European Journal of Orthodontics, 2021, 1–8

doi:10.1093/ejo/cjab006
Original article

Original article

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Short term effects of interceptive expansion
treatment: a prospective study
A.-S. Van de Velde1, L. De Boodt1, M. Cadenas de Llano-Pérula1,
A. Laenen2 and G. Willems1,*
Department of Oral Health Sciences-Orthodontics, KU Leuven & Dentistry, University Hospitals Leuven, Leuven,
1

Belgium; 2Interuniversity Institute for Biostatistics and Statistical Bioinformatics, KU Leuven and University Hasselt,
Belgium

*Correspondence to: G. Willems, Department of Oral Health Sciences-Orthodontics, KU Leuven & University Hospitals Leu-
ven, Dentistry, Kapucijnenvoer 7 Blok A, PO Box 7001, 3000 Leuven, Belgium. E-mail: guy.willems@kuleuven.be

Summary
Objectives:  This prospective cohort study investigated the short term effects of interceptive
orthodontic treatment with a removable expansion plate, evaluating the changes in occlusion in
all its dimensions: transversal, sagittal and vertical.
Subjects and methods:  A total of 226 patients treated with a removable expansion plate (slow
maxillary expansion, SME) by orthodontic residents at the Department of Orthodontics, University
Hospitals Leuven, Belgium were included. The patients had a mean age of 8.5 years at the start of
the treatment. The mean treatment time was 6.9 months. Transversal measurements (intercanine
and intermolar width) and occlusal characteristics (molar occlusion, overjet, overbite and functional
shift) were collected before (T0) and after active treatment (T1). Statistical analysis was performed
using the Wilcoxon signed rank test, Sign test and McNemar test for assessing changes between
T0 and T1. Linear models were used to assess the associations between patient factors and the
amount of expansion.
Results:  A significant increase in transversal width at different occlusal landmarks was found.
Correction of unilateral, bilateral and frontal crossbites was successful in 99.0%, 95.2% and 93.6%
of the cases respectively. Changes in sagittal molar occlusion were significant: 64.9% (right side)
and 62.6% (left side) remained stable, 28.4% (right) and 29.3% (left) improved and 6.7% (right)
and 8.1% (left) deteriorated. Overbite changes were found to be statistically significant, though
clinically irrelevant. Overjet changes were non-significant.
Conclusions:  A removable expansion plate is successful in improving the transversal dental
dimensions of the maxilla. Statistically significant sagittal effects on molar occlusion were found.
Long-term follow-up is needed to evaluate the long-term stability of this treatment.

Introduction the risks for each patient until conclusive evidence is published. Early
intervention has been suggested in the following cases: anterior or
Timing of orthodontic treatment has been elaborately debated in the
posterior crossbites with or without mandibular shifts, aberrant
past and opinions on whether to correct certain malocclusions at an
eruption patterns, impaction of teeth due to a lack of space, risk
early stage of development vary between countries and practitioners.
of trauma or psychological reasons. Other arguments mentioned in
The available evidence concerning this matter is scarce and poor in
favour of early orthodontic treatment are compliance and the adapt-
quality, which makes it difficult to extract solid conclusions. It is
ability of the craniofacial complex at a younger age (1–4).
therefore up to the practitioner to evaluate if the benefits outweigh

