Arch Expansion

By
AMR SAMY
MSc student, Orthodontic Department
Faculty of Dental Medicine
Al-Azhar University (Assiut)

Under super vision of

Ass. Professor/Mohamed Ahmed Salem
Head of orthodontic department
Al-azhar university
Assiut branch
 Arch expansion

Content:
 Introduction.
 Diagnosis.
 Causes For Transverse Maxillary Deficiency.
 Types of Expansion:

1) Orthodontic Expansion.
2) Orthopedic Expansion.
3) Passive Expansion.

 Slow expansion.
 Rapid expansion.
 Surgically assisted rapid palatal expansion.

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Introduction
The goals of orthodontic treatment are well established for static and
functional occlusal relationships. In order to achieve Andrews‘ six keys to
normal occlusion for the dentition, 1 the jaws must be optimally proportioned in
three planes of space and positioned in CR. Orthodontists have well-established
methods for diagnosing the skeletal relationship of the maxilla to the mandible
in the sagittal and vertical dimensions. 2,6 Several analyses for the transverse
dimension are also available, 3,6,7 but these analyses are not well accepted as
forming part of traditional orthodontic diagnosis. In the sagittal dimension,
when the jaws do not relate optimally, the dentition will attempt to compensate,
resulting in excessively proclined or retroclined anterior teeth. In the transverse
dimension, when the jaws do not relate optimally, usually due to a deficiency in
the width of the maxilla, 7,8 the teeth will erupt into a crossbite or reconfigure
their inclinations to avoid a crossbite. This compensation typically involves
lingual tipping of the mandibular posterior teeth, which are then described as
being excessively negatively inclined. In addition, the maxillary posterior teeth
are tipped facially. These teeth are then described as being excessively
positively inclined.

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Methods of Transverse Diagnosis

1) Ricketts’ P-A Analysis:

In 1969, Ricketts introduced analysis of the transverse skeletal dimension as

part of his method of cephalometric diagnosis. 3 His method uses the frontal, or
postero anterior (P-A) cephalogram, and is based on the dimensions of the jaws
compared to a table of age-adjusted normative values .The premise of the
analysis is based on locating two skeletal points to determine maxillary width
and two additional skeletal points to determine mandibular width For the
maxilla, the jugal point (Mx) is located on the right and left sides of the
maxillary skeletal base at ―the depth of the concavity of the lateral maxillary
contours, at the junction of the maxilla and the zygomatic buttress.‖ 3 The
maxillary width is determined by the horizontal distance connecting these two
points. For the mandible, a similar measurement is taken between the two
antegonial notches (Ag). These notches are located on the right and left sides of
the mandibular body at the ―innermost height of contour along the curved
outline of the inferior mandibular border, below and medial to the gonial angle.3
Once the measurements have been taken, the mandibular width (Ag-Ag) is
subtracted from the maxillary width (Mx-Mx) to get the difference in width
between the jaws. Ricketts then determined skeletal age-determined normative
relation-ships between the maxilla and the mandible. This allows the analysis to
accommodate growing patients, and allows for the differential growth rates and
potentials of the maxilla and the mandible.

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2) Andrews’ Element III Analysis:

In 1970, L. F. Andrews published his landmark paper describing the six keys
to normal static occlusion. 1 Over the next several decades, he and his son, W.
A. Andrews, worked to develop the six elements philosophy of orthodontic
diagnosis. One of the diagnostic criteria, Element III, is devoted to analyzing
the transverse relationship of the maxilla and mandible and is based on both
bony and dental landmarks. 10 The Element III analysis is based on the
assumption that the WALA (named after Will Andrews and Larry Andrews)
ridge determines the width of the mandible. According to Andrews‘ definition,
the WALA ridge is coincident with the most prominent portion of the buccal
alveolar bone, when viewed from the occlusal surface The WALA ridge is
essentially coincident with the mucogingival junction and approximates the
center of resistance of the mandibular molars. In a mature patient, the WALA
ridge and the width of the mandible cannot be modified with conventional
treatment. Thus the WALA ridge forms a stable basis for the Element III
analysis. 6The Element III analysis is based on the width change, if any, of the
maxilla needed to have upper and lower posterior teeth upright in bone, centered
in bone, and properly intercuspated.

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To determine the discrepancy, the first step is to determine the width of the
mandible, or the horizontal distance from the WALA ridge on the right side to
the WALA ridge on the left side. According to Andrews, optimally positioned
mandibular molars will be upright in the alveolus, and their facial axis (FA)
point, or center of the crown, will be horizontally positioned 2 mm from the
WALA ridge. With this information, the width of the mandible is then defined
asthe WALA-WALA distance minus 4 mm. 6

The width of the maxilla is based on optimization of the angulation of the

maxillary molars. To determine this width, one measures the horizontal distance
from the FA point of the left molar to the FA point of the right molar and
records the measurement.

