Arch width development in Class II

patients treated with the Frbzkel appliance Dr McDougall

Paul D. McDougall, D.D.S., M.S.,* James A. McNamara, Jr., D.D.S., Ph.D.,**

and J. Michael Dierkes, D.D.S.; M.S.***
Detroit and Ann Arbor, Mich.

This article compares the arch development in growing Class II patients after FrBnkel therapy with arch
development in a similar group of untreated Class II subjects. Sixty treated and forty-seven untreated persons
were compared for a 2- to 4-year period. Expansion of the maxillary and mandibular dental arches occurred to a
much greater extent in patients undergoing FrBnkel treatment than in the control subjects. The expansion was not
limited to a particular region of the dental arch in the treated cases, although the largest expansion values were
recorded in the premolar and molar regions. Lesser vaiues were recorded in the canine region.

Key words: Expansion, Frankel treatment, arch width, functional regulator, Frlnkel appliance

A major portion of the treatment rendered

in any orthodontic practice is concerned with lack of
space-the transverse and sagittal crowding of teeth
within the alveolus. Orthodontic philosophies over the
years have vacillated between a strict nonextraction
approach’ and an approach which requires the extrac-
tion of teeth in the majority of treated cases.2-4 A tradi-
tional explanation of dental arch crowding has been one
based on genetics. For example, patients are sometimes
told that since they inherited the large teeth of one
parent and the small jaw structure of the other parent,
dental crowding has resulted. According to the expla-
nation, jaw size is assumed to be genetically predeter-
mined and therefore immutable, Consequently, extrac-
tion of selected teeth is necessary in order to provide
adequate space in the dental arch to align the remaining
teeth. This explanation has been used to justify to the
orthodontic patient the need for extraction procedures.
Another explanation of dental arch crowding is
based on the assumption that jaw size is not immutable
and that crowding results from a failure of the jaws to
develop fully and accomodate the teeth. From a con-
ceptual point of view, it may be not that the teeth are
too large for the underlying skeletal structures but,
This research was supported in part by United States Public Health Service
Grant DE-03610.
*Formerly in the Department of Orthodontics, University of Detroit; now in
private practice in Victoria, British Columbia.
**Professor of Anatomy and Research Scientist, Center for Human Growth and
Development, The University of Michigan.
***Clinical Assistant Professor, Department of Otthodontics, University of
Detroit, and in private practice in Jackson, Michigan.
rather, that the underlying skeletal structures have not
developed fully and are too small to accommodate the
teeth. Since jaw size is to some extent environmentally
determined and not under strict genetic control, early
orthodontic intervention can be directed toward full de-
velopment of the bony support of the dental arch and
accommodation of the entire dentition.
The orientation of the teeth to one another within a
given dental arch can be viewed, in part, as being de-
pendent upon the interplay of the soft tissues surround-
ing the arches. Friinkel” has stated that the devel-
opmental inhibition in the size of the underlying
skeletal structures that support the teeth is causally re-
lated to perioral and buccd muscle function. He has
postulated that the elimination of aberrant perioral and
buccal muscle activity during development will result
in full development of dental arches with less func-
tional and morphologic deviation.
On the basis of this theory, Frlnkel has designed,
constructed, and clinically applied a series of functional
appliances (functional regulators) for the treatment of
anteroposterior, vertical, and transverse jaw discrepan-
cies seen in Class II malocclusions, Class III malocclu-
sions, and malocclusions involving open-bite cases.Jm-‘4
Frankel has emphasized the use of the labial and buccal
vestibule as the basis of operation for the functional
appliance. The lower labial lip pads, which are located
inferior to the lower incisors, and the vestibular shields,
which are located adjacent to the posterior teeth, pre-
sumably change the balance of forces between the
tongue and the perioral musculature. The lower labial

10 0002.9416/82/070010+13$01.30/0 0 1982 The C. V Mosby Co.