© The Author(s) 2021. Published by Oxford University Press on behalf of the European Orthodontic Society.
1
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2 European Journal of Orthodontics, 2021
One of the most common interceptive treatments is maxillary
expansion. Research in subjects receiving rapid maxillary expan-
sion (RME) suggests that with increasing age, the amount of skel-
etal opening at the midpalatal suture decreases and that it occurs
more in the anterior than in the posterior part of the suture. It
has also been suggested that the total amount of expansion gen-
erated is only 20–50% of skeletal nature and that it decreases
with age, which supports the decision to carry out this treatment
at a younger age (5, 6). For slow maxillary expansion (SME), the
available evidence is more limited and no conclusions concerning
short and long term effects on the skeletal and dentoalveolar level
can be drawn (7, 8).
This present study aims to evaluate the effects of maxillary ex-
pansion in a prospective way, based on records taken at the start
and the end of early orthodontic treatment. The aim is twofold:
(1) to evaluate the immediate expansion efficiency of intercep-
tive treatment with removable expansion plates (SME), and (2)
to evaluate the efficiency of SME in correcting the malocclusion
in all aspects.
Subjects and methods
The present article reports the short term effects of SME immedi-
ately after treatment and it is part of a long-term, ongoing study.
Patient recruitment started in September 2015, when a specific
protocol was implemented for interceptive treatment with remov-
able expansion plates at the Department of Orthodontics, University
Hospitals Leuven, Belgium. After a first intake consultation, patients
who were advised to start interceptive expansion treatment were in-
vited to participate in the study. Records were taken at the beginning
(T0) and at the end of expansion (T1) to evaluate the effects of the
intervention.
The follow-up of included patients will continue and evaluation
of the records at the start (T2) and the end of comprehensive treat-
ment (T3) will follow.
Inclusion criteria were:
1. Healthy children receiving interceptive orthodontic treatment in
the mixed dentition with a removable expansion plate.
2. Treatment needed for crossbite, lack of space, canine impaction,
severe retrognathia with a narrow maxilla or functional shift.
3. Availability of a complete set of records (intra-oral photographs,
digital dental casts, panoramic radiographs and cephalograms) at
the start (T0) and at the end of interceptive treatment (T1).
Exclusion criteria:
1. Previous orthodontic treatment.
2. Patients with syndromes or craniofacial abnormalities.
3. Cases with lack of records due to discontinuation of treatment
because of non-compliance and cases with loss of follow-up.
4. Lack of records after expansion.
The records taken before the start of treatment consisted of sagittal
occlusion of the first permanent molars, overjet, overbite, presence of
a functional shift, presence of a frontal or posterior crossbite, digital
dental models (DigiModel®, Orthoproof, Netherlands), intra- and
extra-oral pictures, a panoramic radiograph and a cephalogram.
These records were collected again after active expansion, but radio-
graphic images were only taken when needed for diagnostic reasons.
SME was performed with the ‘KULeuven-appliance’ which con-
sists of an acrylic plate with a symmetrical jackscrew, Adams clasps
on the first permanent molars, button clasps between the deciduous
molars, wrap around clasps on the deciduous canines, a labial bow
and preferably a complete coverage of the occlusal and incisal sur-
faces. The labial bow is used to control the inclination of the inci-
sors, as sometimes also protrusion springs were used. This complete
coverage prevents the lower incisors from overeruption during treat-
ment, avoids deepening of the bite and creates disclusion, avoiding
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occlusal interferences during expansion. If needed, extra mesializa-
tion, distalisation, extrusion springs or a tongue fence were added to
the plate (Figure 1).
After placement, patients wore the appliance passive for 1–2
weeks to adapt before active expansion started at a rate of 1 activa-
tion per week (0,25 mm, slow maxillary expansion). Patients were
instructed to wear the appliance 24h/day and to remove it only for
tooth brushing, rinsing and cleaning. Follow-up appointments were
planned every 6–8 weeks and expansion continued until the trans-
verse relation was corrected when the patients were guided to neu-
tro-occlusion intra-orally. In cases with space deficiency expansion
continued until adequate space was gained, always without creating
a scissor bite. No transversal overcorrection was performed, and all
patients were treated by orthodontic residents at the Department of
Orthodontics, University Hospitals Leuven, Belgium.
After the active expansion, a retention period of two months
full-time passive wear and two months of half-time passive wear
followed. At the start of the retention period, the occlusal acrylic
coverage was removed so occlusion could settle. Retention periods
were individually revaluated and adapted to the patient’s specific
needs. If interdigitation was not sufficient, the retention period was
prolonged.
Patient files were used to collect the following data: gender, date
of birth, age at T0 and T1, appliance design, treatment time, reten-
tion period and the extra aids used during treatment. The presence
of a frontal or posterior crossbite, presence of a functional shift,
occlusion at the first permanent molars on the right and left side,
overjet and overbite were scored by one observer for T0 and T1.
Measurements of sagittal molar occlusion were based on Angle’s def-
inition and were scored in the amount of premolar width deviation