One then looks at the angulation of the maxillary molars and estimates the
amount of horizontal change that will occur between the FA points of the right
and left molars when they are optimally angulated. The estimated amount of
change is subtracted from the original FA-FA measurement. The result
represents the width of the maxilla. 6
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In order to have optimally positioned and optimally inclined molar teeth that
intercuspate well, Andrews states that the maxillary width must be 5 mm greater
than the mandibular width. 6 In order to determine the amount of transverse
discrepancy, or Element III change, needed to produce an ideal result, one takes
the optimal mandibular width, adds 5 mm, and subtracts the maxillary width.

3)University of Pennsylvania Cone-Beam CT Analysis

The trend in orthodontic imaging and diagnosis is toward three-dimensional

analysis. With the advent of cone-beam imaging, orthodontists can obtain
precise measurements without any distortion caused by radiographic projections
or ambiguity of point identification. The same rationale can subsequently be
applied to the transverse measurement of the maxilla and the mandible.
Ricketts‘ and Andrews‘ methods for determining the amount of transverse
discrepancy between the jaws are based on using readily discernable landmarks
that represent the width of the base of the alveolar housing. For Ricketts, these
landmarks are Mx-Mx for the maxilla and Ag-Ag for the mandible. For
Andrews, these landmarks are the two sides of the WALA ridge and the FA
points of the maxillary and mandibular molars. The WALA measurement
represents the width of the mandible, and the FA-FA points are used, as
described above, to determine the width of the maxilla. Both of these methods
have merit. However, with cone-beam CT imaging, it is no longer necessary to
have a measurement dictated by ease with which landmarks can be identified to
represent the widths of the jaws.

Before choosing a method for measuring the base of the jaws, we must first
decide what location to use for measurement. In determining the location of the
WALA ridge, Andrews stated that the WALA ridge is an approximation of the
center of resistance of the mandibular teeth. Above the WALA ridge, the
alveolus can be dimensionally molded and altered, depending on the change in
angulation of the teeth. However, the same cannot be said for the portion of the
alveolus below the WALA ridge.

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Thus, in a mature patient, any portion of the alveolus apical to the WALA
ridge can be assumed to be reasonably dimensionally stable during tooth
movement, and,therefore, can define the dimensions of the patient‘s arch. In
Ricketts‘ analysis, Ag-Ag represents the basal portion of the mandible.
However, when one looks at the position of Ag on a three-dimensional image,
one sees that its correlation with the base of the alveolus is relatively weak in all
three planes of space for mature patients Thus, to locate the beginning of the
base of the mandible with a CT scan, it would seem best to find the skeletal
representation of the WALA ridge. This is approximately at the edge of the
cortical bone opposite the furcation of the mandibular first molars. We can also
use this technique to locate the beginning of the base of the maxilla. If we
assume that the maxilla begins at the projection of the center of resistance of the
maxillary teeth onto the buccal surface of the cortical bone, Ricketts‘ use of Mx
to determine maxillary width appears to be at approximately at the same
horizontal position. Additionally, by using Mx point, any exostoses present
along the buccal portion of the alveolus will not interfere with the measurement.
Andrews‘ method, on the other hand, has no directly definable skeletal
landmark for the maxilla; it relies on estimated changes in the angulation of the
molars to determine the skeletal transverse discrepancy.

Therefore, Ricketts‘ method of defining the basal skeletal width of the maxilla
appears to be more appropriate. We begin, then, by defining locations for
measuring maxillary and mandibular skeletal basal width. Next, we explore
concepts for defining these locations on cone-beam CT imaging.The basic
premise for the mandible is to locate the most buccal point on the cortical plate
opposite the mandibular first molars at the level of the center of resistance.
According to Katona, this location is approximately coincident with the
furcation of the roots of the molars. 30 As we explained above, the authors
chose this point due to the relative immutability of the alveolus apical to this
location with orthodontics and because it represents the absolute minimal width
of the basal bone for each jaw.For the purposes of this technique, the authors
used Dolphin 3D, release 11, but the concepts can be applied to any software
with the capability to analyze a cone-beam CT image. After properly orienting
the image, we open the multiplanar view (MPV) screen to see simultaneous
axial, sagittal, and coronal cuts of the image.

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To determine the width of the mandible, we scroll down through the image
until we locate the furcation of the first molar. Then we scroll posteriorly
through the scan until we locate the coronal cross-section through the center of
the mandibular first molars. Now we switch to full-screen axial view. Using the
cut lines as a guide, we measure the width of the mandible from the intersection
of the cut line with the most buccal portion of the cortical plate on both the right
and left sides.