Volume 82
Number I
pads and the vestibular shields also prevent an interin-
cisal or interocclusal positioning of the cheeks and lips,
which can have a restricting effect on the vertical erup-
tion of the teeth,
The Frinkel appliance was conceived in accordance
with Hotz’s’j principle of equilibrium of physiologic
forces. (That is, the transverse and sagittal develop-
ment of the dental arch is influenced primarily by the
interplay of the tongue on one side and the lips and
cheek on the other.) While this relationship has not
been completely verified or agreed upon in clinical
studies,16 it appears that there is a relationship be-
tween the position of the dental arches on the alveolus
and the role of the tongue, lip, and cheek musculature.
This relationship is clearly seen in cases of partial or
total aglossia in which the dental arches are crowded
and the teeth are displaced lingually. In cases of mac-
roglossia, spacing and lateral positioning of the teeth
are observed.
Notable aspects of cases treated with the Frlinkel
appliance are the change in arch form and the relative
increase in arch width, particularly in the posterior re-
gion. Frankel explains that the mechanism by which
arch expansion occurs is related to a change in the
relative balance of biomechanical forces adjacent to the
dentition. As a tooth erupts, it follows the path of least
resistance. I’, l8 If the biomechanical forces are changed
during therapeutic intervention, the eruption path of the
tooth can be altered. In the maxillary arch the eruption
usually occurs laterally and vertically at the same time.
Thus, a downward and outward movement of the tooth
is noted. The posterior teeth in the mandible normally
tend to erupt in a lingual direction.‘s Franke15 believes
that removal of the buccal muscular forces allows for
an uprighting of the lower posterior teeth during erup-
tion. This could account for the observation that a dif-
ferent path of eruption is seen in the lower arch in cases
treated with the Fr;inkel appliance.
There are a number of possible mechanisms which,
alone or in combination, can account for the arch ex-
pansion observed in cases treated with the Friinkel
appliance. As mentioned earlier, the Frankel appliance
removes the pressure generated by the tonicity of the
buccal and perioral musculature from the dentition. In
addition, since the appliance interferes very little with
tongue position, the tongue is relatively free to exert
more force in an anterior and lateral direction.20 (This is
in contrast to most other functional jaw orthopedic
appliances.)
Another possible mechanism of arch expansion in-
volves an aspect of the appliance that has been con-
tinually stressed by Frinkel.js lo He has stated that the
Arch Mfdth development following Frtinkel therupy 11
vestibular shields (which are kept 3.0 mm. away from
the maxillary alveolus and 0.5 mm. away from the
depth of the vestibular sulcus in the mandible) should
be extended into the vestibular reflex so that tension is
produced on the soft tissue. Frankel theorizes that the
pull on the soft tissue is transferred to the periosteum
and results in deposition of new bone on the facial
aspect of the alveolus. It has been shown in experimen-
tal studiesz1-2” that tension placed on the periosteum
will result in increased deposition of new bone.
Whether this occurs in a clinical situation under the
influence of the vestibular shields remains to be proven.
Regardless of the mechanisms, Frlnkel theorizes
that this appliance is especially valuable when treat-
ment is undertaken during the mixed dentition. The
appliance can utilize the ability of an erupting tooth to
act as a matrix for alveolar growth.” Frinkel states that
the developmental stage most amenable to arch expan-
sion is that of the late mixed dentition when the canines
and premolars are erupting.
Statistical investigations of results of Friinkel appli-
ance therapy have been limited. Mosch (cited by Frin-
kel]O), who studied 400 cases treated with only the
Fr%nkel appliance, observed that as a result of merely
withholding cheek pressure through the use of the
vestibular shields and lower labial pads, a spontane-
ous widening of the dental arch occurred with great
regularity. Mosch noted a mean increase in transpalatal
width of over 4 mm. in both the premolar and molar
regions during a 2-year treatment time. No data regard-
ing mandibular arch expansion were published. In
many articles Frinkel has documented that arch expan-
sion occurs when the Frlinkel appliance is used.+”
However, to date no systematic study of treatment re-
sults in both the mandible and the maxilla has been
published.
PURPOSE
The purpose of this study is to investigate the po-
tential for arch expansion in a North American popula-
tion of patients with Class II malocclusions treated with
the Frankel appliance (FR I or FR II) and, specifically,
to answer the following questions: (1) How much arch
expansion occurs in a population of treated Class II
patients compared with a longitudinal sample of un-
treated Class II patients? (2) Does more expansion
occur in the maxillary arch or in the mandibular arch?
(3) Do narrower arches at the beginning of treatment
expand more than those arches that were wider at the
beginning of treatment? (4) Is there a relationship be-
tween the duration of Friinkel treatment and the amount
of expansion observed?
 Table I. Pretreatment arch dimensions
----__ ---.. -_
----r- C~ontrol Fi-tidd

Maxillur~ (ml. )
-3-3 44 24. I 2.1 50 23.9 2.2 NS
-4-4 46 26.0 3.2 56 25.6 2.3 NS
5-5 41 29.7 3.1 57 29.4 2.4 NS
-6-6 44 32.1 3.0 55 32.1 2.3 NS
Mandibular (mm. )
-
1J-3 37 20.2 I .9 37 20.2 1.6 NS
-4-4 42 24.0 2.6 48 23.4 1.8 NS
-5-s 47 26.8 2.3 56 26.6 2.1 NS
6-6 46 30.4 2.4 55 30.3 2.1 NS

Fig. 1. Diagrammatic representation of values measured in this NS = No significant difference between groups. ‘“p <: 0.05.
study. **p < 0.01. ***p C- 0.~1. *-+**p ‘C 0.0001,

