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Rapid maxillary expansion

Article in American Journal of Orthodontics and Dentofacial Orthopedics · November 2006

DOI: 10.1016/j.ajodo.2006.08.006 · Source: PubMed

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432 Readers’ forum
Rapid maxillary expansion
On the surface, the recent article on rapid maxillary
expansion seems like good ammunition for anti-RME faction-
ists (Garib DG, Henriques JFC, Janson G, de Freitas MR,
Fernandes AY. Periodontal effects of rapid maxillary expan-
sion with tooth-tissue-borne and tooth-borne expanders: A
computed tomography evaluation. Am J Orthod Dentofacial
Orthop 2006;129:749-58). It is also a good example of how
not to do rapid maxillary expansion (RME). The following
are a just few problems with this very interesting article.
1. Girls with a mean age of 12.4 to 12.6 years could be
considered too old by most competent orthodontists to be
part of a RME study.1
2. The study neglected to determine beginning and ending
skeletal transverse dimensions. Most commonly, those mea-
surements are taken lateral to the maxilla at Mx-Mx or at the
lateral aspect of the nasal cavity. There are other methods.2-5
3. Actual skeletal expansion is important to determine. If the
palatal suture were to be fused, which is highly probable
with a 12-year-old girl, all the apparent expansion could
be unwanted dental expansion—which has unwanted
periodontal effects as detailed in the article. We all know
that, when a rapid maxillary expander axle is turned, it
does not mean that the maxillary midline suture has
opened. We also know that, if the suture has not opened,
all the expansion is seen at the teeth, resulting in a
combination of temporary increased inclination and trans-
lation. If fixed appliances are placed too soon and if the
translation is not corrected, temporary becomes perma-
nent. And that may become a problem.
4. The eight girls in the study were all treated to 7 mm
turnbuckle measurement. Accordingly, it would be rea-
sonable to estimate actual skeletal expansion of 2.5 to 3.5
mm.6-8 And that would be true if expansion actually had
occurred. Of the 8 patients, did they all need 2.5 to 3.5
mm of skeletal expansion? Did some need more and some
less? RME usage without clear skeletal goals in mind, and
thus without clear diagnosis, could be considered risky.
5. The study proceeds along a familiar treatment path:
identify a crossbite, use RME to expand, and then, after
the crossbite is corrected, place fixed appliances immedi-
ately. There are problems with that approach.
● A patient might have a debilitating, narrow maxilla
without a crossbite. That patient should also have RME.
● Immediate placement of fixed appliances after RME,
although a common treatment,9 should be avoided to
let the posterior teeth (those used as abutments for the
RME) relapse— back to their prior inclination. Main-
taining increased inclination after RME might be peri-
odontally detrimental. That problem is easily avoided.
Six weeks of nonretention (no retainer and no fixed
appliance) is usually adequate to allow the unwanted
RME inclination to disappear.5
● If a crossbite returns after RME removal and after 6
weeks of nonretention, it would indicate that the RME
was not taken far enough or that the palate was fused.
American Journal of Orthodontics and Dentofacial Orthopedics
October 2006
● Dental expansion with untoward periodontal conse-
quences can occur with improper RME, with improper
fixed appliances (eg, a highly flexible archwire placed
on crowded teeth), with an expanded palatal bar, or
with an expanded headgear, and so on. There might be
a periodontal price to pay for dental expansion over the
long term. Thus, many appliances might contribute to
thinning of the maxillary bone buccal plate.
● It is also possible that the patient’s original presenta-
tion, with highly inclined teeth—possibly without
crossbite— could also be a long-term periodontal prob-
lem, if left untreated with RME.
Contrary to the article, RME, when used correctly and
effectively, can improve the long-term periodontal progno-
sis.10 Competent RME usage can increase maxillary buccal
plate thickness. Because peer-reviewed articles might not be
caught up with clinical results, one can use philosophical
reasoning: if one can improve the skeletal transverse with
RME, then the apical bases will be positioned farther buc-
cally. If one were then to allow the posterior teeth (formerly
used as RME abutments) to relapse to prior inclinations, then
the situation would be different from that detailed by Garib et
al. Furthermore, if one were then to move the posterior teeth
palatally—with available transverse space—the situation
would again be dramatically different from that detailed by
Garib et al. In the new position, the posterior teeth would be
in a highly protected and improved position—minimal incli-
nation with increased buccal plate thickness.