For the maxilla, a similar method is employed. The only difference is that the
axial and coronal cuts must be taken at the position Mx-Mx, and the same
measurement as in the Ricketts‘ analysis is used.

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Causes For Transverse Maxillary

Deficiency

 Habits—thumb sucking.
 Syndromes.
 Klippel-Feil syndrome.
 Cleft lip and palate.
 Congenital nasal pyriform aperture stenosis.
 Marfan syndrome.
 Craniosynostosis (Apert syndrome, Crouzon disease, Carpenter
syndrome)
 Osteopathia striata.
 Treacher Collins.
 Duchenne muscular dystrophy.
 Obstructive sleep apnea.
 Iatrogenic (cleft repair).
 Palatal dimensions and inheritance.
 Muscular.
 Nonsyndromic palatal synostosis.
 Multifactorial.

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Types Of Expansion

1) Orthodontic Expansion
This is produced by conventional fixed appliances and different types of
removable appliances. In orthodontic expansion, there is lateral movement of
the buccal segments, which results in mainly dentoalveolar expansion. There is
buccal tipping of the crowns and lingual tipping of the roots. Aberrant soft-
tissue pressure from cheeks can cause relapse of the achieved expansion.

2) Orthopedic Expansion
In this type of expansion, changes are produced mainly in the skeletal
structures. There is less amount of dentoalveolar expansion. Rapid maxillary
expansion (RME) appliances are classical examples for true orthopedic
expansion. RME causes separation of midpalatal suture,and also affects
circumzygomatic and circumaxillary sutures. After expansion, new bone is
deposited in the midpalatal suture.

3) Passive Expansion
Passive expansion is the result from the intrinsic forces exerted by the tongue.
With the use of buccal shields (e.g. Frankel), the forces from the labial and
buccal musculature are prevented from acting on the dentition. This results in
the widening of the arches, because the forces from tongue exert expansible
forces on the arches. The tongue force is not counteracted by bucci nator
mechanism. Passive expansion is not achieved by mechanical appliances but by
the vestibular or lip shields.

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Slow Maxillary Expansion

Slow expansion appliances basically produce dentoalveolar expansion or
changes. The rate of activation of the appliance is less when compared to the
rapid maxillary expansion appliances. In young children, slow expansion
appliances have been demonstrated to open midpalatal suture thereby producing
skeletal expansion. They usually provide few hundred grams of force around 2
lb of pressure, with the expansion carried out at the rate of 1 mm/week.

Classification of Slow Expansion Appliances

1. Removable slow expansion: Expansion plate with jackscrew, Coffin
springs and removable quad helix.

2. Fixed slow expansion appliance: W arch appliance, quad helix, NiTi

palatal expander and fixed appliance.

1. Removable Slow Expansion Appliances:

 Expansion Plates

Schwarz appliance 12 is the first removable appliance with jackscrew. It

is a horseshoe-shaped removable appliance that fits along the lingual
border of the mandibular dentition, with a midline expansion screw. It is
indicated in patients with mild crowding in the lower anterior region or
when there is significant lingual tipping of the posterior dentition. The
appliance is activated once per week. It produces on an average 3–4 mm
arch length interiorly. Like Schwarz appliance, removable acrylic plate
with jackscrew in the midpalatal region is used for slow palatal
expansion. The expansion schedule for slow palatal expansion is 1
mm/week. 25 Refer chapter on removable appliances for Coffin springs.

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 Removable Quad Helix

It has the same design as a fixed quad helix appliance, which is inserted
into the lingual attachment soldered to the molar band.

2. Fixed Slow Expansion Appliances:

 W Arch Appliance

W arch 26 is a slow expansion appliance and is constructed with 0.036 inch

stainless steel wire. The wire is adapted in the form of W, which extends from
the first permanent molar to the canine in the anterior palate. The free ends of
the ‗W‘ are adapted closely to the palatal surfaces of premolars/deciduous
molars. The appliance should be away from the palatal or the lingual mucosa to
prevent tissue irritation. The first lingual arch is soldered to the bands on molars
and the finished appliance is cemented to the first permanent molars. Activation
The appliance is activated by opening the apices of W for anterior expansion
and for posterior expansion the anterior portion is opened. The appliance
delivers proper force levels, if opened 4–5 mm wider than the passive width and
should be adjusted to this dimension before being inserted.

 Quad Helix Appliance 27

This appliance was introduced by Ricketts; it incorporates four helices or coils

to increase flexibility. The general form of the appliance is similar to the Crozat
appliance and the W arch appliance, which was later modified by Ricketts by
adding loops.