MATERIALS AND METHODS
Sixty treated and forty-seven untreated patients
with Class II, Division 1 malocclusions were examined
in this study. The patients in the treated group wore the
functional regulator of Frinkel (FR- 1 or FR-2)5. 26 and
were selected from the private practices of two of the
authors (J. M. D. and J. A. M.) and from the Frankel
Clinic of the University of Detroit Orthodontic De-
partment. In addition, all Frlnkel patients selected were
deemed satisfactory cooperators by the clinicians in
that they wore the appliance for at least 18 to 20 hours
per day during the first 2 years of treatment. All treated
subjects were Caucasians; the average age was 9 years
5 months (S.D. 1 year 2 months), with a range of 6
years 11 months to 12 years 6 months at the beginning
of the study.
In order to analyze the changes in arch width mea-
sured in the treated group, a control group of forty-
seven subjects with similar ethnic and skeletal make-up
were selected from the records of The University of
Michigan Elementary and Secondary School Growth
Study2’. 2x located at the Center for Human Growth and
Development, The University of Michigan, in Ann Ar-
bor. These subjects had no record of orthodontic treat-
ment and presented with Class II, Division 1 maloc-
clusion. The average age of the patients in the control
group was 8 years 10 months (S.D. 9 months) with a
range of 7 years 8 months to 11 years 0 months at the
beginning of the study.
Measurement of arch width
Sequential maxillary and mandibular casts of the
subjects in the treated and control groups were measured
with helios calipers calibrated to 0.1 mm. All mea-
surements were made by one investigator (P. D. M.)
in order to reduce systematic error. Measurements were
repeated on twelve sets of dental casts, and the average
variation between the values of the first and second
readings was 0.2 mm.
Changes in arch width were measured for the
canine, first premolar, second premolar, and first per-
manent molars. The following points were used in
measuring dental and alveolar changes:
Lingual valurs. Values were recorded at the cervi-
cal margin of the tooth from the point of greatest con-
vexity of one tooth to its counterpart in the same arch
(Fig. 1). Where first permanent molars or second de-
ciduous molars were present, values were recorded at
the junction of the cervix with the cervical extension of
the lingual developmental groove.
Buccal values. Values were recorded at the cervical
margin of the tooth from the point of greatest convexity
of one tooth to its counterpart in the same arch (Fig. I).
Where permanent first molars or second deciduous mo-
lars were present, the values were recorded at the junc-
tion of the cervix with the cervical extension of the
buccal developmental groove.
Alveolar \la/ues. In this article we will use the term
alveolar expansion to indicate changes in the measure-
ment between specific points of the dental casts. The
structures in the areas measured include the alveolus
and its adjacent soft tissues. We recognize that these
alveolar points are more susceptible to measurement
error than are tooth-related points (for example, distor-
tion of the gingiva by the fit or position of the impres-
sion tray). However, since both treated and control
groups are considered, the reliability of these mea-
surements should be the same for both groups.
Measurements were made of the gingiva in
the area which overlies the root. Measurements were
made 4.0 mm. below the gingival margin at approx-
imately the same position mesiodistally as were
Volume 82 Arch width development following Friinkel therapy i3
Number 1

Fig. 2. Arch changes observed in an untreated girl during a 24-month period. The patient was 9
years of age at the time the initial records were taken.

Table II. Maxillary dental expansion (lingual)

Control Frtinkel

Region N x S.D. Min. MaX. N x S.D. Min. Max. Sig.

Short-term (mm.) (.f = 21 months)
3-3 28 0.4 1.2 -1.0 4.1 21 1.7 1.3 0.0 3.6 ***
-44 33 0.0 0.8 -1.8 1.7 33 3.2 1.6 0.1 7.0 ****
-5-5 41 0.4 0.7 -1.8 1.6 36 2.8 1.2 0.5 5.1 ****
0.8 6.8 ****
-6-6 41 0.4 1.0 -1.7 3.4 37 3.0 1.3
Long term (mm.) (2 = 41 months)
- -0.5 4.8 *
-3-3 a 0.0 1.2 -2.4 1.4 18 2.1 1.4
4-4 18 0.0 1.1 -2.2 1.7 24 3.5 2.1 0.8 8.1 ****
5-5 19 1.0 0.9 -0.2 2.9 28 4.2 2.3 0.4 10.6 ****
-
6-6 20 0.8 1.3 -1.5 4.1 29 3.9 2.4 0.5 13.0 ***
-

NS = No significant difference between groups. *p < 0.05. **p < 0.01. ***p < 0.001. ****p < 0.0001

