repositioning of the maxilla all required patient compliance. The Alt-RAMEC significantly
without the possibility for bone resorption behind the maxil- facilitated the maxillary protraction, compared with the single
lary tuberosities. The lack of need for patient compliance with course of expansion.
the intraoral maxillary protraction spring has an advantage In addition to the maxilla, the nasal bones were also dis-
over the facemask (Haas, 1970; McNamara, 1987; Turley, placed and protracted anteriorly in the Alt-RAMEC group.
This explains why some patients in the Alt-RAMEC group
reported discomfort over the nasal bones and zygomatic key-
TABLE 4 Two-Year Stability After Maxillary Protraction in the
Alt-RAMEC Group (NT " Tip of Nasal Bone, ANS " Anterior ridges during Alt-RAMEC. The discomfort may indicate that
Nasal Spine, A " A Point, U1 " Tip of Maxillary Central the nasomaxillary complex was being disarticulated. Anatom-
Incisor, B " B Point, POG " Pogonion, L1 " Tip of ically, the nasal bones articulate with the frontonasal processes
Mandibular Central Incisor)
of the maxilla. The nasomaxillary complex was protracted as
Measurements (mm) one piece three times more frequently than with RME. This
T1-T3 T1-T4 T1-T3 versus suggests that the circumaxillary sutures were disarticulated by
(Mean ! SD) (Mean ! SD) T1-T4 the Alt-RAMEC protocol.
NT H† 1.9 ! 1.3‡ 4.0 ! 2.0 ** The results suggest that the circumaxillary sutures in the
V "0.1 ! 0.4 "0.1 ! 1.5 ns Alt-RAMEC group were separated and stretched to a greater
ANS H 4.8 ! 2.5 4.8 ! 3.2 ns
degree than those in the RME group. It would be interesting
V "0.2 ! 1.6 1.5 ! 1.2 **
A H 5.8 ! 2.3 5.7 ! 3.0 ns to know how circumaxillary sutures react under such an ac-
V 0.3 ! 1.2 1.6 ! 1.1 ** celerated stretch. Experimental separation of craniofacial su-
U1 H 7.1 ! 4.0 8.4 ! 3.6 ns
V "0.8 ! 2.0 0.0 ! 2.0 ns
tures in rats and monkeys, with both high and low expansion
B H "3.1 ! 1.6 "0.1 ! 1.4 ** or traction forces, resembles those seen during normal growth,
V 4.5 ! 2.5 6.0 ! 2.5 * though more marked (Linge, 1972; Droshl, 1975; Engstrom
POG H "1.9 ! 3.6 2.6 ! 4.7 **
V 4.2 ! 2.4 5.7 ! 2.2 *
and Thilander, 1985). The mechanical response to traction in-
L1 H "4.2 ! 2.0 "0.3 ! 1.6 ** cludes a widening of the suture, changes in the orientation of
V 2.8 ! 2.1 4.3 ! 2.6 ns fiber bundles, increase of osteoblasts, and deposition of osteoid
† H # horizontal movement; V # vertical movement. on both sutural bone surfaces (Engstrom and Thilander, 1985).
‡ Positive value indicates forward or downward movement; negative value indicates back-
ward or upward movement.
For this reason, the rapid expansion of the intermaxillary su-
* p $ .05; ** p $ .01; *** p $ .001; ns # nonsignificant. ture is recognized as sutural expansion osteogenesis, resem-
 Liou and Tsai, MAXILLARY PROTRACTION IN CLEFT PATIENTS
bling distraction osteogenesis (Liu et al., 2000). It also has
been shown that cranial sutures, the frontonasal suture, and the
sutures of the nasomaxillary complex can be distracted suc-
cessfully by using distraction devices (Movassaghi et al., 1995;
Staffenberg et al., 1995; Tung et al., 1999).
