ORIGINAL ARTICLE

Influence of the hyrax expander screw

position on displacement and stress
distribution in teeth: A study with finite
elements
Let
ıcia Chaves Fernandes,a Robert Willer Farinazzo Vitral,a Pedro Yoshito Noritomi,b Gustavo Silva Maximiano,a
and Marcio Jose
da Silva Camposa
Juiz de Fora, Minas Gerais, and Campinas, S~ao Paulo, Brazil

Introduction: This study aimed to simulate the different positions of the hyrax appliance expander screw and
evaluate tooth displacement and the stress distribution standard on the periodontal ligament using the finite
element method. Methods: Part of the maxilla with anchorage teeth, periodontal ligament, midpalatal suture,
and the hyrax appliance was modeled, and finite element method models were created to simulate 6 different
screw positions. There were 2 vertical positions at distances of 20 mm and 15 mm from the occlusal plane.
Another position was anteroposterior, the center of the screw placed between and equidistant from the mesial
face of the first molar and the distal face of the first premolar, aligned to the center of the crown of the first molar,
with the anterior edge of the screw aligned to the distal face of the first molar. A 1 mm activation of the expander
screw was simulated. The displacement (total, vertical, and buccolingual) and the stress distribution on the peri-
odontal ligament of supporting teeth in each model were registered. Results: The model simulating the
expander screw in a more occlusal and anterior position presented higher displacement values and higher stress
concentration, followed by the model with the screw in a more posterior but same vertical position. With the
exception of the first premolar, the teeth presented cervical-apical displacement in the vestibular face and
apical-cervical displacement in palatal faces. This displacement is compatible with the vestibular inclination
associated with the activation of the expander screw. The first premolar presented an atypical tendency for
the mesial and lingual displacement of the vestibular surface and counterclockwise rotation. Conclusions:
The supporting teeth presented a tendency for vestibular crown displacement and lingual root displacement
associated with compression areas in the vestibular-cervical region and tensile strength in the linguoapical
region. Placing the expander screw in a more occlusal and anterior position generated more mechanical
stress transfer, resulting in greater dental displacement. (Am J Orthod Dentofacial Orthop 2021;-:---)

R
apid maxillary expansion (RME) is the recommen-
ded treatment to correct the transversal maxillary
deficiency associated with crossbite in patients
undergoing bone growth.1 RME is a procedure that
a
Department of Orthodontics, Juiz de Fora Federal University, Juiz de Fora,
Minas Gerais, Brazil;
b
Renato Archer Information Technology Center, Campinas, S~ao Paulo, Brazil
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest, and none were reported.
This study was financed in part by the Conselho Nacional de Desenvolvimento
Cient
ıfico e Tecnol
ogico (CNPq) and Coordenaç~ao de Aperfeiçoamento de Pes-
soal de N
ıvel Superior (CAPES), Finance Code 001.
Address correspondence to: Robert Willer Farinazzo Vitral, Department of Ortho-
dontics, Juiz de Fora Federal University, R 21 de Abril, 117/404, Juiz de Fora,
Minas Gerais 36025-090, Brazil; e-mail, robertvitral@gmail.com.
Submitted, September 2019; revised and accepted, April 2020.
0889-5406/$36.00
Ó 2021 by the American Association of Orthodontists. All rights reserved.
https://doi.org/10.1016/j.ajodo.2020.04.031
separates the midpalatal suture (MPS) and expands the
maxilla transversally through lateral force applied on
the maxillary teeth and maxillary bones using ex-
panders.2-4 During RME, the expected result is the
sideward expansion of both maxillary segments.5,6 How-
ever, even though the strength applied on the maxillary
bones is high,7 this procedure is not merely orthopedic,
at it causes undesirable dental inclination of the teeth
supporting the expander.5,6,8,9 This fact harms the sta-
bility and the prognosis, which restricts the orthopedic
results of the treatment.8,10
During the activation of the expanders, the higher the
undesirable dental movement, the shorter the bone
expansion obtained because the excessive vestibular
dental inclination causes the clinical limit of RME to
be achieved early. When the palatal cusps of the maxil-
lary teeth and the vestibular cusps of the mandibular