the points used to establish the buccal values (Fig. 1).
Data were not recorded for teeth in the process of
initial eruption or exfoliation, teeth that were severely
tipped, rotated, or carious, or teeth that were ectopi-
tally erupted. Similarly, casts with defects of any sort
were not used to record data,
Short-term versus long-term changes
Since either two or three sets of dental casts were
available for each subject, the findings were arbitrarily
divided into short-term and long-term results. The in-
terval between the initial and second set of casts was
considered short term and ranged from 12 to 30
months. The interval between the second and third sets
of dental casts was considered long term and ranged
from 31 to 48 months. The short-term interval for both
control and treated subjects averaged 21.6 months. The
average interval for the long-term treated cases was
36.7 months for the treated group and 41.3 months for
the control group. There were forty-one pairs of casts
for the treated group and forty-three for the control
group in the short-term range and thirty-one for the
 Fig. 3. Arch changes observed in a female patient
taken when the patient was 9 years 9 months of age;
the patient was 11 years 5 months of age; the third set
Note the arch expansion, particularly in the premolar
treated group and twenty-two for the control group in
the long-term range. Some subjects had both short- and
long-term casts, whereas others had only short-term or
only long-term casts.
RESULTS
Before an analysis of changes in arch width could
be undertaken, it was first necessary to determine
whether there were any differences between the control
and treated samples at the beginning of the study. The
mean values for the initial observation of the variables
under consideration were calculated for both groups.
There were no significant differences in the eight dental
measurements (buccal and lingual values for four teeth)
or for the four alveolar measurements in either arch
(Table I). For example, the lingual measurements for
the upper first deciduous molar/first premolar region
were 26.0 mm. in the control group and 25.6 mm. in
the Friinkel group. The transpalatal width between the
upper first permanent molars was 32.7 mm. in each
group. Similar measurements were observed in the
mandible (Table I).
after Frtinkel treatment. The first records were
the second set was taken 20 months later, when
when the patient was 13 years 2 months of age.
region.
Analysis of arch dimensional GhangeS
As mentioned earlier, the findings were arbitrarily
divided into short-term and long-term results. Since the
two measurements of the dentition (that is, buccal and
lingual values) yielded similar results, only the lingual
dental measurements will be reported here.
Maxillary dental expansion. A comparison of the
increases in transpalatal widths between the Friinkel
and control groups revealed that the expansion pro-
duced by the FrGnkel appliance is much greater than
that which would have occurred during normal growth.
For example, the average increase in transpalatal di-
mension during the 2 1-month short-term period in the
control group averaged less than 0.5 mm. (Table II and
Fig. 2), whereas during the same period of time in the
treated subjects (Table II and Fig. 3), the average
amount of arch expansion ranged from 1.7 mm. in the
canine region to 3.2 mm. in the first premolar region.
In all instances, the differences in arch expansion be-
tween the treated and control groups were highiy sig-
nificant (Table II).
The differences between the control and treated
Volume 82 Arch width development following Friinkel therapy 15
Number 1

Fig. 4. Arch changes observed in an untreated boy over a period of 36 months. Initial records were
taken when the patient was 9 years 11 months of age.

Table III. Maxillary alveolar expansion

Control Friinkel

Region N x S.D. Min. Max. N T S.D. Min. MU. Sig.

Short-term (mm.) (2 = 21 months)

3-3 28 0.2 0.9 -1.3 2.3 22 1.3 1.4 -1.0 3.9 ***
4-4
- 34 0.9 1.1 -1.6 3.0 35 3.8 1.7 0.0 8.6 ****
5-5 42 0.7 0.9 -1.7 2.7 35 3.2 1.2 0.0 5.5 ****
6-6
- 38 1.0 0.9 -0.7 4.0 37 3.2 1.4 0.5 7.0 ****
Long-term (mm.) (X = 41 months)
3-3 9 0.7 1.0 -0.8 2.0 18 1.0 2.3 -2.6 6.9 NS
4-4 19 2.5 1.5 0.3 6.3 25 4.8 2.5 1.5 11.8 ***
5-5 18 1.8 1.5 -0.3 5.9 28 4.3 2.3 1.4 12.9 ***
6-6 18 1.9 1.3 0.3 5.6 29 4.4 2.0 1.7 12.5 ***

NS = No significant difference between groups. *p < 0.05. **p < 0.01. ***p i 0.001. ****p < 0.0001.

groups became even more apparent when the long-term
measurements were considered. In the control sample
the average distance between the canines and between
the first premolars did not increase during the 3%year
interval between the first and third sets of dental casts
and approximately 1 mm. of arch expansion occurred
posteriorly (Table II and Fig. 4). In contrast there was
more than a 2 mm. average increase in intercanine dis-
tance and at least a 3.5 mm. increase in arch width
between the remaining maxillary teeth in the treated
group (Table II and Figs. 3, 5, and 6).
Maxillary alveolar expansion. Alveolar measure-
ments were made 4 mm. below the gingival margin. In
the short-term sample, the control subjects showed a
modest amount of alveolar expansion ranging from 0.2
mm. in the canine region to 1.O mm. in the first premo-
lar region (Table III and Fig. 2). The amount of alveo-
lar expansion in the short-term Friinkel group was, on
the average, slightly greater than the amount of dental
expansion, particularly in the premolar and molar re-
gions (Fig. 3). In the long-term groups the amount of
alveolar expansion in the control group was sig-
Fig. 5. Arch changes observed in a female patient treated with a FrMkel appliance for 36 months. Initial
records were taken when the patient was 9 years 9 months of age; the second set of records was taken
when the patient was 12 years 10 months of age.