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Indications of quad helix appliance:

 Narrow upper arch that needs expansion, e.g in cross bites (Fig. 36.10).
 Crowded mixed or permanent dentition in which long range growth can
be predicted and requires mild expansion as there is lack of space for the
upper
 laterals.
 Class II malocclusions where upper arch needs effective widening and
upper molars need distal rotation.
 Class III malocclusions where upper arch needs effective widening and
advances with class III elastics.
 Thumb sucking and tongue thrusting cases with its modifications.
 Unilateral or bilateral cleft palate.

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Activation of quad helix:

Initial activation of the appliance involves activation of the loops such that
when the appliance is cemented on one side, the other side should be sprung
back into opposite molar band. Separating or moving apart the two buccal arms
such that the buccal arms are standing away from the lingual surface of the
bicuspids and cuspids allows the molar to rotate before expansion.

Quad helix can be activated at four positions:

1. In the anterior bridge: Results in expansion in the molar region.

2. In the palatal bridge: Derotation and expansion of molar on the same side and
distalization of molar on the opposite side.

3. Outer arms are activated to expand canines and pre-molars.

4. Opening of posterior helix expands the buccal arm.

An initial expansion of 8 mm will produce 14 oz offorce. Average force is 200–

400 g depending upon the amount of expansion or activation.Apart from arch
expansion, quad helix is modified for other purposes. Bending the anterior
bridge downward, it can be used for breaking thumb sucking habit; also, adding
additional anterior bridge can be used for breaking thumb sucking habit. If
tongue spikes are soldered to the anterior bridge, it is used for intercepting
tongue thrusting habit. Incorporating helices in lateral arms, near the anterior
end, can be used for anterior expansion.

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Advantages And Disadvantages Of Quad Helix

Advantages:

1) It provides excellent expansion in cleft palate patients.

2) Expansion is smooth and controlled.
3) In young children, skeletal expansion can be achieved.
4) Anterior bridge with helices acts as reminder for habit breaking.

Disadvantages:

One major disadvantage of this appliance is buccal tipping of molars during

excessive activation. This can be prevented by torquing the roots buccally

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 NiTi PALATAL EXPANDER 28

Conventional rapid palatal expanders are uncomfortable, require patient

cooperation, and rely on labor intensive laboratory production. They are
inefficient because of the intermittent nature of their force application. Also,
they are often soldered to maxillary first molars with pre-existing mesiolingual
rotations that the devices are unable to correct. These rotations can distort the
appliances.

To overcome the limitations of conventional expansion appliances, Wendell V

Arndt, in 1993, developed atandem-loop, NiTi, a temperature-activated palatal
expander. This has the capability to produce continuous light force on
midpalatal suture and uprights, rotates and distalizes maxillary first molars
simultaneously.

This fixed removable appliance has stainless steel extensions that could be
adjusted and inserted into standard horizontal lingual sheaths which are welded
to the molar bands. An indent on the lingual attachment locks the expander to
the molar band ensuring patient protection. For increased protection, an
elastomer may also be placed.

The appliance has got a central component and a lateral component . The central
component is made of thermally activated NiTi alloy and the lateral arm, which
is bracing the palatal aspect of the maxillary posterior teeth, is made of stainless
steel. At room temperature, the expander is too stiff to be compressed and
inserted into the maxillary arch. The transition temperature of the NiTi alloy
used in the expander is 94°F, which is close to intraoral temperature. For the
appliance to be inserted into the mouth, it is chilled so that the central part
softens and can be easily inserted. Once the appliance is fitted, the expander
warms to the body temperature, becomes stiff and returns back to its original
position. The expander delivers constant force as it deactivates.

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The expander is available in various sizes from 26 to44 mm in eight different

intermolar widths generating 180–300 g of force. The 26–32 mm sizes have
softer wires to produce low level force in children. Clinically, the correct size is
estimated by measuring the amount of expansion needed and then by adding 3
mm as overcorrection. The expander is inserted into the lingual sheaths attached
to the palatal aspect of the molar bands. The size of the appliance is also
selected by measuring the mandibular intermolar width (between the central
fossa of the right and left first permanent molars). This width will provide the
exact width to which the maxillary is going to be expanded because the
mesiolingual cusps of the maxillary molars normally occlude on the central
fossa of the mandibular.The appliance is cooled before insertion and covered
with moist gauze before insertion. Cooling can be done either by freezing or
using a refrigerant spray, like ethyl chloride or tetrafluoroethane. This
expansion appliance was further developed by Marzban and Nanda in 1999.