1
2 Fernandes et al
teeth touch, the MPS opening is reduced.5,6,11 Although
the orthopedic changes obtained with the RME may pre-
sent some degree of recurrence,12 dental movement is
the most unstable change in this procedure.10,13 Its re-
striction is related to a lower degree of recurrence after
correcting posterior crossbite.5,6,9
One of the devices used to perform RME is the hyrax
expander screw, which has a side expander transversal to
the MPS. When activated, this expander forces the
maxilla segments laterally.3,4 Laboratory production al-
lows changes in the palate along with both the height
and anteroposterior axes. Such changes may interfere
clinically in distributing orthopedic forces generated by
the expander and in dental effects during use, influ-
encing the efficiency and the stability of RME.7,11
The finite element method (FEM) is a computer
method applied to biomechanics that is used to deter-
mine stress and deformation in structures submitted to
different mechanical loads.14,15 In orthodontics, the
FEM has been used to analyze the tendency of move-
ment and tension distribution on teeth and craniofacial
bones during mechanic orthodontic simulations, such as
RME.7,11,16-19
A FEM study conducted by Fernandes et al7 described
a standard of tension and deformation distribution on
maxillary bone structures after placing the expander
screw into 6 different positions during maxillary expan-
sion. Only the impact on bone structures was analyzed.
The possibility of dental movement during the process
was ignored.
The objective of this study was to simulate the
different vertical and anteroposterior positions of the
hyrax appliance expander screw and to evaluate using
the FEM tooth displacement and stress distribution on
the periodontal ligament.
MATERIAL AND METHODS
A computer-aided design model from the Renato
Archer Information Technology Center, Campinas, S~ao
Paulo, Brazil, was employed. It included the maxilla,
the skull base (with the zygomatic, nasal, sphenoid,
and frontal bones), the central incisor, the lateral incisor,
the canine and the first premolar (U4), the second pre-
molars (U5), the first molar (U6), the second molars
(U7), the periodontal ligament, and a bone-suture unit
representing the MPS. The dental crowns contact and
transfer the force to each other. The model was created
(Rhinoceros 4.0; McNeel North America, Seattle, Wash)
from computerized tomography images (GE Lightspeed
Pro 16; GE Healthcare, Chicago, Ill) taken from an
adult, without any evident facial asymmetry, with all
the permanent teeth emerged, with the exception of
- 2021  Vol -  Issue - American Journal of Orthodontics and Dentofacial Orthopedics
the third molars, and without any dental restoration or
congenital or acquired craniofacial alterations. The use
of these images was approved by the ethics research
committee of the University of S~ao Paulo (no. 97/06).
The anatomic model of part of the maxilla, teeth,
periodontal ligament, and MPS was imported into the
software program FEMAP (version 10.1.1; Siemens
PLM Software, Plano, Tex), incorporating the single-
body hyrax appliance, composed of 1 expander screw
and 3 wire segments of 0.036-in diameter that joined
the screw to the U4 and U6 and the teeth to each other
(from U4 to U7), resulting in a geometric model with a
tetrahedral mesh (Fig 1).
The geometric model was subjected to mathematical
analysis (Ansys 17.2; Ansys, Inc, Canonsburg, Pa), using
a bone thickness of 2 mm and bar elements with elastic
properties to represent the MPS. A horizontal movement
restriction was imposed on the body of the device to
simulate soldering to the orthodontic bands connected
to the U4 and U6. The model structures were determined
with specific properties (Table I), and the simulated ma-
terials had elastic, isotropic, and uniform characteristics.
Six distinct positions of the expander screw were
simulated in FEM models.7 Three of them were antero-
posterior, and 2 of them were vertical. In all the simula-
tions, the expander screw was placed in the transversal
center of the palate, perpendicular to the MPS and par-
allel to the occlusal plane.
In anteroposterior position 1, the center of the screw
was positioned equidistant to the mesial face of U6 and
the distal face of U4. In anteroposterior position 2, the
center of the screw was aligned to the center of the U6
crown. In anterior position 3, the anterior edge of the
expander was aligned to the distal face of U6. Vertically,
the expander screw was positioned 20 mm (vertical po-
sition 1) and 15 mm (vertical position 2) from the
occlusal plane. Table II and Figure 2 show the positions
of all 6 models.
Fig 1. FEM model comprising bone, teeth, periodontal
ligament, MPS, and hyrax appliance.
Fernandes et al 3