as follows: one-fourth unit (1/4), one-half unit (1/2), three-quarters
unit (3/4), full unit and more than one unit (>1) deviation (9, 10).
A lateral crossbite was assumed when one or more elements from
canine to first permanent molar had a transverse discrepancy in rela-
tion to the antagonist's tooth, while a frontal crossbite was scored if
one of the 4 incisors had an inverted relation. Edge to edge relation
of the teeth was also scored as a crossbite.
Figure 1.  Basic plate design.
A.-S. Van de Velde et al.
The evaluation of the transversal effects was performed by
one observer on digital dental casts using DigiModel® software
(OrthoProof®, Netherlands).
The following measurements were made on the occlusal plane
mode (Figure 2):
1. 53g–63g: distance between the most lingual and cervical point of
the maxillary deciduous canines if present
2. 53c–63c: distance between cusps of maxillary permanent canines
if present
3. 16g–26g: distance between the most lingual and cervical point of
the first maxillary permanent molars
4. 16f–26f: distance between the central fossae connected to the
vestibular groove of the first maxillary permanent molars
5. 16MB–26MB: distance between the mesiobuccal cusps of the
first maxillary permanent molars
6. 16DB–26DB: distance between the distobuccal cusps of the first
maxillary permanent molars
These measurements were based on those of other studies evaluating
the transversal outcome of expansion treatment (11). In case of bad
definition or lack of landmarks due to missing teeth, exfoliated de-
ciduous teeth or caries, measurements were omitted. The remaining
available data of these patients were still used for analysis.
Cephalometric analysis was performed by one observer. The
ANB angle, the mandibular plane angle (Steiner) and the Wits ap-
praisal were measured.
Statistical analysis
The models of 20 randomly selected patients were measured twice by
the same observer to determine intra-observer reliability and another
observer measured these models again to evaluate inter-observer re-
liability by calculating the intraclass correlation coefficient (ICC).
The cephalometric measurements were repeated by the same ob-
server in 20 other randomly-selected patients and intra-observer re-
liability was analysed as well.
The Wilcoxon signed rank test was used to assess change be-
tween T0 and T1 on continuous or ordinal variables with multiple
levels. The sign test was used to assess change between T0 and T1 on
ordinal variables with few levels. To assess change between the time
points on binary variables the McNemar test was performed.
Linear models were used to assess the association between pa-
tient factors (age, gender, crossbite, type of appliance) and the change
Figure 2.  Measurements performed on DigiModel® software.
3
in canine and molar width. When a characteristic was measured by
multiple variables such as for intermolar width (4 measurements)
and occlusion (2 measurements, left and right) the raw p-values were
calculated as well as the Holm p-values, hence correcting for multi-
plicity. Differences with P-values smaller than 0.05 were considered
as statistically significant.
Statistical analysis was performed using SAS software (version
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9.4 of the SAS System for Windows).
Ethical approval
This study has been approved by the ethics committee of the
University Hospitals Leuven with the registration number s56398.
Results
Sample description
At the moment of analysis, 274 patients had initially started inter-
ceptive treatment with a removable plate. From these, 48 patients did
not meet the inclusion criteria due to lacking records, non-compli-
ance, appliance loss or change to an external orthodontist.
226 patients were finally included for analysis from T0 to T1:
125 girls and 101 boys. The mean age at the start of interceptive
treatment was 8.7  years (SD 1.0) with a median of 8.5  years and
a range of 6.5 to 12.6  years. Regarding appliance design, 186 pa-
tients (82.3%) had total coverage of all occlusal and incisal surfaces,
31 (13.7%) had bilateral coverage and 9 (4.0%) had no occlusal
coverage.
Out of the total of 226 patients, a bilateral crossbite was diag-
nosed in 21 patients (9.3%), a unilateral crossbite in 102 patients
(45.1%) and 103 (45.6%) had no lateral crossbite. A frontal cross-
bite was present in 47 patients (20.8%) and a functional shift in
108 patients (47.8%). Initial transversal dimensions are reported in
Table 1.
At T0, the mean overjet and overbite were respectively 3.7 mm
(SD 2.5) and 1.9 mm (SD 2.3).
The cephalometric measurements at T0 were 34.8° (SD 5.5°),
3.9° (SD 2.2°) and −0.4 (SD 2.6) for a mandibular plane angle to
SN-line, ANB angle and Wits appraisal respectively.
At the end of active treatment, the mean age was 9.3 years (SD
1.0) with a median of 9 years and a range of 7 to 13.3 years. The
active expansion was on average 6.9  months, retention excluded.
The retention phase was on average 2.2 months full-time wear and
2.2  months half-time wear. The average total treatment time was
thus 11.3 months (Table 2).
At T1, 222 patients (98.2%) had no lateral crossbite, while 2
patients (0.9%) still had a unilateral and 2 (0.9%) a bilateral cross-
bite. A frontal crossbite was still present in 5 patients (2.2%) and
a functional shift in 16 patients (7.6%). A mean overjet and over-
bite of respectively 3.8  mm (SD 2.2) and 2.0  mm (SD 1.6) were
registered.
Descriptive information concerning the sagittal occlusion on the
left and right side at both time points can be found in Table 1.
Assessment of the method error
The inter- and intra-observer reliability for DigiModel® and ceph-
alometric measurements were excellent. Values for DigiModel®
variables range from 0.987 to 0.999 for intra-observer reliability
and from 0.994 to 0.998 for inter-observer reliability. Intra-
observer reliability for cephalometric measurements ranged from
0.987 to 0.993.
 4