Mandibular Expansion Appliances

Expansion of the mandible is difficult to achieve with appliances and usually
the results are not stable. Many factors, like age of the patient, skeletal maturity,
type of expansion desired, expected patient compliance, number of teeth
available for anchorage, will influence the selection of expansion appliance.
Judicious use of expansion appliance will yield good results and expansion
appliances are a potent tool in the hands of a competent orthodontist.

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From a neuromuscular perspective, the lip bumper theoretically creates a more

desirable treatment effect than does the Schwarz appliance. (The Schwarz
appliance simply produces orthodontic tipping of the teeth through direct force
application to the dentition and alveolus.) On the other hand, the lip bumper
shields the soft tissue from the dentition, allowing for spontaneous arch
expansion as is seen with the Fränkel and other soft tissue shielding appliances.
We tend to favor the use of the Schwarz appliance over the lip bumper,
however, in most instances because of the predictability of the treatment
outcome and the ease of clinical management. Only in patients with very
constricted (tense) soft tissue is the lip bumper the appliance of choice.

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Rapid Maxillary Expansion

Rapid palatal expansion involves split opening of the maxillary suture and the
movement of the palatal shelves away from each other. It involves rapid force
application to the posterior teeth, which are not given enough time for the
posterior teeth to move; hence, the forces are transmitted to sutures and the
sutures open while the teeth move minimally relative to the supporting bone.

This concept was reported in the dental literature by Emerson Angell in 1860,
which was initially opposed by McQuillen (1860) 2 and Coleman (1865).

Till the early 1900s, rapid palatal expansion was still uncommon as some
clinicians, like Lundstrom (1923), Brodie (1938), questioned the stability of the
rapid maxillary expansion. It was reintroduced by Hass (1961), called Hass
expander, whose clinical studies and animal experiments strongly supported
rapid maxillary expansion. Hass (1961) (1965), 7 (1970), Timms (1971),
(1980) and Wertz (1970) stated that rapid maxillary expansion produces true
orthopedic expansion wherein the changes are produced in the skeletal
structures rather than by the movement of the teeth through the alveolar bone.

Indications of Rapid Maxillary Expansion Appliances 13

1. Maxillary constriction (narrow maxillary base or wide mandible), dental or a

combination of both skeletal and dental constrictions.

2. Skeletal Class II division 1 malocclusions with or without posterior crossbite.

3. Class III malocclusions, borderline skeletal Class III,Pseudo-Class III with

posterior crossbite and/or constricted maxilla.

4. Patients with cleft lip and palate with collapsed maxilla.

5. To gain arch length in patients with moderate tooth size arch length
discrepancy. In a child with decreased maxillary width and dental crowding
expansion can be the correct method of gaining space to align the teeth.

6. Another use of RME is to widen the maxilla to make the smile more
attractive.

7. Other indications for rapid maxillary expansion include poor nasal airway,
septal deformity, recurrentear, nasal or sinus infection, allergic rhinitis, asthma
and before septoplasty.

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Contraindications of Rapid Maxillary Expansion Appliances 13

1. Patients with poor compliance.

2. Cases of single tooth crossbite do not require rapid maxillary expansion.

3. Subjects with skeletal asymmetry of maxilla and mandible.

4. Patients with severe anteroposterior and vertical skeletal discrepancies.

Applied Anatomy:

The maxilla together with the palatine bone forms the hard palate, floor and
greater part of the lateral walls of nasal cavity. It is paired bone that articulates
with its opposite. The maxillae articulate with 10 other bones of the face and
cranium including frontal, ethmoid, nasal, lacrimal, vomer, zygomatic and
palatine bones. These bones join the maxilla by suture in posterior and superior
aspects leaving the anterior inferior aspect free. The tenacity of circumaxillary
attachments due to buttressing is strong posterosuperomedially and postero
superolaterally. The midsagittal portion of the anterior and middle part of the
cranial base is formed by the sphenoid bone and lies posterior to maxilla. The
other significant articulation is that between frontal and zygomatic bones at the
lateral aspect of the orbit and the frontomaxillary sutures at their union with the
basal bone.

Though the pterygoid plates of sphenoid are bilateral, midsagittal suture that
will allow for lateral displacement is absent. The pyramidal process of the
palatine bone intertwine with the pterygoid plates. This confinement of
sphenoid ptery goid plates drastically reduces the ability of palatine bones to
segregate at the midsagittal plane.

Another equally important factor is the soft-tissue complex that invests these
skeletal structures. Masticatory muscles, facial muscles and its investing fascia
are relatively elastic so that it stretches on application of expansion force.
However, the ability of permanent adaptation of the stretched muscles,
ligaments and the fascia to the new environment needs further investigation.
During teeth movement, orthodontists are aware of this soft tissue limitation.

