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Seminars in Orthodontics
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Myth and evidence in palatal expansion

Birte Melsen a,b,c,*
a
Department of Orthodontics, Aarhus University, Denmark
b
Department of Orthodontics NYU, New York, United States
c
Department of Orthodontics, University of West Australia, Perth, Australia

A R T I C L E I N F O A B S T R A C T

Untruths and distortion of scientific findings inhabit the medical and dental fields, not intentionally but often
because of the lack of firm evidence. The aim in this paper is to visit a common orthodontic treatment modality,
palatal expansion, and explore whether the accumulated biologic and mechanical findings are sufficient or misin-
terpreted for proper intervention. Specifically, questions are raised regarding the sutural response to maxillary
widening in relation to the age-related changes in the morphology of the suture. The fractures occurring when
expansion is performed of a heavily interdigitated suture and the healing that leads to closure that, depending on
the timing may impede the sutural pubertal growth spurt. Later widening of the arch width, even when surgically
assisted, may lead to a bony relapse and severe bony dehiscence of the lateral teeth. Extensive research is needed
to help generate appropriate guidelines for palatal expansion especially the age of the patient, timing and amount
of expansion duration of retention and factors of importance for maintenance of the treatment results.

Introduction of the mandibular incisors through their inclination to the mandibular

A myth is a widely held but likely false idea or belief that is coun-
tered by the provision of evidence, the available body of information or
facts that indicate the validity or misconception of the belief. In a scien-
tific concept, we consider the myth in this paper to include a body of
workable hypotheses awaiting the confirmation of reliable evidence. A
myth may originate from an observation (a credible report of treatment
success or failure in one or more individuals), but its generalization is a
risk, requiring the rigor of focused investigation.
In this perspective, myths have inhabited the world of orthodontics
not the least because esthetics has misplaced function as the main indi-
cation for orthodontic treatment, undoubtedly because a nice smile is
closely related to an improved life quality and as such not life threaten-
ing. The differentiation between myth and evidence is illustrated in
facial esthetics. The perception of beauty has varied over time, likely
influenced by the prevailing culture, social norms and fashion, as well as
the popularity of persons at the special time. Such concepts are readily
recognized through the images of the Virgin Mary whose representa-
tions over 20 centuries have varied in vertical and sagittal proportions,
and the consideration at one time that a flat profile (e.g. Monaco prin-
cess Grace Kelly’s) was ideal and an inspiring goal for orthodontic treat-
ment, and at another time that a more protruded profile (e.g. Sofia
Loren’s) was desirable. The different assessments of beauty translated
into variations in cephalometric analyses. Tweed’s focus on the position
and Frankfort planes as essential to facial balance1 was strongly criti-
cized by Wylie2 as unfounded.
Orthodontists have also been subjected to differing and at times con-
flicting treatment modalities related to appliances such as a special
“technique” being superior to other approaches, or a distinctive bracket
foregoing the need to bend wires,3 and more recently aligners possibly
correcting all malocclusions.4 Melsen5 stated that orthodontics cannot
claim to be scientific without focusing on biology, and that although
orthodontists manage the same tissues as bone biologists, they do not
share a common perception: orthodontists regard tissue reaction as
related to forces whereas bone biologists focus on bone deformation.
The gap in perception, if not knowledge, propagates in the approach to
treatment, which may rely on interpretation of evidence rather than
solid scientific confirmation of theory.6
In this context, the focus of this paper is to explore the gaps between
facts and practice in the treatment of arch width that has been related to
both esthetics and mechanics. Evidence is assembled from published
and some supportive unpublished material to examine maxillary sutural
anatomy and its impact on the time of palatal expansion, and explore
the problems that could emerge if treatment does not account for biolog-
ical limitations and suture adaptation. The presented information does
not provide solutions to the long-term problems resulting from palatal
widening, but rather demonstrates reasons for unexpected long-term
results. Findings from studies of skulls, human autopsy and biopsy

* Corresponding author.
E-mail address: birte@melsen.com

https://doi.org/10.1053/j.sodo.2023.04.003

1073-8746/© 2023 Published by Elsevier Inc.