The M4 model presented the highest maximum total

Table I. Mechanical properties attributed to the struc-
displacements among all models, with values close to
tures of the geometric model
0.4 mm in U6 and U5, 0.3 mm in U4, and 0.15 mm in
Poisson Young's U7. However, this model was the only one whose
Material coefficient modulus (MPa) expander screw presented total displacement values
Cortical bone14 0.3 13,700 lower than 0.533 mm (orange displacement). The M5
Trabecular bone14 0.3 1370
Teeth20 0.3 20,000
model presented a standard similar to M4 in teeth
Periodontal ligament21 0.49 0.69 displacement. However, its maximum values were
Hyrax expander14 0.33 200,000 reduced between 30% and 50%. The M6 model pre-
Midpalatal suture22 0.49 1 sented a maximum total displacement 3 times lower
than M4, with a standard displacement similar to M2.
A condition for the outline of the maxillary bone was However, its values were slightly higher in the distolin-
set for both stress distribution and displacement analysis gual area of U6.
to restrict vertical, anteroposterior, and transverse move- A diastema opened between U4 and U5. In all models,
ments in the model. A bar element was created for each U4 presented mesial and lingual displacement of the
node on the edge of the face in the MPS and perpendic- vestibular face. It also presented a counterclockwise rota-
ular to it,7 simulating the MPS during the RME. The acti- tion (Video 1, available at www.ajodo.org: M1, M2, and
vation of the hyrax appliance was achieved only by the M3; Video 2, available at www.ajodo.org: M4, M5, and
enforced displacement toward maxillary expansion. M6). This rotation was observed even in M3, where
In the MPS region, symmetry was required as a con- vestibular tooth displacement was insignificant.
dition, and the loading was recreated symmetrically on In M2, M4, M5, and M6, there was a tendency toward
the opposite side to obtain equivalent results for both a cervical-apical displacement of the vestibular face in
sides. For each model, a transversal displacement of U5, U6, and U7. However, U4 presented a contrary
0.5 mm in the center of the screw was simulated. displacement (apical-cervical) of the vestibular face in
Because of its symmetry, it was the same as 1 mm of acti- models: M1, M2, M3, and M6 (Fig 4, A). Through a
vation of the hyrax expander. lingual view, the teeth presented apical-cervical
displacement, with an exception in U4 again, which pre-
RESULTS sented apical displacement of the dental crown in
models M3 and M4 (Fig 4, B). Models M4 and M5 pre-
After simulating the opening of the expander screw, sented more significant vertical displacements, located
tooth displacement was analyzed as a whole and sepa- in U6 and U5, apical-cervically toward the palatal roots
rately on vertical and buccolingual axes. and cervical-apically toward the vestibular faces of those
The total tooth displacement in each model after teeth. Contrary to the tendency of other teeth, U4 pre-
opening the screw was evaluated from an axial point sented apical-cervical displacement toward the vestib-
of view, represented in Figure 3. The M1, M2, and M3 ular face in M1, M2, M3, and M6 and cervical-apically
models presented a similar maximum total displacement toward the lingual face of its crown in M3 and M6.
of approximately 0.2 mm. However, such displacements Evaluation of the isolated horizontal displacement
occurred in different areas. On the M1 model, there was (Fig 5) showed a general tendency for vestibular
a distolingual displacement in U6, U5, and the vestibular displacement of dental crowns, being inexpressive in
area of U4. In M2, the entire U6 crown presented U5 and U7 in model M3 and U7 in M1. Models M4
displacement. A few areas in U4 and U5 also presented and M5 presented the greatest horizontal displacements,
short displacement. In M3, only the vestibular and mesial with maximum values near the occlusal regions of U5
faces of U4 and the distolingual face of U6 presented and U6. However, in M5, the values were approximately
displacement. 55% lower than in M4.
In models M1, M2, M3, and M6, the 3-dimensional
representation (initial position) on the distal vestibular
Table II. FEM related to the anteroposterior and verti- region of the first premolar indicate that this tooth un-
cal positions of the expander screw derwent mesial movement (Fig 5, A), which causes an in-
crease in the size of the 3-dimensional models, as the
Vertical variation
expander screw is displaced posteriorly in all the vertical
Anteroposterior variation Vertical position 1 Vertical position 2
Anteroposterior position 1 Model 1 (M1) Model 4 (M4) position models 1 (M1, M2, and M3).
Anteroposterior position 2 Model 2 (M2) Model 5 (M5) Although the dental crown in U7 did not present
Anteroposterior position 3 Model 3 (M3) Model 6 (M6) any significant horizontal displacement in any of the