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suture

The intermaxillary and interpalatine sutures are called midpalatal sutures. RME
should be initiated prior to the ossification of the midpalatal suture. In infancy,
the sutures in vertical coronal section have a ‗Y‘ shape and bind the vomer with
the palatine processes. In the juvenile period, the junction between three bones
becomes higher and assumes more of a ‗T‘ shape with the interpalatal section
taking a serpentine course. By adolescence, the oronasal course of the suture
may become so interdigitated that mechanical interlocking is as in a jigsaw
puzzle and islets of bone are formed. Melsen 14 reports that transverse growth
of midpalatal suture continued up to 16years in girls and 18 years in boys. Most
studies report a broad range of ossification between 15 and 25 years, 15 but the
optimal period for performing RME procedure was between 8 and 15 years. The
suture starts to ossify posteriorly and always shows a greater degree of
obliteration posteriorly then anteriorly, while ossification comes very late
anterior to incisive foramen.

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Effects of Rapid Maxillary Expansion Appliances

 Skeletal Effects

In rapid maxillary expansion appliance, when a rapid heavy force is applied to

the teeth, there would not be enough time for tooth movement to take place;
hence, the force is directly transmitted to the sutures. The appliance compresses
the periodontal ligament thereby bending the alveolar process, tipping the
anchor teeth, and gradually opening the midpalatal suture. The sutures open
with minimal movement of the teeth.

The midpalatal suture consists of a fibrous tissue with osteogenic layers on both
surfaces. The suture is nothing but an extension of the periosteal layer of the
bone. At an early age, there is more proliferation of fibrous tissue and with
aging the sutural space is replaced with bone. 16

Microscopic study of the midpalatal suture at different ages reveals that the
suture becomes increasingly tortuous and more interdigitated with bony spicules
as age increases (Melsen 14 ) . Hence, any expansion in late adolescence
becomes very difficult.During expansion, the opening of the suture involves
tissue injury followed by a repair characterized by proliferation of cells for
regeneration of the suture. The space created in the midpalatal area is filled with
fluids and blood, which is later replaced by bone. The tensile force on the suture
initiates bone formation between the sutures.

Healing of suture after rapid palatal expansion involves bony spicules

formation. Ten Cate et al 17 used heavy forces to expand cranial sutures and
showed that fibroblasts proliferate and repair sutural connective tissue before
osteogenesis and remodeling of the suture take place.

As the maxilla is attached to the other cranial bones,the separation of the

midpalatal suture separation is not the same in all planes of space. When viewed
occlusally, the separation of the maxillary bone is wedge-shaped; the separation
is more in the anterior region when compared to the posterior region. When
viewed frontally, the separation of the intermaxillary suture is pyramidal shape,
with the base of the pyramid located on the oral side of the bone with more
expansion in the oral region.

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This is due to the buttressing effect of the other bones in the posterior maxillary
regions. Thus, the maxillary bone opens like a hinge superiorly at the base of
the nose and the opening is more in the anterior region than in the posterior
region. 13 shows opening of the suture in the superior view. Similar
observations were made by Wertz (1970) 18 who noted that the maxilla opens
in a triangular fashion with the apex at the posterior nasal spine and base in the
anterior region. A word of caution is that as the intermaxillary suture is less
ossified in preschool children, rapid expansion force should not be used, as this
may produce undesirable changes in the nose.

 Dentoalveolar Changes

The common dentoalveolar changes after rapid maxillary expansion include

appearance of midline diastema.This is a transient change and the crowns of the
incisors converge late in the treatment due to the pull of the gingival fibers and
some amount of relapse. There is increased buccal inclination and extrusion of
the posterior teeth. The change in the axial inclination may be due to alveolar
bone bending and buccal tipping of the teeth. The buccal movement of the
posterior teeth some time may result in root resorption. The palatal
mucoperiosteum is stretched, whose contraction after expansion may result in
relapse.

 Other Effects

Due to rapid maxillary expansion, the mandible rotates downward and

backward, which may be due to the extrusion and buccal tipping of the posterior
teeth and hence, RME should be done with extra caution in subjects with steep
mandibular plane. Following RME, the mandibular buccal teeth were found to
be upright. But in general, the effect of RME on mandibular dentition is
minimal or unpredictable.

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One of the important effects of rapid maxillary expansion appliances is increase

in the arch perimeter. Adkin and associates (1990) 19 estimated that every 1
mm increase in posterior arch width gained by RME leads to 0.7 mm increase in
arch perimeter. Thus, the overall increase in arch perimeter in RME can be used
to avoid premolar extractions in patients requiring tooth size arch length
discrepancy.

Another effect of RME is reduction in nasal resistance. Hartgerink 20

demonstrated that about two-thirds of the patients undergoing rapid maxillary
expansion showed decrease in nasal resistance.