The authors provided vivid documentation regarding
what can happen when RME goes wrong because of either
misapplication or problems with technique. The same re-
search conclusions could have been reached by evaluating
several other, more commonly used, orthodontic appliances.
And the same research conclusions could have been reached
by evaluating untreated patients with severely inclined pos-
terior teeth. The moral of the story: care needs to be taken
during diagnosis and treatment to avoid possible future
periodontal problems.
John L. Hayes
Williamsport, Pa
Am J Orthod Dentofacial Orthop 2006;130:432-3
0889-5406/$32.00
Copyright © 2006 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2006.08.006
REFERENCES
1. Baccetti T, Franchi L, Cameron CG, McNamara JA Jr. Treat-
ment timing for maxillary expansion. Angle Orthod 2001;71:
343-50.
2. Broadbent BH Sr, Broadbent BH Jr, Golden WH. Bolton
standards of dentofacial developmental growth. St Louis: C. V.
Mosby; 1975.
3. Ricketts RM, Grummons D. Frontal cephalometrics: practical
applications, part I. World J Orthod 2003;4:297-316.
4. Vanarsdall RL Jr. Transverse dimension and long-term stability.
Semin Orthod 1999;5:171-80.
5. Hayes JL. A clinical approach to identify transverse discrepan-
cies. Presentation to the Pennsylvania Association of Orthodon-
tists; Philadelphia; March 2003.
 American Journal of Orthodontics and Dentofacial Orthopedics
Volume 130, Number 4
6. Haas AJ. Rapid expansion of the maxillary dental arch and nasal cavity
by opening the midpalatal suture. Angle Orthod 1961;31:73-90.
7. Haas AJ. The treatment of maxillary deficiency by opening the
midpalatal suture. Angle Orthod 1965;35:200-17.
8. Fenderson FA, McNamara JA Jr, Baccetti T, Veith CJ. A
long-term study on the expansion effects of the cervical-pull
facebow with and without rapid maxillary expansion. Angle
Orthod 2004;74:439-49.
9. Cameron CG, Franchi L, Baccetti T, McNamara JA Jr. Long-
term effects of rapid maxillary expansion: a posteroanterior
cephalometric evaluation. Am J Orthod Dentofacial Orthop
2002;121:129-35.
10. Vanarsdall RL, Jr, Secchi AG. In: Graber TM, Vanarsdall RL Jr,
Vig KWL, editors. Orthodontics: current principles and tech-
niques. 4th ed. St Louis: Elsevier Mosby; 2005. p. 901-36.
Author’s response
We thank John L. Hayes for his interest in our recently
published study on periodontal effects of rapid maxillary
expansion (RME). His letter allows us to discuss this inter-
esting subject further. Most studies on RME—from the first
report in 1860 to the present, including the classics—
performed orthopedic expansion on adolescent patients at 11
to 13 years of age or even older. The following are some
representative examples. Angell1 demonstrated the midpala-
tal suture split in a 14-year-old girl; Haas2 reintroduced RME
as an orthodontic procedure and reported the results of a study
of subjects from 9 to 18 years of age; Krebs,3 in a remarkable
study with implants, used patients 8 to 19 years of age;
Zimring and Isaacson,4 to evaluate the forces delivered during
orthopedic expansion, selected a sample from 11.5 to 15.5
years of age; Wertz5 and Wertz and Dreskin6 performed
reliable studies using samples with ages from 7 to 29 years;
Linder-Aronson and Lindgren7 studied a sample 10 to 21
years of age; Sarver and Johnston8 used a sample of patients
7.5 to 21 years of age; Asanza et al9 performed RME in
patients from 8.5 to 16 years of age; and Baccetti et al10
compared the RME effects between 2 groups of patients with
mean ages of 11 and 13.5 years, respectively.