Table 1.  Occlusal characteristics at T0 and T1. Presence of crossbite; OCCL R: sagittal occlusion first permanent molar at the right side; OCCL L: sagittal occlusion first permanent molar at the
left side; NO: neutro-occlusion; DO: disto-occlusion; MO: mesio-occlusion; Change of occlusal characteristics T0–T1.

Time Variable Values Variable Values Variable Values

T0 Crossbite OCCL R OCCL L

None 70/226 (31.0%) 1 MO 1/222 (0.5%) 1 MO 2/223 (0.9%)

Right 45/226 (19.9%) 1/2 MO 1/222 (0.5%) 1/2 MO 3/223 (1.4%)
Right + frontal 8/226 (3.5%) 1/4 MO 4/222 (1.8%) 1/4 MO 1/223 (0.5%)
Left 44/226 (19.5%) NO 39/222 (17.5%) NO 41/223 (18.4%)
Left + frontal 5/226 (2.2%) 1/4 DO 35/222 (15.8%) 1/4 DO 32/223 (14.3%)
Bilateral 19/226 (8.4%) 1/2 DO 75/222 (33.8%) 1/2 DO 73/223 (32.7%)
Bilateral + frontal 2/226 (0.9%) 3/4 DO 29/222 (13.0%) 3/4 DO 32/223 (14.3%)
Frontal 33/226 (14.6%) 1 DO 36/222 (16.2%) 1 DO 37/223 (16.6%)
> 1 DO 2/222 (0.9%) > 1 DO 2/223 (0.9%)
T1 Crossbite OCCL R OCCL L
None 216/226 (95.6%) > 1 MO 1/226 (0.4%) > 1 MO 1/225 (0.4%)
Right 2/226 (0.9%) 1 MO 1/226 (0.4%) 1 MO 1/225 (0.4%)
Right + frontal 0/226 (0.0%) 1/2 MO 4/226 (1.8%) 3/4 MO 2/225 (0.9%)
Left 0/226 (0.0%) 1/4 MO 7/226 (3.1%) 1/2 MO 2/225 (0.9%)
Left + frontal 0/226 (0.0%) NO 49/226 (21.7%) 1/4 MO 7/225 (3.1%)
Bilateral 2/226 (0.9%) 1/4 DO 53/226 (23.5%) NO 50/225 (22.2%)
Bilateral + frontal 0/226 (0.0%) 1/2 DO 63/226 (27.9%) 1/4 DO 42/225 (18.7%)
Frontal 6/226 (2.6%) 3/4 DO 22/226 (9.7%) 1/2 DO 71/225 (31.6%)
1 DO 26/226 (11.5%) 3/4 DO 26/225 (11.6%)
1 DO 22/225 (9.8%)
>1 DO 1/225 (0.4%)