Types of Rapid Maxillary Appliances:

 Removable rapid maxillary expansion appliances
 Fixed rapid maxillary expansion appliances

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Removable rapid maxillary expansion appliances include a split acrylic plate

with a jackscrew. The problem with a removable RME expansion appliance is
that there is not enough rigidity to produce rapid maxillary expansion; rapid
expansion may affect the stability of the appliance. Because of the change in
position of teeth during expansion, failure to wear the appliance even for a day
requires adjustment by the practitioner to constrict the screw and refit the
appliance. Patient compliance is another important issue with this appliance.

There are two types of fixed RME, namely, bonded and banded. Banded RME
appliances include Derichs- weiler, Haas, Issacson (Minne expander) and
Hyrax.

Basic Steps in Fabrication:

Banded Rapid Maxillary Expansion Appliance Banded RME involves banding
the first deciduous molars and the first permanent molar. They are joined
labially and palatally by soldering with heavier gauge wire.The expansion screw
is placed in the midline. The four legs of the expansion screws are cut and
adapted to the bands. The whole assembly is soldered. The various banded
RMEs differ in the type of screw and mode of attachment.

 Derichsweiler Type

In this, the screw is connected to the bands by means of tags that are welded and
soldered to the palatal aspects of the band on one side and embedded in acrylic
on the palatal aspects of all nonbanded teeth except the incisors. Acrylic adapts
to the palate and is in two halves to permit activation of screw.

 Haas type 6

Heavy stainless steel wire 0.045 inch or 1015 mm in diameter is welded and
soldered along the palatal aspects of the band. The free ends are turned back
embedded in acrylic (Fig. 36.6B). Both Derichsweiler and Haas types
incorporated the same type of expansion screw.

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 Isaacson 21 Type

The drawback of expansion screw is because of the buildup of pressure; it is

hazardous to tissue. To over-come this, Minne expander was used by Issacson.
This is flexible and has a spring loaded screw (Fig. 36.6C). This is adapted and
soldered directly to the bands. Acrylic plates are not used in this type of
expander.

 Hyrax 12

This type of expander uses the Hyrax (hygienic rapid expansion) screw. It has
heavy wires that are adapted, welded and soldered to the palatal aspects of the
bands .

Bonded Rapid Maxillary Expansion Appliance:

There are two types of bonded rapid maxillary expansion appliances. Cast metal
cap splints have a cast cap splint to which the screw is soldered and the entire
assembly is cemented.

Acrylic splints involve thick-gauge stainless steel wire being adapted closely to
the premolars and premolars both buccally and palatally and the screw is
soldered to the wire. The acrylic splint covers the occlusal, buccal and palatal
occlusal third of all the posterior teeth.

Advantages:

 Using a bonded RME rather than banded RME is more favorable in

mixed dentition patients as it is difficult to band the deciduous first
molars.
 The occlusal covering in a bonded appliance prevents increase in the
mandibular plane angle. Hence, bonded appliance is the appliance of
choice in high-angle patients.

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Appliance Management :
Rapid palatal expansion appliance is done with two turns daily of the jackscrew
(0.5 mm activation), which produces 10–20 lb of pressure across the suture,
sufficient enough to create separation of suture by causing micro-fractures in the
bony spicules.

The maximum load occurred during turning of the screw, which dissipates soon
after (Zimring and Issacson 22 ). In younger individuals, the load dissipation is
longer in a twice daily activation. Therefore, slower rates of expansion would
allow for physiologic adjustment at the maxillary articulations, and would
prevent the accumulation of large residual loads within the maxillary complex.
22,23

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Activation Schedule :
The expansion schedule advocated by Zimring and Issacson: 22

1. Young patients: Two turns a day for 4–5 days and one turn a day for the rest
of the treatment period.

2. Adult patients: For the first 2 days, 2 turns/day are given. For the next 5–7
days, 1 turn/day is given and during the rest of the treatment period, 1 turn is
given every other day.

Every turn of the screw opens the appliance by 0.25 mm. Each turn involves 90°
activation. With rapid maxillary expansion at a rate of 0.5–1 mm/day, a 10 mm
expansion is achieved in 2–3 weeks.

Advantages and Disadvantages of Fixed RME

 The advantage of fixed RME is that patient compliance is not required
and rapid changes are produced within a short period of time.

 But there are disadvantages, like bulkiness of the appliance and difficulty
in cleaning the appliance, which limits its use in young child in the mixed
dentition.