Please cite this article as: B. Melsen, Myth and evidence in palatal expansion, Seminars in Orthodontics (2023), https://doi.org/10.1053/j.
sodo.2023.04.003
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material are presented to support, contradict, or clarify references that

purport to define the “state of the art” of transverse widening.

The “wider” maxillary arch

Past the original objective to correct posterior crossbites, the indica-

tions of palatal widening have expanded to the correction of crowding
and eliminating “black corridors.” An anecdote reveals the association
of the wider arch with the development of dentures. Full dentures would
be renewed regularly with an increased width that contributed to less
wrinkles, thus a rejuvenating effect on the face. The fist author remem-
bers from her childhood experience the neighbour’s wife who sought a
new denture almost every year, the newer always broader than the older
one. The neighbourhood children would laugh and shout: “There is the
denture coming with Mrs H.” In this perspective, the orthodontist’s
equivalent tool to the prosthodontist’s denture widening is palatal
expansion. To understand overcorrection of a posterior crossbite or wid-
ening “on demand” for smile esthetics, normal dentofacial transverse
development is reviewed first.

Normal transverse development

Growth of palatal suture

ork and Skieller6 used tantalum indicators as references to quantify

Bj€
the displacement of bones due to sutural or condylar growth, and to dif-
ferentiate displacement from modelling and intramaxillary tooth move-
ment. They demonstrated that the sutural growth between ages 4 and
18 was on the average 6.9 mm and that after the eruption of the premo-
lars around 10 to 11 years of age, 4 mm of growth were left in the mid-
palatal suture (Fig. 1).7,8 When the authors compared the growth in
height with the sutural growth, they found a close correlation between
the respective growth intensities.
In the same period Melsen9 described the development of the midpa-
latal suture on autopsy material excised from the cranial base (Fig. 2).
The histological analysis of the sutures from individuals at different ages
demonstrated the change in shape of the midpalatal suture from a Y
shaped suture in the children with deciduous dentition to a wavy shape
of the suture from children with mixed dentitions ending in a suture
characterized by a heavy interdigitation in individuals with permanent
dentitions (Fig 3).
Changes in the transverse dimension of the maxillary arch during dentofacial
growth
In their description of the development of the maxillary arch, Bj€ ork
and Skieller8 reported a medial eruption direction of the premolars; the
width of the dental arch was maintained unchanged after the age of 5
(Fig. 4).This conclusion was recently supported by a CBCT study of
transverse maxillomandibular relations in untreated children.10 Greater
dentoalveolar increases were found in the maxilla, attributed by the
authors to sutural growth, while the first molars maintained their
“coordination with each other despite the differential increase in the
maxillary and mandibular dentoalveolar processes.” The available space
within the arch also does not change significantly between 5 and
18 years, the increase in maxillary arch length following the labial erup-
tion of the permanent incisors relative to the primary incisors being
eventually offset by the nearly equal loss of the leeway space.11 A wide
range of variation reflects the possibility of crowding as well as spacing
in the individual child.
Moorrees and co-workers,11 had reported that, on average, the width
of the maxillary arch corresponding to the second deciduous molars at
the age of 5 years ends up nearly unchanged by the end of growth at the
age of 18 and that the available space, although the wide range
Fig. 1. Graphs illustrating the correlation between the growth in height (A) and
the increase in distance between tantalum indicators placed on the right and the
left sides of the midpalatal suture (B). The small peaks shown before the pubertal
growth spurt were likely artefacts. The measurements were taken every year, but
sometimes the study participants did not show up exactly every 12 months. If the
interval was for example 15 months, the growth data were divided by 15 then
multiplied by 12 to calculate the annual growth rate. If the interval included 2
summers, the growth rate was higher than when the 15-month interval included
2 winters, because children grow significantly more during light periods than
during dark periods.8 (graphs adapted from from Bjørkref).
translated in more crowding or more spacing (Fig. 4). The inference
from this observation is that the growth of the midpalatal suture is bal-
anced by the medial eruption direction of the buccal teeth (as described
by Bj€
ork A. and V. Skieller) to maintain proper transverse occlusion with
the non-widening mandibular arch. The first author witnessed first-hand
routine maxillary arch expansion by Isaacson et al12 of patients in the
late mixed dentition to prevent foreseen crowding, and later the aban-
donment of this routine as the patients revealed almost 100% relapse.
Although of great significance, this communicated information was not
published. The collected from autopsy and biopsy material and implant
studies performed by Krebs7 (next section) may provide appropriate
explanation.
Changes in pharynx
Based on measurements performed on skulls and later 3D images, the
width of the pharynx increases by an average of 10 mm between 4 and
18 years of age.13 The pharynx is delineated by the pterygoid plates of
the sphenoidal bone, which is part of the cranial base and has no growth
zone in the mid sagittal plane. The widening of the pharynx is a result of
a modelling expressed through resorption of the medial surfaces and
apposition on the lateral surfaces (Fig. 5). The palatal bone adapts with
differing growth patterns, the separation of the two parts of the maxilla
by sutural growth and the widening of the pharynx by modelling of the
pterygoid plates. In pathologic or morphologic conditions impacting
sutural growth, pharyngeal space may be affected. However, in cleft pal-
ate patients in whom the maxillary arch is collapsed and nasal breathing
is impaired, the absence of suture apparently does not affect pharyngeal

