European Journal

European Journal of
of Orthodontics
Orthodontics 36
1 of(2014)
10 140–149 © The Author 2011. Published by Oxford University Press on behalf of the European Orthodontic Society.
doi:10.1093/ejo/cjr102
doi:10.1093/ejo/cjr102 All rights reserved. For permissions, please email: journals.permissions@oup.com
Advance Access publication 29 August 2011

Comparison of the effects of rapid maxillary expansion caused

by treatment with either a memory screw or a Hyrax screw on
the dentofacial structuresಧtransversal effects
Koray Halócóoálu* and òbrahim Yavuz**
Departments of Orthodontics, Faculties of Dentistry, *Abant òzzet Baysal University, Bolu and **Atatürk University,
Erzurum, Turkey

Correspondence to: Koray Halıcıoálu, Abant òzzet Baysal Üniversitesi, Diġ Hekimliái Fakültesi, Ortodonti Anabilim Dalı,
Ġehir Kampüsü, 14300 Bolu, Türkiye. E-mail: korayhalicioglu@hotmail.com.

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SUMMARY The aim of the present study was to investigate and compare the effects of conventional Hyrax
screw treatment and memory screw treatment on skeletal and dentoalveolar structures. Thirty-two patients
with maxillary transversal deficiency were divided into two groups. The memory-screw group included
17 patients (nine females and eight males), while the Hyrax-screw group comprised 15 patients (eight
females and seven males). Mean ages of the subjects in the memory-screw and Hyrax-screw groups
were 13.00 ± 1.29 and 12.58 ± 1.50 years, respectively. Plaster models and postero-anterior cephalograms
were taken from the patients at the beginning of the treatment (T1) and at the end of expansion (T2) and
retention periods (T3). The mean expansion period was 7.76 ± 1.04 days in the memory-screw group
and 35.46 ± 9.39 days in the Hyrax-screw group. ಫShapiro–Wilk Normality test’ was used to determine
whether the investigated parameters were homogeneous or not. To determine the treatment changes
within the group, ಫpaired t-test’ and ಫWilcoxon signed-ranks test’ were applied to the homogeneous and
non-homogeneous parameters, respectively. Comparison between the groups was carried out using
ಫStudent’s t-test’ for homogeneous parameters and ಫMann–Whitney U-test’ for the rest. Rapid maxillary
expansion was carried out successfully in both the groups. However, the use of memory screw may be
advantageous because it shortens the maxillary expansion period, provides additional expansion in the
retention period, and generates light forces relative to the conventional Hyrax screw.