T0–T1 Variable Values Variable Values

OCCL R OCCL L OVERJET OVERBITE

Improvement 63/222 (28.4%) 65/222 (29.3%) 54/205 (26.3%) 67/204 (32.8%)
Status quo 144/222 (64.9%) 139/222 (62.6%) 99/205 (48.3%) 103/204 (50.5%)
Deterioration 15/222 (6.7%) 18/222 (8.1%) 52/205 (25.4%) 34/204 (16.7%)
P-value Raw <.0001 <.0001 0.9227 0.0013
P-value Holm <.0001 <.0001
European Journal of Orthodontics, 2021

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A.-S. Van de Velde et al. 5

Comparison T0–T1

(37.5; 76.5)
(0.0; 429.0)
The effects on the transversal dimension were evaluated by calcu-
lating the increase in width between first molars and – if present

67.2
53.1
60.0
224
All
– deciduous canines from T0 to T1. The mean increase ranged from
3.2 to 3.8 mm (Table 3). The changes were highly significant (P= <
0.0001) and remained highly significant after Holm correction for
multiple testing was applied.

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Statistic

Median

Range
Mean
Secondly, the efficiency of crossbite correction was evaluated.

IQR
SD
N
Correction was successful in 99.0% of patients with a unilateral and
in 95.2% of patients with a bilateral crossbite. Regarding frontal
crossbite, correction was successful in 93.6% of patients (Table 4).
In the sagittal dimension, changes in molar sagittal occlusion
Retention half-time (days)

and overjet were calculated. We defined a sagittal occlusion of one

quarter unit premolar width mesio- to one quarter unit premolar
width disto-occlusion and an overjet and overbite of 1 to 3 milli-
metres as acceptable. Every change towards these ranges was scored
as an improvement. Opposite to this, every change further away
Variable

was defined as deterioration. Changes in occlusion at the right and

left side were highly significant (P = <0.0001). Additionally, differ-
ences in terms of improvement, status quo and deterioration were
proven to be significant and both sides showed similar percentages
for these variables. Changes in overjet were not statistically signifi-
(39.0; 78.0)
(0.0; 618.0)

cant (P = 0.3282), while high statistical significance (P < 0.0001) was

found for the mean difference in overbite (−0.4 mm) between T0 and
67.9
58.4
57.5
226
All

T1 (Table 3).

Influencing factors
We looked into different factors such as age, gender, presence of
Statistic

Median

Range
Mean

crossbite and type of appliance used during treatment for influences

IQR
SD
N

on the amount of expansion. Only when crossbites were present,

a statistically significant, positive correlation was found with the
Table 2.  Expansion time, retention period full-time and half-time wear. SD: standard deviation.

amount of expansion, with an exception for the change in the 53c–

63c distance (Table 5).
Retention full-time (days)

Discussion
As measurements on digital dental models have been proven to be
Variable

equally accurate and reliable than those performed on non-digital

casts, findings carried out with both techniques can be safely com-
pared (12–15).
When analysing the available literature, we find our sample to be
remarkably larger than that of previous prospective studies, which
(146.0; 259.0)
(45.0; 792.0)

did not include more than 135 patients, subdivided into smaller
groups with different appliances. This is an important strength of
210.1

190.5

our study.
98.6
226
All

The main limitation of our study is the absence of a non-treated

control group. This was found to be unethical since all included sub-
jects had a present treatment need that could not be ignored. In add-
ition, when patients don’t start treatment before a certain age, there
Statistic

Median

Range
Mean

is less refund from insurance in Belgium.