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4 Fernandes et al

Fig 2. Sagittal view of anteroposterior and vertical positions of the expander screw.

models simulated in this study, the apical region of the models M4 and M5. Such displacement, associated
lingual root of this tooth presented a lingual with the vestibular displacement of the crown,
displacement in all models (Fig 5, B). A similar reinforces the tendency of vestibular inclination of
movement was observed in the U6 lingual root in the teeth during RME.

Fig 3. Axial view of the total dental displacement (in millimeters) of simulated models.

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Fernandes et al 5

Fig 4. Vertical teeth displacement (in millimeters) through vestibular (A) and lingual (B) views. The
displacement in the cervical-apical direction was represented by cold colors (blue), and the apical-
cervical direction was represented by hot colors (red).

Aside from displacement, the distribution of tensile
strength (Fig 6) and compression (Fig 7) on areas repre-
senting the periodontal ligament on the posterior teeth
root surface was also evaluated.
The areas of higher tensile strength concentration
occurred in the vestibular-apical lingual root in U6 and
U7 (Fig 6, A) and the cervical region of the lingual faces
in U5 and U6 (Fig 6, B), confirming the tendency for the
vestibular inclination of these teeth after activation of
the expander screw. The values of maximum traction
(warm colors) were located at the top of the palatal
root in the first model (approximately 5 or more MPa)
in M4. The first premolar presented areas of high tensile
strength on the lingual face of the lingual root, espe-
cially on the mesial region (Fig 6, A and B), reinforcing
the tendency for rotation in this tooth.
The highest compression values (cold colors)
occurred in the cervical and lingual-apical region of
vestibular roots of U6 and U7, especially in M4 and
M5 (Fig 7, A), suggesting a tendency for vestibular
inclination and displacement of teeth. The first
premolar presented areas of compression on the vestib-
ular face of the vestibular root, especially on the mesial
region (Fig 7, A and B), indicating a tendency for rota-
tion in this tooth.
DISCUSSION
Although RME is considered a treatment to have
proven effective for patients with maxillary transverse
deficiency (maxillary atresia), its study and the improve-
ment of expander appliances aim to reduce undesirable
dental side effects and maximize orthopedic ef-
fects.11,23,24
During RME, the desirable movement is the lateral
dislocation of both right and maxillary left segments,
with a minimal inclination of teeth. However, even
with the great force7 applied during RME, it is not
possible to obtain an exclusively orthopedic maxillary
expansion. The vestibular dental inclination is undesir-
able,5,6,8,9 impairs stability and prognosis and limits
the orthopedic results of the treatment.8,10

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6 Fernandes et al

Fig 5. Horizontal dental displacement (in millimeters) from vestibular (A) and lingual (B) views. The
black mesh represents the initial position of teeth in the system before the activation of the expander
screw.