Fig. 6. Arch changes observed in a female patient treated with the Frankel appliance for 45 months.
Initial records were taken when the patient was IO years 3 months of age; the sacond set was taken
when the patient was 14 years of age. The patient wore the functional regulator only during the night as
a retainer during the last year of treatment.
Volume 82 Arch width development following Friinkel therapy 17
Number 1

Table IV. Mandibular dental expansion (lingual)

Control Friinkel

Region N x S.D. Min. MOX. N x S.D. Min. MU. Sig

- Short-term (mm.) (2 = 21 months)

-3-3 17 -0.1 0.7 -1.3 1.1 16 1.0 1.2 -1.3 2.5 ***
4-4 30 0.4 1.2 - 1.5 3.6 25 2.4 1.3 -0.7 5.5 ****
1.4 0.9 5.9 ****
-5-5 39 0.7 0.9 -1.0 2.7 35 2.7
6-6 42 0.6 1.7 -1.3 4.1 36 1.9 1.3 -1.5 5.4 ****
- Long-term (mm.) (.? = 41 months)
3-3 14 -0.4 1.3 -2.2 2.2 15 0.9 1.8 -2.5 3.7 NS
4-4 15 1.2 1.6 -2.3 3.4 22 3.3 1.9 0.7 8.0 **
-5-5 17 1.4 1.5 -1.2 4.8 30 3.8 2.2 1.1 11.4 **
6-6 22 1.0 1.5 -0.9 5.7 28 2.7 1.6 0.5 6.8 ***

NS = No significant difference between groups. *p < 0.05. **p < 0.01. ***p < 0.001. ****p < O.COOl

Table V. Mandibular alveolar expansion

Control Friinkel
I

Region N z S.D. Min. MUX. N x S.D. Min. MU. Sig.

- Short-term (mm.) (? = 21 months)

3-3 24 0.6 1.3 -2.3 2.5 19 2.3 2.3 -1.0 9.4 **
-4-4 31 1.6 1.3 -2.2 4.1 28 2.7 2.1 -0.2 7.0 **
5-5 38 0.8 1.8 -1.4 5.2 37 2.1 1.5 -1.1 6.0 ****
6-6 30 0.0 0.7 -1.5 1.3 34 1.4 1.3 -1.4 5.0 ***
- Long-term (mm.) (i = 41 months)
3-3 13 1.0 1.1 -1.4 2.3 18 2.1 1.6 -0.1 5.2 **
4-4 17 2.3 1.4 0.0 4.9 25 3.8 1.9 -0.1 8.2 *
5-5 19 1.0 2.4 -1.4 5.2 31 2.7 1.9 -0.8 7.8 ***
6-6 18 0.3 0.7 -0.9 1.5 27 2.0 1.9 -1.9 6.2 ***

NS = No significant difference between groups. *p < 0.05. **p < 0.01. ***p < 0.001. ****p < 0.0001.

nificantly greater than the average amount of dental dental expansion value were statistically significant ex-
expansion, ranging from 0.7 to 2.5 mm. (Table III and cept for a long-term comparison between the increases
Fig. 4). However, the subjects treated with the Frlnkel in intercanine dimension. Although the intercanine dis-
appliance showed two to three times as much alveolar tance decreased, on the average, in the control group
expansion as did the control subjects (Table III and and increased by approximately 1 mm. in the treated
Figs. 3, 5, and 6), with more than 4 mm. of arch group, these values were not statistically different.
expansion occurring in the premolar and molar regions. Mandibular alveolar expansion. The amount of al-
Mandibular dental expansion. During the 2 l-month veolar expansion in the short-term control sample was
short-term control period, there was very little increase variable, depending upon the subject and the region in
in interdental dimension in the control group, with no the dental arch considered (Table V). Less change oc-
average change in intercanine dimension and only a curred adjacent to the lower first molar than in any
slight (0.5 mm.) change posteriorly (Table IV and Fig. other region. A similar finding was observed in the
2). In contrast, there was an average of 1 mm. increase Frtikel subjects, although the magnitude of change
in intercanine distance in the FrGnkel group and a 1.9 to was greater. The amount of change adjacent to the
2.7 mm. increase posteriorly (Fig. 3). lower first molar was 1.4 mm., with at least 2 mm.
Similar findings were observed in the analysis of occurring in more anterior regions. The amount of al-
the long-term cases (Figs. 3 to 6). A 1.0 to 1.4 mm. veolar expansion was approximately the same as the
increase in arch dimension was observed in the premo- amount of dental expansion.
lar and molar regions of the control group. Two to three Similar findings were observed when the long-term
times more arch expansion occurred in those cases treated sample was compared with the corresponding
treated with the Frgnkel appliance, with averages of 2.7 control group (Figs. 3 to 6). The amount of alveolar
to 3.8 mm. All comparisons between the mandibular expansion was greater in the treated group, and in both
18

Fig. 7. Arch changes observed in an untreated male patient during a period of 23 months. The initial
records were taken at 9 years 2 months of age; the second set at 11 years 1 month of age. This patient
was placed in the narrow subgroup.