Introduction
Interest in rapid maxillary expansion (RME) has increased
during the past four decades. In spite of the recommended
use of the RME (Sarver and Johnston, 1989) for different
aims, its fundamental objective is to increase the transverse
width of the upper dental arch at the apical base. Although
the major treatment effects could be observed in the dental
area, transversal expansion of the skeletal structure may be
considered as an additional contribution.
Usually, appliances with xed jack screw are used for
RME and they produce heavy forces (Isaacson and
Ingram, 1964; Zimring and Isaacson, 1965). RME occurs
when heavy forces applied to the maxillary anchorage
teeth and alveolar structures exceed the limits required
for orthodontic movement. Pressure caused by the applied
forces compresses the periodontal ligament of the anchorage
teeth and subsequently produces orthopaedic movement
by opening the midpalatal suture (Haas, 1961) and
orthodontics movement by tipping the upper posterior
teeth and alveolar structures (da Silva Filho et al., 1991;
Ciambotti et al., 2001; Oliveira et al., 2004; Klç et al.,
2008). The aims of the RME treatment are to achieve
minimal dental and maximum skeletal effects (Haas, 1961),
and many different RME appliances have been developed
for this purpose.
In a recent paper, Wichelhaus et al. (2004) described and
evaluated a new maxillary memory palatal split screw that
includes nickel–titanium open coil springs in the screw bed in
order to lessen massive expansion forces. The screw could
be activated six times a day to produce a constant force level
of 12–14 N (1224–1428 grams) providing effective and
rapid expansion. According to these authors, this new screw
could produce rapid, constant, and physiological expansion
forces, thus making the expansion procedure more effective,
more physiological, and well tolerated by patients. However,
Halcoğlu et al. (2010) showed that memory palatal split
screw produced signicant increases in the interpremolar
and intermolar distances and reduced the nasal airway
resistance. Although studies about memory screw have
increased in the past years, till date no study has been carried
out to compare the effects of RME caused by memory screw
and Hyrax screw on the dentofacial structures.
The aim of the present study was to investigate and
compare the transversal changes in subjects treated with a
conventional Hyrax screw and memory screw on plaster
models and postero-anterior cephalograms.
2 of 10 WITH MEMORY SCREW
EXPANSION
Subjects and methods
The material of this study consisted of plaster models and
postero-anterior radiographs of 32 patients aged between
11 and 14.5 years. All the subjects had bilateral maxillary
crossbites and caused by basal apical narrowness, which
underwent RME at the Department of Orthodontics, Faculty
of Dentistry, Atatürk University, Erzurum, Turkey.
The subjects were randomly assigned to two groups:
memory-screw and Hyrax-screw groups. Maxillary rst
premolars and rst molars were banded and four-armed
expansion screws were soldered to the bands in both groups.
Expansion was carried out by means of midpalatal jackscrews.
Memory-screw group included 17 patients (nine females
and eight males), while Hyrax-screw group comprised 15
patients (eight females and seven males). The mean ages of
the subjects in the memory-screw and Hyrax-screw groups
were 13.00 ± 1.29 and 12.58 ± 1.50 years, respectively.
In the conventional Hyrax-screw group, the patients were
instructed to activate the jack screw (Product number:
Figure 1 Occlusal photographs with radiographs at the beginning of the treatment (T1) and at the
end of expansion (T2) and retention periods (T3) of rapid maxillary expansion caused by memory
screw.
141
K. HALICIOĞLU AND ò. YAVUZ
167-1633—Palatal split screw type ‘N’; Forestadent,
Pforzheim, Germany; Forestadent USA, St Louis, Missouri,
USA) twice (0.225 × 2 = 0.45 mm) a day until the suture
was opened and then one turn per day for the remainder of
the RME treatment as suggested by Zimring and Isaacson
(1965) and Isaacson and Ingram (1964). In the memory-
screw group, the patients were instructed to activate the
jack screw (Product number: 167M1529—Memory expander
type ‘N’; Forestadent; Forestadent USA) six times
(0.2 × 6 = 1.2 mm) a day: two in the morning, two after
lunch, and two in the evening (Figure 1).
These screws were activated until the occlusal aspect of
the maxillary lingual cusp of the upper rst molars contacted
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the occlusal aspect of the facial cusp of the mandibular rst
molars, thus producing the desiring expansion. The mean
expansion period was 7.76 ± 1.04 days in the memory-
screw group and 35.46 ± 9.39 days in the Hyrax-screw
group. The average total screw turning activated in the
memory-screw group was 46.52 ± 6.42 turns and that in the
142
EXPANSION
WITH MEMORY SCREW
conventional Hyrax-screw group was 40.46 ± 9.39 turns;
however, it was not xed for both the screws after expansion.
Furthermore, the mean retention period was 6.42 ± 0.59
months in the memory-screw group and 6.17 ± 0.32 months
in the Hyrax-screw group.
The splitting at the suture palatine media was observed
on different days of the expansion treatment. In all the patients,
sutural opening without any problem and suture palatine
media that was lled with bone after the retention periods
were determined using occlusal radiographs (Figure 1).
Plaster models and postero-anterior cephalograms were
taken from the patients at the beginning of the treatment (T1)
and at the end of expansion (T2) and retention periods (T3).
The evaluation of the models was carried out according
to the method described by Oktay and Klç (2007). Briey,
a line (1 mm in diameter) was drawn on the upper plaster
models using a brush and barium sulfate solution. The line
began from the gingival margin of the mesiobuccal cusp of
the maxillary right rst permanent molar, passed through
the tips of the mesiobuccal and mesiopalatal cusps of that
tooth, crossed the palatal vault between the rst molars, and
ended at the vestibular gingival margin of the left rst
permanent molar. After drawing, the models were placed
in a cabinet plastic box that permitted X-rays to pass
freely and then a radiographic image of the box was
obtained in a standardized manner. The lms were taken by
a cephalometric unit manufactured by Siemens Corporation
(Erlangen, Germany), which was operated at 65 kVp and
15 mA with an exposure time of 15 seconds.
The radiographs were scanned (Epson Expression 1860
Pro, Seiko Epson Corp., Nagonaken, Japan) under ×100
magnication and digitized by one of the authors using
Quick Ceph 2000 (Quick Ceph systems, San Diego, California,
USA). Eight points were used in the evaluation of dentoalveolar
inclination. Three angles were measured on the radiographs,
which included right molar crown tipping, left molar crown
tipping, and alveolar process inclination (Figure 2).
In addition, maxillary expansion was evaluated at T1, T2,
and T3 by measuring the changes in the width on the study
models. All the measurements were carried out by one of
the authors using high-precision digital callipers with
an accuracy of 0.01 mm (Digimatic Calliper CD-6 inCX;
Mitutoyo American, Plymouth Michigan, USA).
Postero-anterior radiographs were scanned using the same
equipments under ×100 magnication and digitized by one of
the authors using Quick Ceph 2000. Fourteen points and two
planes were used in the evaluation of transversal changes, and
eight distances were measured on the radiographs (Figure 3).
This research was approved by the local ethics committee
(23.06.2006–2006.3,1/20).
Statistical analysis
Fifteen randomly selected radiographs and plaster models
were retraced and remeasured by the same investigator
3YAVUZ
K. HALICIOĞLU AND İ. of 10
Figure 2 The reference points used for dentoalveolar inclination: (1–4)
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right and left mesiobuccal and mesiopalatal cusp tips, (5 and 7) right and
left upper alveolar tipping points (midpoint of the junction between
alveolar process and palatal gingiva of the rst molar), and (6 and 8)
right and left lower alveolar tipping points (midpoint of the junction
between alveolar process and palatal shelf). The references angles used
for dentoalveolar inclination: α1 and α2, inner angles between the
transversal occlusal line connecting the mesio-palatal cusp tips of the
right and left molars and the lines passing through the mesio-buccal and
mesio-palatal cusp tips of the molars. α3, inner angle between the right
and left alveolar lines connecting the upper and lower alveolar tipping
points in each side.
2 weeks after the initial analysis. The error of the method
was examined using the coefcient of reliability calculated
for each measurement: coefcient of reliability = 1−Se2/
St2, where Se2 is the variance due to random error and St2
is the total variance of the measurements (Houston,
1983).
The data were analysed using SPSS for Windows, version
10.0 (SPSS Inc., Chicago, Illinois, USA). ‘Shapiro–Wilk
Normality test’ was used to determine whether the
investigated parameters were homogeneous or not. To
determine the treatment changes within the group, ‘paired
t-test’ and ‘Wilcoxon signed-ranks test’ were applied
to the homogeneous and non-homogeneous parameters,
respectively. Comparison between the groups was carried
out using ‘Student’s t-test’ for homogeneous parameters
and by Mann–Whitney U-test for the rest.
Results
The value of the coefcient of reliability was above 0.90 for
all the measurements.
Changes within the group
The means and standard deviations of the changes on the
dentofacial structures in the memory-screw and Hyrax-screw
groups and their within-group comparisons are shown in
Tables 1 and 2, respectively.
Changes in the memory-screw group
During treatment (T1–T2). Right and left maxilloman-
dibular width (Mxr–FFP) and Mxl–FFP demonstrated
4 of 10 WITH MEMORY SCREW
EXPANSION 143
K. HALICIOĞLU AND ò. YAVUZ