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Fig. 2. (A-C): Graphic (A) and anatomical (B) representation of images shoving how the midpalatal suture was excised after the brain had been removed at autopsy.

Fig. 3. (A-C): Drawings and corresponding histological images (D-E) of the midpalatal suture from individuals in the deciduous dentition (A,D), mixed (B,E) and per-
manent (C,F) dentitions.

airway dimensions compared to control individuals with normal
occlusion.14
Closure of palatal suture
Does the palatal suture close, and if so, when? Two panels are consid-
ered: natural closure and post-expansion closure.
Natural closure: In most skulls of adults, the intermaxillary suture is
heavily interdigitated, but still open. A study of the skull collection at
the Dental college in Aarhus revealed that most skulls from individuals
with fully erupted third molars still demonstrated an open midpalatal
suture, whereas some exhibited no visible suture. Therefore, too many
intermaxillary sutures in adults will be estimated closed on CBCT
images, which remain the optimal mean for in vivo appraisal.15 The
interdigitation complicates the detection of absent transmaxillary bridg-
ing.
To find out if sutural status was associated with function in studies
conducted before the development of the CBCT, alginate impressions
were taken and cut in thin slices to analyse the occlusal surfaces (Fig. 6).
The results indicated that in the presence of both latero- and medio-tru-
sion facets, whereby the right and left maxilla would be moved in both
contraction and expansion during occlusion movements, the suture was
open. In the presence of only laterotrusion facets, reflecting merely lat-
eral movement, the suture was closed.