Fig. 8. Arch changes observed in an untreated boy during a period of 24 months. The initial records
were taken at 9 years 11 months of age; the second set of records was taken at 11 years 11 months of
age. This patient was placed into the wide subgroup.
Volume 82 Arch width development following Friinkel therapy 19
Number 1

Fig. 9. Arch changes observed in a patient treated with a Frtinkei appliance for 33 months. The initial
records were taken at 9 years 2 months of age; the second set at 10 years 8 months of age; the third set
at 11 years 11 months of age. The initial records indicated placement in the narrow subgroup.

Table VI. Maxillary dental expansion (lingual) in narrow and wide arches
Control Friinkel

I Narrow I Wide I Narrow I Wide

Region N x S.D. N x S.D. f test Sig. N % S.D. N x S.D. t test Sig.

Short-term (mm.)
-3-3 14 0.2 0.9 14 0.6 1.9 0.39 NS 9 2.0 2.0 12 1.5 1.1 0.28 NS
-4-4 17 0.0 0.5 16 0.1 1.1 0.93 NS 15 3.6 1.3 18 2.9 1.8 0.13 NS
-5-5 18 0.4 0.7 22 0.4 0.8 0.99 NS 14 3.3 1.2 19 2.8 1.2 0.21 NS
-6-6 18 0.2 0.9 22 0.5 1.1 0.57 NS 15 3.2 1.1 19 2.9 1.5 0.43 NS
Long-term (mm.)
-3-3 1 4.0 NS 7 0.0 1.2 0.71 NS 9 2.9 1.0 9 1.2 1.0 0.001 ***
-4-4 5 0.4 0.5 13 -0.2 1.2 0.48 NS 12 4.4 2.3 12 2.7 1.9 0.01 **
5-5 6 0.7 0.5 13 1.0 1.0 0.67 NS 14 5.0 2.7 13 3.6 1.5 0.05 *
-6-6 6 0.1 1.0 14 1 .o 1.3 0.31 NS 14 4.7 3.0 14 3.8 1.3 0.09 NS

NS = No significant difference between groups. *p < 0.05. **p < 0.01. ***p < 0.001. ****p < 0.0001.

groups the amount of expansion was greater in the pre- sured on the initial set of study models. This particular
molar region than in the molar region. measurement was chosen because it was thought that
the width of the deciduous first molar was more sensi-
Arch expansion versus initial arch width tive to changes in arch form than the maxillary first
In order to determine whether or not arches that are permanent molar was, particularly in the case of ta-
narrow at the beginning of treatment expand more than pered arches. Those cases which had a transpalatal
those that are wide, both the control and the treated width of less than 24.5 mm. were placed in the nar-
samples were divided into narrow and wide subgroups. row group (Fig. 7) and those cases which had a trans-
After consideration of a number of measures, the groups palatal width of 24.5 mm. or greater were placed in
were arbitrarily divided on the basis of the transpalatal the wide group (Fig. 8).
width between the upper first primary molars as mea- Maxillary expansion. There was no statistical dif-
 Fig. 10. Arch changes observed in a male patient treated with the Frankel , appliance. Initial records
were taken at 10 years 4 months of age; the second set at 12 years 1 month of age; the third set at 13
years 6 months of age. This patient was classified in the wide subgroup.

Table VII. Mandibular dental expansion (lingual)

Control Friinkel

Narrow Wide Ntrrrow Wide

Region M x S.D. N 2 S.D. t lest Sig. N ,? S.D. A’ 2 S.D. 1 fCSf Sig

- Short-term (mm.)
-3-3 I -0.1 0.8 9 -0.6 0.6 0.86 NS 4 1.2 1.3 10 1.1 1.3 0.92 NS
-4-4 14 0.5 1.2 16 0.3 1.1 0.69 NS 11 2.1 I.1 13 2.1 1.5 0.26 NS
-5-5 18 0.5 0.9 20 0.8 0.9 0.41 NS 14 2.6 1.4 19 3.0 1.3 0.30 NS
6-6 18 0.3 0.9 22 0.8 2.2 0.31 NS 14 2.1 1.3 I9 1.9 1.3 0.66 NS
- Long-term (mm.)
-3-3 2 -1.2 0.1 I1 -0.1 1.3 0.39 NS 6 1 .o 2.1 4, 0.9 I.6 0.85 NS
--4-4 3 1.8 1.0 II 1.2 1.6 0.61 NS 12 3.2 1.6 10 3.4 2.0 0.83 NS
-5-5 5 1.7 1.6 12 1.3 1.5 0.75 NS 15 3.1 2.1 14 3.8 2.2 0.85 NS
6-6 6 0.5 0.8 15 0.9 1.1 0.55 NS 14 3.0 1.9 13 2.3 1.1 0.20 NS