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Figure 3 Postero-anterior cephalometric landmarks: Lateroorbitale (Lo): the intersection of the
lateral wall of the orbit and the greater wing of the sphenoid. Zygomatic (Z): the most lateral point of
zygomatic arch. Maxillary (Mx): the point located at the depth of the concavity of the lateral maxillary
contour. Nasal (Nc): the most lateral point of the nasal cavity. Antegonion (Ag): the point located at
the antegonial notch. Upper molar (Um): the most prominent lateral point of the buccal surface of the
upper rst molar. Lower molar (Lm): the most prominent lateral point of the buccal surface of the
lower rst molar. ‘Postero-anterior cephalometric planes’: frontal face plane (FFP) and occlusal plane.
‘Postero-anterior cephalometric measurements’: (1) face width (Zgr–Zgl), (2) maxillary width (Mxr–
Mxl), (3) nasal width (Ncr–Ncl), (4) mandibular width (Agr–Agl), (5) right maxillomandibular width
(Mxr–FFP), (6) left maxillomandibular width (Mxl–FFP), (7) right molar relation (Umr–Lmr), and (8)
left molar relation (Uml–Lml). (7) and (8) measurements are called posterior overjet.

a statistically signicant decrease (P < 0.001), while all
the other postero-anterior parameters showed statistically
signicant increase (P < 0.001) during the treatment.
Furthermore, the upper interpremolar, upper intermolar,
lower intercanine width, right and left crown tipping,
and palatal angulation angles (α1, 2, and 3) signicantly
increased (P < 0.001). In addition, the lower interpremolar
and intermolar width also increased (P < 0.01).
Retention period (T3–T2). At the retention period, the
face width (Zr–Zl) as well as mandibular width (Agr–Agl;
P < 0.001), maxillary width, and right and left molar relation
(Umr–Lmr and Uml–Lml) increased (P < 0.01), while the
nasal width (Ncr–Ncl) and right and left maxillomandibular
width (Mxr–FFP and Mxl–FFP) showed no statistically
signicant changes.
Furthermore, the upper intermolar, lower intercanine,
interpremolar, intermolar widths (P < 0.001), and upper
interpremolar width also increased (P < 0.01). However,
right and left crown tipping and palatal angulation angles
(α1, 2, and 3) showed no statistically significant
changes.
Total treatment period (T3–T1). At the end of all the
observation periods, the right and left maxillomandibular
width (Mxr–FFP and Mxl–FFP) showed statistically
signicant decrease (P < 0.001), while all the other postero-
anterior parameters demonstrated statistically signicant
increase (P < 0.001). Furthermore, all the parameter
measurements in the model demonstrated statistically
signicant increase (P < 0.001).
Changes in the Hyrax-screw group
During treatment (T1–T2). During treatment, while the
right and left maxillomandibular width (Mxr–FFP and Mxl–
FFP) showed statistically signicant decrease (P < 0.001),
all the other postero-anterior parameters demonstrated
statistically signicant increase (P < 0.001). In addition,
except lower interpremolar, all the other parameters
signicantly increased (P < 0.001).
 144
EXPANSION