We believe that what occurred in the circumaxillary sutures
in the Alt-RAMEC group was not a simple deposition of os-
teoid found in facemask traction. It could be an orthopedic
process of sutural expansion/protraction osteogenesis, which
is similar, but less vigorous, than sutural distraction osteogen-
esis. The similarity is that all sutures are rapidly separated or
stretched to produce osteogenesis, and the differences relate to
the mechanical approaches used (protraction, expansion, dis-
traction) and the varying degrees of osteogenesis.
One of the limitations in this clinical study was the inability
to provide evidence of disarticulation of circumaxillary su-
tures. Animal studies are needed to provide histological evi-
dences on disarticulation and tissue reactions to circumaxillary
sutures during Alt-RAMEC and maxillary protraction.
CONCLUSIONS
The repetitive weekly protocol of Alt-RAMEC displaced the
maxilla anteriorly two times better and facilitated maxillary
protraction three times better than a single course of RME.
Maxillary protraction in cleft patients using the 2-hinged ex-
pander, a repetitive weekly protocol of Alt-RAMEC, and in-
traoral protraction springs appears to be an effective treatment
course, and the results obtained remain stable.
REFERENCES
Alcan T, Keles A, Erverdi N. The effects of a modified protraction headgear
on maxilla. Am J Orthod Dentofacial Orthop. 2000;117:27–38.
127
Droshl H. The effect of heavy orthopedic forces on the suture of the facial
bones. Angle Orthod. 1975;45:26–33.
Engstrom C, Thilander B. Premature facial synostosis: the influence of bio-
mechanical factors in normal and hypocalcemic young rats. Eur J Orthod.
1985;7:35–47.
Haas AJ. Palatal expansion: just the beginning of dentofacial orthopedics. Am
J Orthod. 1970;57:219–255.
Haas AJ. Long-term posttreatment evaluation of rapid palatal expansion. Angle
Orthod. 1980;50:189–217.
Haas AJ. The non-surgical treatment of the skeletal Class III. Book of Abstract,
American Association of Orthodontists 100th Annual Session 2000, p.85.
Kim JH, Viana MAG, Graber TM, Omerza F, BeGole EA. The effectiveness
of protraction facemask therapy: A meta-analysis. Am J Orthod Dentofacial
Orthop. 1999;115:675–685.
Linge L. Tissue reactions incident to widening of facial sutures. An experi-
mental study in the Macaca mulatta. Trans Eur Orthod Soc. 1972;48:487–
497.
Liou EJ, Huang CS, Chen YR, Figueroa AA. Validity of using fixation screws/
wires as alternative landmarks for cephalometric evaluation after LeFort I
osteotomy. Am J Orthod Dentofacial Orthop. 1998;113:287–292.
Liu C, Song R, Song Y. Sutural expansion osteogenesis for management of the
bony-tissue defect in cleft palate repair: experimental studies in dogs. Plast
Reconstruc Surg. 2000;105:2012–2025.
McNamara JA Jr. An orthopedic approach to the treatment of Class III mal-
occlusion in young patients. J Clin Orthod. 1987;21:598–608.
Movassaghi K, Altobelli DE, Zhou H. Frontonasal suture expansion in the
rabbit using titanium screws. J Oral Maxillofac Surg. 1995;53:1033–1042;
discussion 1042–1043.
Nanda R. Biomechanical and clinical considerations of a modified protraction
headgear. Am J Orthod 1980;78:125–139.
Staffenberg DA, Wood RJ, McCarthy JG, Grayson BH, Glasberg SB. Midface
distraction advancement in the canine without osteotomies. Ann Plast Surg.
1995;34:512–517.
Tung TH, Robertson BR, Winograd JM, Mullick T, Manson PN. Successful
distraction osteogenesis across a growing cranial suture without an osteot-
omy. Plast Reconstr Surg. 1999;103:362–370.
Turley PK. Orthopedic correction of Class III malocclusion with palatal expan-
sion and custom protraction headgear. J Clin Orthod. 1988;22:314–325.