IQR
SD
N

Another fundamental difference is that in the current patient

population not only patients with crossbites were included. Patients
with lack of space, tooth impaction or a very narrow maxilla also
received expansion treatment for these matters.
Time expansion (days)

However, even if in this sense our population was more heteroge-

neous, our mean maxillary transversal values were comparable with
those of other studies investigating only subjects with crossbites of
the same age (16–20). This finding is also supported by our own
Variable

population: comparing initial widths of non-crossbite patients with

crossbite patients resulted in no statistically significant differences.
 6 European Journal of Orthodontics, 2021

Table 3.  Initial values and differences (T0–T1) for intercanine and intermolar width, overjet, overbite. Med: Median; Min: lowest value; Max: highest value; Q1: percentile 25; Q3: percentile 75; This suggests that a constricted maxilla is one of the underlying

P (Holm)

<0.0001

<0.0001

<0.0001

<0.0001

<0.0001

<0.0001
causes of tooth impaction or lack of space.

.
Comparison of the amount of expansion generated is more com-
plex, as each study performs cast measurements differently and at
different points in time. This is why in the present study 4 different
points at the first molars were selected for evaluation. Values are
generally of the same magnitude, with an exception for values at

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<0.0001

<0.0001

<0.0001

<0.0001

<0.0001

<0.0001

<0.0001
P (Raw)
P(Raw)

0.3282
the canine level which are higher in our results compared to others
(17–19, 21–23). These higher values can be attributed to a greater
.

.
.

.
.
dental tipping component or the extra retention ¾ clasps that are
placed at the deciduous canines. One would expect our values to
be lower compared to crossbite-only populations, as the statistical
analysis of our results found a correlation between the amount of
23.9
4.0
30.4
5.0
31.8
4.5
45.0
4.6
49.0
4.8
51.4
4.4

2.0
2.0
0.5
1.0
1.0
0.0
expansion and the presence of a crossbite at the start of treatment.
Q3

Q3 Even though the treatment protocol included a retention period

of 2 months full-time and 2 months half-time wear, the duration of
active expansion and retention periods were variable. Patient files
of the outliers were reviewed to investigate the underlying causes.
21.1
2.1
27.0
2.6
28.9
2.2
41.4
2.0
45.3
2.1
48.1
2.0

0.0
0.0
−1.0
0.0
0.0
−1.0
The main reason for a prolonged expansion time was a need for
Q1

Q1

greater transversal correction in case of a bilateral crossbite or in

combination with the protrusion or mesialization of anterior teeth.
Another frequent reason for longer active treatment was a poor fit
of the appliance due to breakage of the retention clasps (caused by
Max

Max
29.9

37.8
10.0
38.0
10.3
52.3
17.0
57.6
11.2
58.7
12.2

the patient’s wrong use of the appliance). This lead to repair of the
7.4

9.0
9.0
5.0
7.0
4.0
2.0

appliance in the lab, subsequently resulting in a certain relapse of

the already achieved results. Lastly, non-compliance in terms of not
wearing the appliance 24/7 or not activating it weekly also resulted
in longer treatment time.
The longer retention periods were due to individual patient factors:
15.0
−0.2
20.2
−0.2
22.9
−0.5
31.2
−0.7
37.7
−5.4
40.6
−1.6

−5.0

−7.0
Min

Min
0.0
0.0

0.0
0.0

high sensitivity to relapse, the use of the appliance as a space maintainer

or distalization of molars during the full-time retention phase. Details
regarding expansion and retention times can be found in Table 2.
In 10 cases, extra aids that could have influenced the transversal
dimensions were used, such as crisscross elastics or a palatal bar. 20
SD: standard deviation; P: P-value from Wilcoxon signed rank test comparing T0 and T1.