Table 1 Descriptive statistics of the measurements at the beginning of the treatment (T1) and at the end of expansion (T2) and retention periods (T3) in the memory-screw group (N = 17)
and their within-group comparisons.
WITH MEMORY SCREW

Memory-screw groups T2–T1 T3–T2 T3–T1

T1 T2 T2 T3 T1 T3

Parameters Mean SD Mean SD t Mean SD Mean SD t Mean SD Mean SD t

Upper interpremolar width 29.82 3.33 37.57 3.88 −17.556*** 37.57 3.88 38.04 3.54 −2.461* 29.82 3.33 38.04 3.54 −18.709***
Upper intermolar width† 41.22 2.75 49.36 3.35 −3.621*** 49.36 3.35 50.17 3.14 −3.053** 41.22 2.75 50.17 3.14 −3.621***
Lower intercanine width 26.08 1.82 26.23 1.83 −4.021*** 26.23 1.83 26.57 1.86 −3.362** 26.08 1.82 26.57 1.86 −4.790***
Lower interpremolar width 33.91 1.96 34.16 1.84 −3.137** 34.16 1.84 34.53 1.79 −2.950** 33.91 1.96 34.53 1.79 −4.147***
Lower intermolar width 49.70 3.03 49.99 3.03 −3.116** 49.99 3.03 50.41 2.82 −2.975** 49.70 3.03 50.41 2.82 −4.575***
Molar crown tipping, right (α1) 4.46 3.39 13.41 4.12 −12.534*** 13.41 4.12 13.23 4.71 −0.425 4.46 3.39 13.23 4.7 −9.248***
Molar crown tipping, left (α2) 10.74 7.23 18.77 5.89 −7.388*** 18.77 5.89 19.03 6.47 −0.445 10.74 7.23 19.03 6.47 −7.068***
Alveolar process inclination (α3) 66.04 10.81 74.37 9.71 −9.865*** 74.37 9.71 74.66 9.73 −1.025 66.04 10.81 74.66 9.73 −11.514***
Zr–Zl 130.77 5.06 131.44 5.06 −5.685*** 131.44 5.06 132.19 4.80 −3.895*** 130.77 5.06 132.19 4.80 −6.109***
Mxr–Mxl 61.58 3.11 65.11 2.99 −19.011*** 65.11 2.99 65.32 3.06 −3.038** 61.58 3.11 65.32 3.06 −21.206***
Ncr–Ncl 30.71 2.62 33.88 2.69 −24.667*** 33.88 2.69 33.83 2.64 1.089 30.71 2.62 33.83 2.64 −23.786***
Agr–Agl 89.51 4.33 90.22 4.63 −4.762*** 90.22 4.63 91.47 4.63 −5.310*** 89.51 4.33 91.47 4.63 −6.639***
Mxr–FFP 13.65 1.43 12.79 1.56 8.433*** 12.79 1.56 12.80 1.53 −0.126 13.65 1.43 12.80 1.53 10.042***
Mxl–FFP† 12.92 2.00 11.70 2.34 −3.625*** 11.70 2.34 11.84 2.21 −0.986 12.92 2.00 11.84 2.21 −3.626***
Umr–Lmr −2.22 1.41 2.44 0.67 −13.239*** 2.44 0.67 2.54 0.660 −3.367** −2.22 1.41 2.54 0.660 −13.918***
Uml–Lml −2.88 1.13 2.34 0.76 −17.423*** 2.34 0.76 2.46 0.76 −2.970** −2.88 1.13 2.46 0.76 −18.121***

†Wilcoxon test (z → t).