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B. Melsen
Fig. 4. Available space at ages 5 and 18 (after Moorrees6).
An early finite element analysis indicated that the strain on both
sides of the suture was identical when only laterotrusion facets were
simulated during occlusion (Fig. 7).16 However, the strain was different
between the two sides of the suture when both latero- and medio-trusion
facets were simulated. These observations provide a qualified estimate
of the open or closed status of the suture in relation to function yet to be
further researched for conclusive evidence. In this context, variations
with malocclusion and related function can be achieved on autopsy
material if allowed by institutional review boards.
Post-expansionclosure: The histological images from the biopsies fol-
lowing palatal expansion demonstrated that fractures had occurred and
that the suture was in the state of repair following the fracture six weeks
Fig. 5. Image of a dry skull from an individual in the early mixed dentition illus-
trating that the width of the palate (blue arrow) is nearly unchanged between
the ages of 5 and 18. The increase in the width of the pharynx results from bone
modelling, apposition on the lateral aspect and resorption on the medial side of
the adjacent bones. This process widens the pharynx the same amount as the
growth of the midpalatal suture widens the upper airways.
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Seminars in Orthodontics 00 (2023) 1−11
after expansion.17 The question was therefore whether the healing
would lead to a closure of the suture. In a female patient age 14 at the
time of expansion, the surgeon who took out the biopsies declared that
he could not verify an open suture 1 year after expansion. The signifi-
cance of this observation is the verification that suture closure can result
from expansion, a finding difficult to ascertain in individual patients
undergoing maxillary distraction, possibly impacting the opportunity of
a repeated maxillary expansion if needed. In the context of natural facial
growth, it is reasonable to hypothesize that growth of the mid-palatal
suture, which reaches about 7mm in an average course of
development,7,8 would not escort and might impede pharyngeal opening
if the suture closes following palatal expansion.
Effects of maxillary expansion on the palatal suture
A limiting factor in the assessment of biological palatal sutural
response to maxillary expansion is that any intervention for in situ obser-
vation in humans is invasive. A historic landmark in this field that
impacted current knowledge by providing unique qualitative assessment
of the sutural response was the analysis by Melsen17 of 5 children (ages
8-14) who volunteered for biopsies, a study that could not be repeated
in larger samples with current limitations by institutional review boards
(Fig. 8). The histological image of a midpalatal suture from an 8 year-
old boy in the early mixed dentition who had undergone palatal expan-
sion with a hyrax expander revealed apposition of woven bone on both
sides of the suture and what appeared as an island (indicated with an
arrow in Fig. 8C) on the histological image was a section of the bony
extension.
Krebs18 analysed the result of palatal expansion in a 10-year-old boy
in whom they had inserted the Bj€ ork implants (Fig. 9). Following the
expansion of 8 mm at the dental level and approximately 6 mm between
the implants, a minor relapse occurred when the appliance was
removed. However, of significant importance was the finding that
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Fig. 6. Two skulls of adult individuals. A-C. Skull with a narrow maxilla and an open suture. The sliced alginate impressions (C) reveal both laterotrusion (yellow
arrows) and mediotrusion (white arrows) facets. D-F Skull with a wide maxilla and a closed suture. The sliced alginate impressions revealed only laterotrusion facets.
approximately 1 year after the expansion, an increased distance between
the implants reflected growth in the midpalatal suture in relation to the
pubertal growth spurt, underscoring the potential for maintenance of
the pubertal growth after the early hyrax expansion.
These observations indicate that in the early growing (likely prepu-
bertal) years, an open suture with less interdigitation facilitates maxil-
lary expansion, resulting in apposition on both sides of the suture
(Fig. 8). In contrast, opening the suture following expansion in older
individuals could not be conceived without fractures across the interdig-
itation, because of the pronounced interdigitation between the sutural
sides (Fig 10).17 Delineating the individual variation in the topology of
interdigitation is not possible with present diagnostic tools. In this con-
text, the earlier the intervention, the less risk of closure from the ensuing
fractures.
Effects of expansion on craniofacial structures
Maxillary expansion has been shown to result in distant compensa-
tions. Animal research has shown the distant histological effect of pala-
tal expansion in the nasal cavity and structures of the neurocranium
including the floor and lateral and medial walls of the orbits,19 as well
as opening of the spheno-occipital synchondrosis and “severe disori-
entation” of the lambdoid, parietal, and midsagittal sutures.20 This
potential is informative in the “orthopaedic” context of bone modelling.
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Research is warranted to determine whether such effects are common,
under which circumstances, and at which age.
Three-dimensional radiographic records do not provide information
that mirrors the histologic revelations but may provide additional infor-
mation on the response in the total maxilla, such as suture opening
depicted on a frontal tomogram (Fig. 11). CBCT imaging revealed a
small increment of the volume of the spheno-occipital synchondrosis
and a posterosuperior pattern of displacement of basion.21 However,
CBCT remains limited as radiation is not allowed in short-term intervals.
Non-invasive finite element modelling has not yet simulated the expan-
sion effect beyond the immediate surrounding maxillary structures.
Future development of these technologies, combined with vast longitu-
dinal data aided by artificial intelligence will hopefully bring present
questions to a higher threshold of knowledge.
Recognizing gaps of knowledge for improved clinical outcome
In current practice, proper diagnosis not only focusing on the hard
tissue, but also soft tissue and genetics should determine the planned
changes in the position of teeth, the dental width, and the skeletal width,
before performing the bony expansion. These and potentially other ques-
tions have yet to be addressed to generate appropriate guidelines for pal-
atal expansion including age of patient, timing and amount of
expansion, and duration of retention. In this section, we cover salient
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Fig. 7. Results of a finite element model in a study of the palatal suture. A. Changes occurring when the person occludes with only laterotrusion facets; the arch widens
slightly (arrow). B. Higher density is concentrated at the sutural area. C,D. Strain in the sutural area when the teeth occlude: in a person with a closed suture (C), and
when a person has both latero- and medio- trusion facets (D)- note the difference on the two sides of the suture.