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Clinical Management of Rapid Palatal Expansion Appliances

After banding the first permanent molar and the first deciduous molars, an
alginate impression is taken, the bands are removed from the teeth and
stabilized in the impression and the cast is poured. The wire framework along
with the screw is then soldered to the bands and the acrylic portion is added, if
required during fabrication. After expansion, it is difficult to remove the bands
as the teeth are mobile during which time the bands are best removed by
sectioning. Fabrication of bonded RME included adding stabilizing wire on the
palatal and buccal aspects followed by acrylization. A composite resin is used to
retain the appliance, with only the facial and lingual surfaces of the posterior
teeth etched, without etching the occlusal surfaces. After activation, the patient
should be instructed to report, if they experience unusual symptoms, like pain
and dizziness. If the symptoms persist, the activation is either decreased or
discontinued.

A string or floss is tied to the key to prevent it from being swallowed. The
patient is monitored at weekly intervals and the amount of expansion is
measured as the distance between the two halves of the screw. Usually, as a
matter of overcorrection of the crossbite, expansion is stopped when the
maxillary lingual cusps come into contact with mandibular buccal cusps. After
the expansion is completed, the appliance itself serves as a fixed retainer for 3
months. The expansion screw is immobilized by adding cold-cure acrylic over
it. After 3 months of fixed retention, the RME is removed and replaced by a
removable retainer with acrylic covering the palate.

If further treatment with fixed appliance is planned, a heavy labial expanded

archwire is inserted into the headgear tubes. An alternative to this is a fixed
lingual arch, which should be inserted immediately after removal of RME. If
there is a delay in placement of fixed lingual arch, the labial wire should be used
temporarily.

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Semirapid Maxillary Expansion Appliances:

There is a resistance offered by the surrounding craniofacial structures during
RME. The high forces generated during RME displace the various craniofacial
bones to different degrees, which may increase the tendency toward relapse.
Hence, to reduce the tendency to prevent the relapse after RME, another
expansion schedule named semirapid maxillary expansion was introduced, as
slower expansion of the maxilla reduces the tissue resistance and can reduce the
relapse tendency.

Semirapid maxillary expansion involves two turns a day for the first 5–6 days
after appliance insertion and three turns a week for the rest of the treatment
period. Semirapid maxillary expansion is nothing but initial RME followed by
slow expansion. 24

Surgically Assisted Maxillary Expansion 30,31

Palatal expansion in full grown adults is performed with parasagittal

osteotomies in lateral wall of nose or medial floor of sinuses connected by
anterior transverse cut. As maxillary expansion in adults is not possible due to
the increased resistance to sutural split from the interdigitated midpalatal and
lateral maxillary sutures, surgically assisted expansion would decrease the
resistance at the same time not totally freeing the maxillary segments. The
surgical procedure is followed by expansion with a jackscrew.

Surgically assisted palatal expansion (SARPE) that cuts the bone for reducing
the resistance without completely releasing the maxillary segments succeeded
by Jackscrew rapid expansion is another possible treatment approach in adults
with narrow maxilla. The original concept of surgically assisted expansion was
that in adults, the cuts in maxillary lateral buttress decreases the resistance to a
level where midpalatal suture is opened forcefully (i.e. microfractured).

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Although this usually works in patients in their twenties, the chance of

inadvertent fractures in other areas is a concern for patients in their thirties or
older. For SARPE now surgeons often make all the cuts needed for a LeFort-I
osteotomy, omitting only the final step of down-fracture. The effect allows
widening of the maxilla against only soft-tissue resistance manipulating the
osteotomy sites with what amounts to distraction osteogenesis. If only
expansion is desired, this provides a somewhat less invasive approach than
segmental osteotomy and better stability.

The implication of SARPE is that the problem affects only the transverse plane
of space, and this is when it is most useful. It is difficult to justify the additional
cost and morbidity of surgically assisted expansion as a first stage of surgical
treatment, in a patient who would require another operation later to reposition
the maxilla in the anteroposterior or vertical planes of space. The primary
indication for SARPE is such severe maxillary constriction that segmental
expansion of the maxilla in the LeFort I procedure might compromise the blood
supply to the segments.

Indications:
SARPE is indicated for the treatment of the adults with narrow palatal
arch for the following:

1. To expand the arch for correcting posterior cross bite when no other surgical
jaw movements are considered.

2. To widen the collapsed maxillary arch in cleft palate.

3. For presurgical arch expansion even in planned orthognathic surgery to

prevent increased risks and inaccuracies with segmented total maxillary
osteotomies.It is also done when expansion required exceeds that which can
be performed by segmental expansion (i.e.greater than 8 mm).

4. To expand the arch for creating space without premolar extractions, if the
space required could be gained reasonably due to maxillary expansion 10 and
if other factors, like maxillary incisor protrusion on the underlying bone, have
been considered.
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