All these studies proved that the midpalatal suture is still
patent during the second decade of life, at least before skeletal
maturity. It is also well documented that the orthopedic effect
caused by RME decreases as age increases.3,6,10 This does not
mean that RME can be performed only during the deciduous
and mixed dentitions, and should be abandoned in the
permanent dentition. During the early permanent dentition,
even after the adolescent growth spurt peak, RME can cause
transverse skeletal changes (equivalent to approximately a
third of the amount of screw activation in contrast with 50%
of skeletal gain when RME is performed earlier3).
Dr Hayes might be painting himself into a difficult corner
when he suggested so many restrictions on adolescent RME
use. Under his proposed guidelines that would limit the use of
RME, what should a “competent” orthodontist do to correct
maxillary constriction in a 12-year-old girl with a posterior
crossbite? Would he or she use surgically assisted RME
treatment for this patient? Or perform slow expansion and
View publication stats
Readers’ forum 433
accept the great probability of tooth tipping relapse in the
long term? Or must the orthodontist tell the patient it is too
late to treat the problem?
RME was successful in opening the midpalatal suture in
all of our patient-subjects, as we reported in a previous study
on the same sample published in 2005,11 which was quoted in
the discussion (reference 15). This previous study had the
main purpose of evaluating the dentoskeletal effects of RME
with computed tomography, and the results can answer
questions 2, 3, and 4. It is significant that our expansion
protocol replicated methods developed and used in previous
studies on RME. Therefore, sharp criticism of this method-
ology is the same as dismissing the main body of RME
literature for the last 6 decades. Additionally, the periodontal
evaluation was performed by comparing pre- and postexpan-
sion images, and, in this way, the subsequent fixed appliance
therapy had no influence on the results. Furthermore, no
patient showed any bone dehiscence before expansion.
Dr Hayes implied in his opening sentence that our work
could represent political “ammunition” against RME usage in
orthodontics. This negative inference disturbs us. My associ-
ate authors and I fully embrace the RME procedure, which we
use routinely in our clinics. Our objective was simply to share
the results of a carefully designed prospective and controlled
study on the periodontal effects of RME to alert clinicians
about the risk of gingival recession in the long term12 and to
emphasize preventive measures to help avoid this sequela.
Daniela G. Garib
Bauru, São Paulo, Brazil
Am J Orthod Dentofacial Orthop 2006;130:433-4
0889-5406/$32.00
Copyright © 2006 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2006.08.007
REFERENCES
1. Angell EH. Treatment of irregularity of the permanent or adult
teeth. Dent Cosmos 1860;1:540-4, 599-601.
2. Haas AJ. Rapid expansion of the maxillary dental arch and nasal
cavity by opening the midpalatal suture. Angle Orthod 1961;31:
73-90.
3. Krebs A. Midpalatal suture expansion studies by the implant method
over a seven-year period. Trans Eur Orthod Soc 1964;40:131-42.
4. Zimring JF, Isaacson RJ. Forces produced by rapid maxillary
expansion. III. Forces present during retention. Angle Orthod
1965;35:178-86.
5. Wertz RA. Skeletal and dental changes accompanying rapid
midpalatal suture opening. Am J Orthod 1970;58:41-66.
6. Wertz R, Dreskin M. Midpalatal suture opening: a normative
study. Am J Orthod 1977;71:367-81.
7. Linder-Aronson S, Lindgren J. The skeletal and dental effects of
rapid maxillary expansion. Br J Orthod 1979;6:25-9.
8. Sarver DM, Johnston MW. Skeletal changes in vertical and anterior
displacement of the maxilla with bonded rapid palatal expansion
appliances. Am J Orthod Dentofacial Orthop 1989;95:462-6.
9. Asanza S, Cisneros GJ, Nieberg LG. Comparison of hyrax and
bonded expansion appliances. Angle Orthod 1997;67:15-22.
10. Baccetti T, Franchi L, Cameron CG, McNamara JA Jr. Treatment
timing for maxillary expansion. Angle Orthod 2001;71:343-50.
11. Garib DG, Henriques JFC, Janson G, Freitas MR, Coelho RA.
Rapid maxillary expansion—tooth-tissue-borne vs tooth-borne