The FEM has been used to demonstrate tensions and
deformations imposed on teeth and bones during
RME.7,11,16,25,26 In a previous study7 simulating 6 posi-
tions of the expander screw with anteroposterior and
vertical variations, FEMs were used to simulate the
maxillary bone structure, the hyrax anchor teeth (first
premolar and first molar), and the MPS to analyze the
distribution of tensile strength on the maxilla during
RME. Then, to analyze the effect on the teeth of the
same positions of the expander screw, the study added
the second premolar, the second molar, and the peri-
odontal ligament of the involved teeth to the computer-
ized models in the experiment. The aim was to evaluate
dental movement caused by the same activation of
simulated expander appliances.
Generally, the simulated models exhibited less total
dental displacement as the expander screw was moved
posteriorly and along the palate. This result explains
the higher distance between the screw and the point of
application of force (the dental crowns of the first pre-
molar and the first molar), which amplifies the lever
arms and the extension and flexibility of the appliance's
dimensions. This increase in the extension of the appli-
ance was also associated with a higher rotation of the
first premolar, higher tensile strength in the screw
legs,11,19 lower effectiveness in transferring strength to
the maxilla,7 and reduction of dental movement in the
direction of the screw opening,11,19 as shown in the pre-
sent study.
Contrary to the tensile strength variations in the
expander screw,11,19 in the present study, the connect-
ing legs of the hyrax presented similar displacements
among all models, but M4 was the only one to present
displacement values under 0.533 mm in the anterior
position of the expander screw (orange displacement).
This may have occurred because the movement of the
expander screw after its activation is limited because
of the flexibility of its connecting legs, the opening

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Fernandes et al
Fig 6. Vestibular (A) and lingual (B) views of tensile stress distribution (in megapascal) on the peri-
odontal ligament.
of the MPS, and the dental displacement. The lower
flexibility of the connecting legs in M4 made the dental
displacement restrict the expander screw's movement
even more, even though it presented the highest values
among all models.
There was a greater vestibular displacement of the
occlusal areas of posterior teeth toward apical areas, fol-
lowed by lingual and extrusive displacement of lingual
root apices and increased compression on the
vestibular-cervical regions and increased tensile strength
in the lingual-apical regions of the periodontal ligament,
indicating a vestibular inclination of teeth. This ten-
dency to inclination seems to be proportional to the total
dental displacement that occurred in each model. Such a
tendency is not associated with any specific position of
the expander screw. In contrast, Araugio et al11 identi-
fied lower vestibular dental inclination as the expander
screw became farther from the occlusal plane. Even a
lingual inclination of teeth of around 5 mm over vertical
position 2 was observed. The use of a simplified com-
puter model that disregarded the structural properties
of maxillary bones and used elastic supports placed
over vestibular surfaces of dental roots to imitate the
American Journal of Orthodontics and Dentofacial Orthopedics
7
periodontal ligament may have generated a discrepancy
regarding the results of this study.
Generally, posterior teeth presented a tendency for
displacement in the apical-cervical direction of the
lingual face, especially on the lingual root apex of U6,
and in the cervical-apical direction of the vestibular
face. Such displacements are compatible with the ten-
dency for vestibular dental inclination expected
during RME,5,6,8,9 which is an idea confirmed by the
compression areas of the periodontal ligament in the
vestibular-cervical area of teeth. The atypical vertical
displacement presented in U4 in the models of lower
dental movement amplitude may be related to the mesial
and lingual displacement of the vestibular face, which
has also stood apart from the general tendency. Using
a more apical positioning of the expander screw than
in the present study, Araugio et al11 recorded an extru-
sive movement of the vestibular face of all posterior
teeth, during which U4 did not present any irregular re-
sults in the simulated models.
The extrusive displacement of lingual faces of poste-
rior teeth and the standard opening of the maxilla with
its vertex superiorly and posteriorly placed7 that
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8 Fernandes et al