*P < 0.05; **P < 0.01; ***P < 0.001.
K. HALICIOĞLU AND İ. of 10
5YAVUZ

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 EXPANSION

Table 2 Descriptive statistics of the measurements at the beginning of the treatment (T1) and at the end of expansion (T2) and retention periods (T3) in the Hyrax-screw group (N = 15)
and their within-group comparisons.
6 of 10 WITH MEMORY SCREW

Hyrax-screw groups T2–T1 T3–T2 T3–T1

T1 T2 T2 T3 T1 T3

Parameters Mean SD Mean SD t Mean SD Mean SD t Mean SD Mean SD t

Upper interpremolar width 30.09 2.83 38.37 4.38 −14.155*** 38.37 4.38 38.11 3.99 1.686 30.09 2.83 38.11 3.99 −16.036***
Upper intermolar width 41.18 2.89 50.06 3.84 −13.723*** 50.06 3.84 49.60 3.60 2.876* 41.18 2.89 49.60 3.60 −15.570***
Lower intercanine width† 25.93 1.91 26.33 1.93 −3.267*** 26.33 1.93 26.56 1.91 −3.551*** 25.93 1.91 26.56 1.91 −3.574***
Lower interpremolar width 33.93 3.54 33.96 2.62 −0.045 33.96 2.62 34.39 2.48 −5.847*** 33.93 3.54 34.39 2.48 −1.115
Lower intermolar width 48.48 3.20 48.91 3.15 −5.609*** 48.91 3.15 49.21 2.97 −1.350 48.48 3.20 49.21 2.97 −2.967**
Molar crown tipping, right (α1) 7.27 6.22 15.95 7.04 −5.279*** 15.95 7.04 15.58 6.14 −0.337 7.27 6.22 15.58 6.14 −7.237***
Molar crown tipping, left (α2) 9.49 6.39 17.86 6.94 −5.295*** 17.86 6.94 17.34 6.63 0.382 9.49 6.39 17.34 6.63 −5.290***
Alveolar process inclination (α3) 62.51 11.10 73.51 9.62 −8.580*** 73.51 9.62 73.24 9.78 0.616 62.51 11.10 73.24 9.78 −7.949***
Zr–Zl 128.95 5.20 129.48 5.016 −4.654*** 129.48 5.016 130.07 4.90 −5.024*** 128.95 5.20 130.07 4.90 −5.163***
Mxr–Mxl 62.36 2.12 66.02 1.80 −19.398*** 66.02 1.80 66.16 1.85 −2.881* 62.36 2.12 66.16 1.85 −20.381***
Ncr–Ncl 31.85 3.41 34.62 3.30 −12.632*** 34.62 3.30 34.58 3.27 0.705 31.85 3.41 34.58 3.27 −12.964***
Agr–Agl 90.28 3.32 91.33 3.18 −6.384*** 91.33 3.18 92.80 3.41 −4.885*** 90.28 3.32 92.80 3.41 −8.065***
Mxr–FFP 13.97 1.63 13.02 1.61 12.954*** 13.02 1.61 13.13 1.66 −1.677 13.97 1.63 13.13 1.66 8.060***
Mxl–FFP 13.00 1.58 12.11 1.70 9.805*** 12.11 1.70 12.22 1.58 −2.416* 13.00 1.58 12.22 1.58 9.097***
Umr–Lmr −2.07 1.42 2.71 0.53 −14.162*** 2.71 0.53 2.63 0.57 2.103 −2.07 1.42 2.63 0.57 −13.655***
Uml–Lml −2.26 1.64 2.05 0.80 −10.346*** 2.05 0.80 2.06 0.77 −0.459 −2.26 1.64 2.06 0.77 −10.767***

†Wilcoxon test (z → t).

*P < 0.05; **P < 0.01; ***P < 0.001.