NS = No significant difference between groups. *p < 0.05. **p < 0.01. ***p < 0.001. ****p < 0.0001

ference in expansion between the narrow and wide
subgroups in the control sample (Table VI), although
on the average there was a slightly greater amount of
arch expansion in the wide group at both the short-term
and long-term intervals. However, in the analysis of the
maxillary dental expansion in the cases treated with the
Frankel appliance, there was a trend toward larger in-
crements of arch expansion in the narrow subgroup
(Fig. 9) than in the wide subgroup (Fig. 10). In the
analysis of the long-term results, there was a signifi-
cantly larger expansion in the narrow subgroup than in
the wide subgroup in three of the four lingual mea-
surements considered. For example, the average amount
of intercanine expansion was 2.9 mm. in the narrow
group and 1.2 mm. in the wide group (Table VI). The
maxillary premolar region demonstrated about 1.5 mm.
greater arch expansion in the narrow group than in the
wide group. In the consideration of the short-term val-
ues, in each instance the average value was greater in
the narrow group than in the wide group, although
perhaps sample size prohibits determination of a clear
statistical significance.
The findings for the maxillary alveolar expansion
were similar to those cited for the maxillary dental ex-
pansion and will not be described in detail here.
Mandibular expansion. In contrast to the findings
Volume 82
Number I
reported above for the maxilla, no statistical difference
could be determined for the mandibular arch between
the narrow and wide subgroups in either the control or
the treated group at either the short-term or long-term
intervals (Table VII). Although the sample sizes for the
subgroups were of necessity relatively small, no trend
toward more expansion in the narrow treated group was
observed. In fact, the average expansion of teeth in the
treated wide subgroup was greater than in the treated
narrow subsubgroup approximately one half of the
time.
The findings for the mandibular alveolar expansion
also revealed no significant differences in the sub-
groups of either the treated or the control samples.
DISCUSSION
The results of this study indicate that expansion of
the maxillary and mandibular dental arches occurs rou-
tinely when a functional regulator (FR-1 or FR-2) is
conscientiously worn by the patient. The expansion is
not limited to a particular region of the dental arch,
although in absolute terms the greatest amount of ex-
pansion occurred in the premolar and molar regions
while a lesser amount occurred in the canine region.
It is clear that the expansion observed in the treated
cases is several times greater than that observed in the
untreated controls. The maxillary expansion observed
in the treated cases did not appear to be a simple tipping
of the teeth laterally, as would occur with a finger-
spring appliance. Although no specific quantification
of crown orientation was made in this study, visu-
ally the treated cases in this sample appeared to dem-
onstrate primarily a bodily movement of the buccal
segment laterally, presumably as the teeth migrated
vertically.
Visual inspection of the mandibular casts indicated
that more uprighting of teeth occurred in the lower arch
than in the upper arch. Van der Linden and Duterlools
note that the lower dentition erupts in a more lingual
direction than does the upper dentition. Frankell” states
that the uprighting of the teeth in the lower buccal
segments may be a result of the diminished resistance
of the associated soft tissues. Because of the uprighting
mechanism in the lower arch, Frankel states that there
is less alveolar expansion in the lower arch than in the
upper arch. Also, it should be noted that the vestibular
shields are held 3.0 mm. away from the maxillary al-
veolus but only 0.5 mm. from the mandibular alveolus
at the depth of the sulcus. Thus, there is little, if any,
soft-tissue stretch in the mandible.
In this study we noted less mandibular alveolar ex-
pansion than dental expansion in the second premolar
and first permanent molar regions (as Frankel suggests)
but more alveolar expansion than dental expansion in
the first premolar and canine areas. This difference in
response according to the region of the mandible con-
sidered may be due to the bone architecture of the al-
veolus, which is thicker posteriorly than anteriorly.
Few studies which consider arch expansion pro-
duced by wearing the Frankel appliance have been
published previously. Mosch’O reports average in-
creases of 4.4 to 4.7 mm. of arch expansion in 400
patients treated in Frankel’s clinic for 17 to 23 months.
The amount of expansion observed in our short-term
group was approximately 3.0 mm. (Table II). How-
ever, the long-term results were much closer to the
findings of Mosch in that the average values for the
premolar and molar measurements were 3.5 to 4.2 mm.
(Table II). The differences between the expansion in
those patients treated in Frankel’s clinic and the expan-
sion observed in this study may have been partly due to
appliance design.
Most of the treated patients in this study represent
initial efforts in using the Frlnkel appliance. During
Professor Frankel’s visits to the United States, he had
an opportunity to review the patients in our practices
currently under treatment. One of his most frequent crit-
icisms of the appliances he saw was of an underex-
tension of the vestibular shields into the vestibular fold.
He theorizes that an underextension of the vestibular