Fig 7. Vestibular (A) and lingual (B) views of compressive stress distribution (in megapascal) on peri-
odontal ligament.

occurred on the 6 positions simulated by the expander
screw may be the reason for the RME effects described
previously,27,28 such as the inferior displacement of the
maxilla, counterclockwise rotation of the jaw, and bite
opening.
In a study from Fernandes el al,7 model M4 presented
a more efficient transfer of mechanical effort from the
expander screw toward the bone structures. This transfer
has a higher maximum tensile strength and occurs
nearer to the incisive foramen, and facilitates the initial
opening movement of the MPS.29 In the present study,
the same model presented a higher amplitude of dental
displacement, reinforcing the relationship between the
amount of maxillary expansion and inclination of
posterior teeth,30 which indicates that, among the
expander screw positions that were simulated, the
desirable effect of opening the MPS is necessarily
followed by a dental effect, which must be considered
during the performance of such types of orthopedic
treatment.
Although the relation between dental displacement
and maxillary expansion was established,30 model M6
presented the poorest distribution of tensions in the
maxilla7 and a total dental displacement higher than
models M1, M2, and M3. However, this displacement
mainly consisted of the counterclockwise rotation of
U4 and U6 and the lingual displacement of the dental
crown in U4, which made it hardly productive, or entirely
unproductive, to correct malocclusion related to trans-
verse maxillary deficiency.
In silico studies, like FEM, must be considered
before human application because they simulate
only the morphology and mechanical properties of
biological systems in a computer, disregarding cellular
and chemical mechanisms and individual biological
features, such as quantity, shape, and dental root
area; inclination and position of teeth; format, qual-
ity, and quantity of maxilla bones and alveolar pro-
cess; and MPS hardness. Consequently, this study
had the objective of specifically informing the me-
chanical consequences of changing the hyrax
expander screw position, highlighting the possibility
of obtaining different results in oral tissues during
RME. Therefore, we suggest further investigations
involving clinical trials and computerized methods to
analyze more design factors to help precisely deter-
mine, at the same time, the bone and teeth effects
of each expander device setting.

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Fernandes et al
CONCLUSIONS
The simulations performed in this study using the
FEM showed the following:
1. There was a tendency for displacement in the
cervical-apical direction of the vestibular face and
the apical-cervical direction of the palatal face of
teeth, with a vestibular displacement of the crown
and roots.
2. There were compression areas in the vestibular and
cervical region and stress in the lingual-apical re-
gion of teeth.
3. Placing the expander screw in a more occlusal and
anterior position generated mechanical stress trans-
fer that resulted in a greater dental displacement.
AUTHOR CREDIT STATEMENT
Let
ıcia Chaves Fernandes contributed to methodol-
ogy, formal analysis, investigation, and original draft
preparation; Robert Willer Farinazzo Vitral contributed
to conceptualization, formal analysis, draft review and
editing, supervision, and funding acquisition; Pedro
Yoshito Noritomi contributed to methodology, valida-
tion, investigation, and resources; Gustavo Silva Maxi-
miano contributed to visualization and original draft
preparation; and Marcio Jos
e da Silva Campos contrib-
uted to conceptualization, formal analysis, original draft
preparation, and project administration.
SUPPLEMENTARY DATA
Supplementary data associated with this article can
be found, in the online version, at https://doi.org/10.
1016/j.ajodo.2020.04.031.
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