K. HALICIOĞLU AND ò. YAVUZ
145

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146
EXPANSION
WITH MEMORY SCREW
Retention period (T3–T2). At the retention period, the face
width (Zr–Zl) and mandibular width (Agr–Agl; P < 0.001),
as well as maxillary width and right and left molar relation
(Umr–Lmr and Uml–Lml) increased (P < 0.05), while the
nasal width (Ncr–Ncl), right and left maxillomandibular
width (Mxr–FFP and Mxl–FFP) as well as right and left
molar relation (Umr–Lmr and Uml–Lml) showed no
statistically signicant changes.
Furthermore, lower intercanine and intermolar width
signicantly increased (P < 0.001), while the upper
intermolar width decreased (P < 0.05). However, right and
left crown tipping, palatal angulation angles (α1, 2, and 3),
upper interpremolar, and lower intermolar showed no
statistically signicant changes.
Total treatment period (T3–T1). At the end of all the
observation periods, right and left maxillomandibular width
(Mxr–FFP and Mxl–FFP) showed statistically signicant
decrease (P < 0.001), while all the other postero-anterior
parameters showed statistically signicant increase (P <
0.001).
Furthermore, lower interpremolar showed no statistically
signicant changes, while lower intermolar width (P < 0.01)
and all the other parameters increased (P < 0.001).
Comparison between the groups
The means and standard deviations of the treatment changes
observed and their comparisons between the groups are
shown in Table 3.
During treatment (T1–T2). During treatment, all the
postero-anterior parameters showed no statistically signicant
difference between the groups. In the model measurements,
only lower intercanine width was signicantly different
between the groups (P < 0.05).
Retention period (T3–T2). At the retention period,
right molar relation (Umr–Lmr; P < 0.001) and left molar
relation (Uml–Lml) showed statistically signicant difference
between the groups (P < 0.001 and P < 0.05, respectively).
Furthermore, in the model measurements, upper interpremolar
and upper intermolar width demonstrated statistically
signicant difference between the groups (P < 0.01 and
P < 0.001, respectively).
Total treatment Period (T3–T1). Only the left molar relation
(Uml–Lml) showed statistically signicant difference
between the groups (P < 0.05), while in the model
measurements, no signicant difference between the groups
was observed.
Discussion
The control group allowed us to differentiate the treatment
effects from normal growth. In the present study, the total
7YAVUZ
K. HALICIOĞLU AND İ. of 10
observation period was 6–7 months for both the groups.
Thus, no control group was used because we believe that
growth is negligible in this short period.
Generally, RME screw is turned twice during expansion.
Zimring and Isaacson (1965) as well as Isaacson and Ingram
(1964) suggested turning the screw twice until the suture
opens in adolescent people and recommended that slower
rates of expansion would allow for physiologic adjustment
at the maxillary articulations and prevent residual force. In
this study, the screw was activated twice daily until the
suture has opened and then once per day in the conventional
RME group. In the memory-screw group, screw was
activated six times a day during RME. The difference
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between the screw activation protocols results from the
different levels of forces produced by screws. Isaacson and
Ingram (1964) measured the forces produced by conventional
RME appliance and found that a quarter turns of the screw
produced heavy and intermittent forces ranging from 1.5 to
4 kg, as well as expansion force up to approximately 10 kg.
However, Wichelhaus et al. (2004) evaluated that memory
screw activated six times a day could generate a continuous
force ranging from 1.225 to 1.425 grams. Additionally,
Zimring and Isaacson (1965) hypothesized that the total
expansion might be physiologically stable in a shorter
treatment time with the expansion procedures carried out at
lower forces. In our study, adequate maxillary expansion
was accomplished with the memory screw in 7.76 ± 1.04
days with relatively lower forces than that produced by
conventional expanders. Nevertheless, the hypotheses by
Zimring and Isaacson (1965) as well as Isaacson and
Ingram (1964) have not been conrmed till date, and the
results of this study are very important to conrm them.
At the end of the expansion period (T2–T1), the amount
of mean intermolar distance was 8.14 ± 1.78 mm in the
memory-screw group and 8.87 ± 2.51 mm in the Hyrax-
screw group. Furthermore, at the end of the retention
period (T3–T1), the amount of mean intermolar distance
was 8.94 ± 1.73 mm in the memory-screw group and 8.41
± 2.09 mm in the Hyrax-screw group. Similar increase
occurred in the upper interpremolar distances of both the
groups.
Relapse after maxillary expansion is a common issue in
the literature (Hicks, 1978; Sarnas et al., 1992), and in our
study, Hyrax screw was narrowed in the retention period.
Furthermore, both the screws were not xed after expansion
because according to the manufacturer ’s instructions, the
spindle has been designed to prevent the screw from turning
back. Therefore, we recommend xture of the Hyrax screws
after expansion. Conversely, the intermolar width continued
to increase at this period in the memory-screw group.
The memory screw provided additional expansion in the
retention period, which might have probably resulted from
the activation of the nickel–titanium springs. In other words,
in the retention period, nickel–titanium springs integrated in
the screw might have resisted the residual forces that are
 EXPANSION

Table 3 Descriptive statistics of the differences in the measurements at the beginning of the treatment (T1) and at the end of expansion (T2) and retention periods (T3) and their
between-group (N = 32) and within-group comparisons.
8 of 10 WITH MEMORY SCREW