Med

Med
22.4

28.8

30.5

43.5

47.3

49.9
3.1

3.6

3.2

3.2

3.5

3.1

0.0
0.0
0.0
0.0
0.0
0.0

cases needed extra aids such as extrusion springs for impacted teeth,
distalization springs, a lipbumper, a tongue fence, class III bone an-
chors or spatula biting to complement the interceptive treatment.
In terms of success percentages, ours were high regarding cross-
bite correction even though treatment was done by residents with
2.2
1.5
2.6
1.8
2.5
1.7
2.9
2.0
3.1
2.1
3.0
1.9

1.9
1.8
1.4
1.3
0.8
1.3
SD

SD

limited years of experience: 99.0% for unilateral, 95.2% for bilat-

eral and 93.6% for frontal crossbites. Only the study by Godoy et al.
(22) reported a higher post-treatment success percentage of 100%,
other studies reported much lower percentages of about two-thirds
Mean

Mean

of the patient population (16, 20).

22.5

28.8

30.5

43.3

47.2

49.8

−0.1

−0.4
3.2

3.8

3.3

3.4

3.5

3.3

1.3
1.2

0.9
0.5

A recent study by Sollenius et al. concluded that expansion treat-

ment with a removable plate is more successful when carried out by an
orthodontic specialist than by a general practitioner (20, 24). However,
we achieved high success percentages with a limited amount of clinical
experience of the practitioners. This suggests that interceptive expan-
182
182
180
180
222
222
221
221
221
221
218
218

205
205
205
204
204
204
N

sion with removable appliances is a fairly simple treatment. Since in

some countries, interceptive treatment is carried out by general den-
tists, the simplicity of the method can be seen as an added value.
Nine patients had residual crossbites at T1. When reviewing
these patient files, we could conclude that this was due to local tooth
Deviation from ideal value

malpositions, edge-to-edge relations on one or two teeth, a lower

level of compliance or appliance loss during the active or retention
phase. These local malpositions often make the treatment longer
16MB–26MB T0

16DB–26DB T0

when we try to correct them during this early first phase and tend
Overbite T0
Overbite T1
53g–63g T0

53c–53c T0

16g-26g T0

16f–26f T0

to relapse when retention is discontinued. It is therefore advisable to

Overjet T0
Overjet T1
Difference

Difference

Difference

Difference

Difference

Difference

Difference

Difference

keep the correction of the individual malpositions for comprehensive

treatment.
A.-S. Van de Velde et al. 7

Table 4.  Improvement crossbites and functional shift T0–T1.

Variable T0: No crossbite T0: Unilateral crossbite T0: Bilateral crossbite

P-value lateral crossbite = <0.0001 (Sign test)

  T1: No crossbite 101/103 (98.0%) 101/102 (99.0%) 20/21 (95.2%)
  T1: Unilateral crossbite 1/103 (1.0%) 1/102 (1.0%) 0/21 (0.0%)
  T1: Bilateral crossbite 1/103 (1.0%) 0/102 (0.0%) 1/21 (4.8%)

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T0: No frontal crossbite T0: Frontal crossbite
P-value frontal crossbite = <0.0001 (McNemar test)
  T1: No frontal CB 177/179 (98.9%) 44/47 (93.6%)
  T1: Frontal CB 2/179 (1.1%) 3/47 (6.4%)
T0: No functional shift T0: Functional shift
P-value functional shift = <0.0001 (McNemar test)
  T1: No functional shift 107/110 (97.3%) 89/102 (87.3%)
  T1: Functional shift 3/110 (2.7%) 13/102 (12.7%)