shields will not result in tension on the periosteum and
thus will result in less expansion of the dental arches.
The results of this study seem to support that hypothe-
sis, although this must be tested in a population of
treated cases in which there is adequate extension of the
shields. (The current theories and concepts of vestibu-
lar extension, as well as other clarifications of appliance
design, are discussed by McNamara and Huge.z6)
What are the clinical implications of the expansion
produced by the FrHnkel appliance? When a treated
group is compared with an untreated Class II control
group, it is clear that significant expansion is produced
by wearing the appliance. However, it is also clear that
the Frankel appliance is not a panacea for severely
crowded cases, particularly if the lower permanent
canines have erupted. In this sample, the average in-
crease in intercanine width was approximately 1 mm.,
with a maximum of 3.7 mm. (Table IV). This was not
statistically different from the control group. If incisor
crowding is present and the incisors have a normal axial
inclination and position anteroposteriorly, a dramatic
uncrowding of the incisors is not to be expected. Most
of the expansion occurs in the premolar and molar re-
gions. This expansion produced by the functional reg-
ulator can be sufficient to make a borderline extraction
case treatable without removal of permanent teeth. We
have often observed 6 to 10 mm. of maxillary arch
expansion, particularly in those cases that were con-
sidered narrow at the beginning of treatment. The cur- 8 Frhkel. R.: The practical meaning of the functional matrix in
orthodontic\, Trans. Eur. Orthod. Sot. 45: 207-2 19, 1969.
rent study also has shown that in the maxilla narrower
9). Frinkrl, K.: The treatment of Class II, Division I malocclusion
arches tend to expand more than wider arches. with functtonal correctors, A\I. J. ORTHOD 55: 265.275. 1969.
IO. Frankel. I?.: Guidance of eruption without extractton, Trans.
SUMMARY AND CONCLUSIONS Eur. Orthod. Sot. 47: 303-315. 1971.
Sixty treated and forty-seven untreated Class II, 11. Fr~nkel. R.: Decrowding during eruption under the screening
Division 1 patients were examined in this study. The influence of vestibular shields, AM. J. ORTHOO. 65: 372.406,
1974.
patients in the former group were treated with the func- 12. Frankel. R.: The artificial translation of the mandible by func-
tional regulator of Frankel (FR-I or FR-2), while pa- tional regulators. In Cook, J. T. (editor): Transactions of the
tients in the latter group were not treated but were of Third International Orthodontic Congress. St. Louis. 1975. The
similar ethnic and skeletal composition. Sequential C. V. Mosby Company.
13. Frankel, R.: A functional approach to orofacial orthopedics, Br.
dental casts of the treated and untreated groups were
J. Orthod. 7: 41-51, 1980.
examined, and the changes in lingual, buccal, and al- 14. Friinkel. R., and Frinkel, C.: A functional approach to the
veolar arch widths were compared. treatment of skeletal open-bite, AM. J. ORTHOD. (In press.)
The results of this study indicate that expansion of 15. Hotz, R.: Orthodontia in everyday practice, Philadelphia, 1961,
the maxillary and mandibular dental arches and their J. B. Lippincott Company.
16. Proffit, W. R.: The facial musculature in its relation to the dental
supporting structure occurs routinely when a functional
occlusion. In Carlson, D. S., and McNamara, J. A., Jr. (editors):
regulator (FR- 1 or FR-2) is conscientiously worn by the Muscle adaptation in the craniofacial region, Monograph
patient. The expansion is not limited to a particular No. 8. Craniofacial Growth Series, Ann Arbor, 1978, The
region of the dental arch, although in absolute terms the University of Michigan Center for Human Growth and Devel-
largest expansion values occur in the premolar and opment.
17 Atkinson, S. R.: Jaws out of balance. 1. AM. J. ORTHOD. 52:
molar regions, while lesser values were recorded in the
47-55. 1966.
canine region. In addition, this study indicates that in 18 Atkinson. S. R.: Jaws out of balance. II, AM. J. ORTHOD. 52:
the maxilla narrower arches tend to expand more than 37 I-380. 1966.
wider arches. 19. van der Linden, F. P. G. M. and Duterloo, H. S.: The develop-
The question of stability will be covered in a future ment of the human dentition: An atlas, New York, 1976, Harper
& Row.
article.
20 Graber, T. M., and Neumann, B.: Removable functional
It is the responsibility of the clinician to evaluate appliances. Philadelphia, 1977, W. B. Saunders Company.
the efficacy of this expansion and to apply this treat- 21. Altmann, K.: Experimentalle Untersuchungen iiber mechanische
ment approach in those cases where it is indicated. Ursachen der Knochenbildung, Z. Anat. Entwicklngsgesch.
114: 457. 1949.
The authors thank Mr. Robert L. Wainright for his statis- 22 Altmann, K.: Untersuchungen iiber .Frakturheilung unter be-
tical assistance and Ms. Kathleen A. O’Connor for her tech- sonderen experimentellen Bedingungen, Z. Anat. Entwicklngs
nical assistance on this project. They also acknowledge the gesch. 115: 63, 1950.
help of Ms. Katherine A. Ribbens and Ms. Andrea G. Appel 23. Altmann, K.: Zur kausalen Histogenese des Knorpels, Berlin,
in the preparation of the manuscript. Illustrations are by 1964, Springer Verlag.
William L. Brudon. 24. Pauwels, F.: Gesammelte Abhandlungen zur funktionellen
Anatomie des Bewegungsapparates, Berlin, 1965, Springer Ver-
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