Parameters T2–T1 T3–T2 T3–T1

Memory Hyrax Memory Hyrax Memory Hyrax

Mean SD Mean SD t Mean SD Mean SD t Mean SD Mean SD t

Upper interpremolar width 7.74 1.82 8.29 2.27 −0.755 0.48 0.81 −0.26 0.60 2.921** 8.23 1.81 8.03 1.94 0.299
Upper intermolar width 8.14 1.78 8.87 2.51 −0.961 0.80 0.81 −0.46 0.62 4.920*** 8.94 1.73 8.41 2.09 0.788
Lower intercanine width† 0.15 0.15 0.39 0.44 −1.964* 0.34 0.41 0.23 0.45 −0.208 0.49 0.42 0.62 0.66 −1.851
Lower interpremolar width† 0.24 0.32 0.02 1.62 −1.209 0.38 0.53 0.44 0.29 −1.416 0.62 0.61 0.46 1.58 −1.001
Lower intermolar width† 0.30 0.40 0.43 0.30 −1.852 0.42 0.58 0.30 0.87 −0.925 0.72 0.65 0.73 0.96 −0.076
Molar crown tipping, right (α1) 8.95 2.94 8.68 6.37 0.155 −0.18 1.77 −0.37 4.22 0.165 8.76 3.91 8.31 4.45 0.306
Molar crown tipping, left (α2) 8.03 4.48 8.37 6.12 −0.183 0.26 2.40 −0.52 5.27 0.549 8.29 4.83 7.85 5.75 0.232
Alveolar process inclination (α3) 8.34 3.48 10.99 4.96 0.087 0.29 1.16 −0.27 1.68 0.170 8.62 3.08 10.73 5.23 0.280
Zr–Zl† 0.66 0.48 0.53 0.44 0.294 0.76 0.80 0.59 0.46 0.848 1.42 0.96 1.12 0.84 0.197
Mxr–Mxl 3.53 0.77 3.66 0.73 −0.492 0.21 0.28 0.14 0.19 0.771 3.74 0.73 3.80 0.72 −0.252
Ncr–Ncl 3.18 0.53 2.77 0.85 1.659 −0.05 0.20 −0.04 0.22 −0.174 3.12 0.54 2.73 0.82 1.641
Agr–Agl† 0.71 0.62 1.05 0.64 0.099 1.25 0.97 1.47 1.16 0.777 1.96 1.21 2.52 1.21 0.151
Mxr–FFP −0.86 0.42 −0.95 0.29 0.734 0.01 0.19 0.11 0.25 −1.299 −0.85 0.35 −0.85 0.41 −0.047
Mxl–FFP† −1.22 0.56 −0.89 0.35 0.088 0.14 0.54 0.11 0.17 0.970 −1.08 0.50 −0.78 0.33 0.090
Umr–Lmr 4.66 1.45 4.78 1.30 −0.247 0.10 0.12 −0.08 0.15 3.773*** 4.76 1.40 4.70 1.33 0.121
Uml–Lml 5.21 1.23 4.31 1.61 1.796 0.12 0.17 0.01 0.11 2.117* 5.34 1.21 4.32 1.55 2.072*

†Mann–Whitney U-test (z → t).