Table 5. Correlation crossbite T0 (lateral and/or frontal) and in-
crease width.
Outcome Difference (95% CI) P (Raw) P (Holm)
53g–63g 1.1 (0.6;1.7) <0.0001 0.0003
53c–63c 0.1 (-0.5;0.6) 0.8269 0.8269
16g–26g 0.9 (0.4;1.4) 0.0002 0.0012
16f–26f 0.9 (0.3;1.4) 0.0026 0.0078
16MB–26MB 1.0 (0.6;1.6) 0.0005 0.0019
16DB–26DB 0.8 (0.3;1.4) 0.0041 0.0082
Difference >(<) 0 means higher (lower) value for CB Yes Holm correction
for multiple testing (4 measurements of width change).
Apart from transversal effects, results show a non-significant
mean overjet improvement of 0.1 mm during treatment. This can be
due to the large range of overjet values present in our population.
Changes in overbite were statistically significant, although it can
be debated if an improvement of 0.4 mm in overbite can be regarded
as clinically significant. The change in overbite is also dependent on
the presence and the type of the initial crossbite. When correcting
an edge-to-edge relation in the front or posterior region, an increase
in overbite will be observed. Nonetheless one would expect a de-
crease in overbite from the complete occlusal and incisal coverage as
seen during functional appliance therapy. The moderate effect seen
in overbite could be the result of the heterogeneous sample, the fairly
short time of intervention or the fact that expansion takes place in
a continuously changing mixed dentition. Another possible explan-
ation to this discrete change is that the occlusal coverage functions
the same way as the occlusal coverage in a bonded McNamara ex-
pander: limiting the forward and downward movement of the max-
illa and thus providing some sort of vertical control (25–27). Minor
changes in overjet and overbite were also found in previous studies
with different plate designs by Bjerklin and Petrén (17, 18).
Significant changes in occlusion at the first permanent molars
were observed in our study, which may be explained by the cor-
rection of the unilateral crossbite and the functional shift. This
mostly implies an improvement on the crossbite side and a stable
or deteriorated occlusion at the contralateral side. Deterioration is
also seen when correcting functional shifts with a protrusive com-
ponent, but this should actually be defined as a normalization of
occlusion. Dental midline deviations often spontaneously correct as
well, as previous research has indicated (16, 17). Other possible ex-
planations for these changes could be the changing of teeth and the
individual use of the leeway space, although the latter is less likely as
the treatment time is 6.9 months
Lastly, our specific appliance design, with a complete occlusal
coverage, has not been evaluated yet in any previous studies. With
this design, we aim to disclude the occlusion, eliminate the functional
shift and induce some level of relaxation at the temporomandibular
joint and the oral muscles. As seen through our results, the disclusion
does not influence the amount of expansion generated, but effects on
other occlusal parameters should be explored in further research, as
well as the amount of relapse, the effect of early interceptive expan-
sion on impacted canines and the stability of the generated effects in
terms of the evolution of IOTN/PAR. Other interesting variables to
look into are the correction of the midlines, the gain in terms of arch
length as mentioned by Petrén (16, 17) and to take the third dimen-
sion in consideration as done by Sollenius (20). Lastly, subgrouping
the sample would be interesting to evaluate if a more homogenous
subject group would influence the treatment effects.
Conclusion
A removable expansion plate is successful in improving transversal
dental dimensions of the maxilla in the mixed dentition. Statistically
significant sagittal effects on molar occlusion were found. Further
follow-up will be crucial to evaluate the long-term stability of these
changes.
Funding
No funding was received to carry out this study.
Conflict of interest
None declared.
Data availability statement
Data cannot be shared for ethical/privacy reasons.
The data underlying this article cannot be shared publicly due
to the privacy of individuals that participated in the study, since re-
cords include clinical pictures where they can be recognized. Part of
the data can be shared on a reasonable request to the corresponding
author.
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