*P < 0.05; **P < 0.01; ***P < 0.001.
K. HALICIOĞLU AND ò. YAVUZ
147

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148
EXPANSION
WITH MEMORY SCREW
considered to be the source of relapse. Halcoğlu et al.
(2010) reported similar results when using memory screw
for expansion, where the interpremolar and molar width
increased in the retention period. Before completing the
active phase of RME, it should be taken into account that
some amount of increments will be observed in intermolar
and interpremolar widths during the retention period.
Braun et al. (2000) demonstrated that the amount of
dentoalveolar tipping depends on factors, such as the type
of expansion appliance, age of the patient, resistance of the
surrounding tissues, and schedule of screw activation. In
addition, Alpern and Yurosko (1987) recommended bilateral
buccal corticotomy for this purpose. It has been observed
that the rigidity of the expansion appliance is one of the
factor responsible for decreasing the buccal tipping of the
anchorage teeth (Timms, 1981). Although many different
RME appliances have been developed to decrease and/or
minimize the dentoalveolar inclination (Haas, 1961; Timms,
1981; Memikoglu and Işeri, 1999; Başçiftçi and Karaman,
2002; Klç et al., 2008), occurrence of dentoalveolar
tipping is unavoidable (Wertz, 1970; Bishara and Staley,
1987).
Tipping movement of the posterior dental and/or alveolar
process caused by expansion has been evaluated on postero-
anterior lms (Asanza et al., 1997; Byloff and Mossaz,
2004), tomography (Ölmez et al., 2007), and plaster models
(da Silva Filho et al., 1991; Ciambotti et al., 2001; Chung
and Goldman, 2003; Klç et al., 2008) using different
methods. Recently, Oktay and Klç (2007) have developed
a new method to evaluate the buccal inclination of the
maxillary posterior dentoalveolar structures. This new
method provides precise cross-sectional views of the
morphology of the molar area and is simple, reliable, and
inexpensive. Moreover, in such techniques, the patients
are not exposed to excessive X-rays (Klç et al., 2008).
Therefore, this method was used in this study.
Hicks (1978) found that the angulation between the
molars increased from 1 to 24 degrees during slow maxillary
expansion (SME). In addition, Ciambotti et al. (2001) and
Erdinç et al. (1999) also showed that the SME appliances
cause more dentoalveolar tipping than the RME appliances.
However, numerous authors have claimed that the tipping
of the alveolar processes and/or supporting teeth by the
rigid appliance was lesser than that by the Hyrax appliance
(Başçiftçi and Karaman, 2002; İşeri and Özsoy, 2004; Klç
et al., 2008).
In the present study, both the screws produced statistically
signicant (P < 0.001) dentoalveolar tipping. At the end of
the expansion period (T2–T1), the right crown tipping (α1),
left crown tipping (α2), and palatal tipping (α3) values
(degree) were 8.95 ± 2.94, 8.03 ± 4.48, and 8.34 ± 3.48
degrees, respectively, in the memory-screw group and 8.68
± 6.37, 8.37± 6.12, and 10.99 ± 4.96 degrees, respectively,
in the Hyrax-screw group. Furthermore, the anchorage teeth
are expected to tip during expansion and remain upright at
9YAVUZ
K. HALICIOĞLU AND İ. of 10
retention (Hicks, 1978). On the other hand, at the end of the
retention period (T3–T1), the right crown tipping (α1), left
crown tipping (α2), and palatal tipping (α3) values (degree)
were 8.76 ± 3.91, 8.29 ± 4.83, and 8.62 ± 3.08 degrees,
respectively, in the memory-screw group and 8.31 ± 4.45,
7.85 ± 5.75, and 10.73 ± 5.23 degrees, respectively, in the
Hyrax-screw group. However, the right crown tipping (α1)
and left crown tipping (α2) increased along with the
retention period in the memory-screw group. This again
might have resulted from the nickel–titanium springs in
the screw, which exert continuous force and prevent molar
teeth to remain upright. On the contrary, as expected, at the
retention period, these angles decreased in the Hyrax-screw
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group. However, no statistically signicant differences
were found between the groups.
Our ndings regarding the banded appliances are
consistent with the literature. In addition, our crown tipping
values are comparable with those presented in the work by
in Klç et al. (2008) (9.47 and 9.16 degrees, respectively),
who employed the same method to evaluate the tipping
caused by the Hyrax appliance. However, Asanza et al.
(1997) and Ciambotti et al. (2001) found less molar tipping
in patients treated with a Hyrax expander. This difference
might be owing to the different measurement techniques
employed for the determination of inclination. Additionally,
in a recent study, Garrett et al. (2008) showed that
dentoalveolar inclination lacks signicant correlations with
the schedule of screw activation but correlate well with the
amount of expansion. In the present study, both groups have
most maxillary expansion in between these studies that
found less molar tipping.
Oliveira et al. (2004) found that the Hyrax expanders
could produce more dentoalveolar effects by increasing the
palatal angulation (8.77 degree) than the Haas expanders.
Klç et al. (2008) also demonstrated that the Hyrax
appliance (11.30 degree) tipped the alveolar process more
than the rigid acrylic bonded expansion appliance. Our
ndings are consistent with these studies.
Bishara and Staley (1987) concluded that the RME could
inuence mandibular dentition, but the accompanying changes
were neither pronounced nor predictable. However, Gryson
(1977) reported that the mean increase in the mandibular
intermolar width was 0.4 mm, and this nding is consistent
with our study.
In our study, the sutural opening and the subsequent
important skeletal and dental expansion were obtained in all
patients of both the groups. When viewed from a frontal
plane, a pyramidal opening of the maxilla could be observed
(Haas, 1961). Our results showed that after RME, the amount
of expansion followed a triangular pattern, with the greatest
increase in the maxillary arch width, followed by maxillary
width, nasal width, and face width. Previous studies have
reported similar changes in the dental and skeletal structures
after RME (Haas, 1961; Wertz, 1970; Memikoglu and Işeri,
1999; Başçiftçi et al., 2002). Garrett et al. (2008), who
10 of 10 WITH MEMORY SCREW
EXPANSION
investigated the changes after RME with computerized
tomography, showed that the nasal width of approximately
2 mm and maxillary width of approximately 3 mm
increased to an average of 5 mm after screw activation,
and these ndings are compatible with our data.
Thus, our study showed that the transversal skeletal
width signicantly increased after RME and that the results
were stable at the end of the retention period. In other
words, the RME carried out using the memory screw
resulted in stable expansion, similar to the Hyrax screw.
Conclusions
RME procedure has been successfully carried out in both
groups. In the memory-screw group, it may be considered
as advantageous for the clinician to complete maxillary
expansion in a relatively short time. However, long-term
stability of this type of maxillary expansion with lighter
forces in a shorter time should be evaluated in a larger
patient population.
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