issues related to palatal expansion and the corresponding gaps of knowl- needs an appropriate answer: what is the biological background for any
edge heretofore not answered and requiring focused research. expansion protocol beyond the basic indications to correct a posterior
crossbite, such as the reduction of the “black corridors” between the
Biological knowledge buccal teeth and commissures?

This review indicates that the main biological underpinnings of pala-

tal development and palatal expansion have been determined by the
qualitative works of Melsen,9,17 who contributed knowledge about his-
tological sutural anatomy and response to expansion, and Bjork et al,7,8
who documented sutural separation relative to implants. Most of the
later publications have focused on mechanical issues, because of the
invasive nature of biological explorations in humans.
Gaps: These relate to biological diagnosis and clinical indications.
Biological markers to routinely gauge the status of the suture (open,
closed, interdigitated at higher or lower levels) and time its expansion
are not available for palatal distraction and other orthodontic proce-
dures (e.g. state of tooth movement or root resorption). Much work is
invested in the non-invasive finite element modelling to help predict
clinical intervention, but shortcomings have yet to be overcome, not
least of which the individual variation.22 Clinically, this question still
Time of expansion
The observations reported in this paper would indicate that earlier
expansion is recommended, when the suture is less interdigitated, not-
withstanding the fact that less resistance from the buttressing zygomatic
bones would also be expected.23 However, adequate knowledge is miss-
ing of the impact of the expansion on post-expansion growth of the den-
tofacial complex.
Such limitation was exemplified in the use by Isaacson et al12 of a
hyrax expander in late mixed dentition in whom crowding and/or
impaction of permanent canines could be predicted. Years later, the
authors abandoned this approach as they experienced transverse prob-
lems reoccurring during puberty, probably because closure of the
sutures impeded sutural growth that would occur at puberty. Also, the

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Fig. 8. Biopsy made from a girl of early mixed dentition (A) the palatal mucosa was flapped back and a 5mm cylinder biopsy (B) was removed before the appliance was
recemented. C,D. Histological images of two adjacent sections . What can be perceived as an island on image C will on the next section (D) show that it is a cutting of an
extension.
trend towards a later initiation of the orthodontic treatment, in one
rather than two stages of treatment, reinforced the same tendency.
Gaps: Whether the suture can be fractured again in a subsequent
expansion with tooth borne or bone borne expanders may not be pre-
Fig. 9. Graph redrawn from Krebs12 illustrating the development of various
transverse dimensions after rapid palatal expansion in an 11-year-old boy. An
immediate small relapse of all the variables occurs except for the interdental dis-
tances that were maintained with a retention plate until the plate was removed.
A significant finding is the increase in the distance between the implants the age
of 12 years reflecting the pubertal growth spurt. This finding is possible when
the expansion is performed when the sutural morphology allows for a separation
of the two maxillary halves.
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dicted, particularly in the individual patient. Such outcome is con-
founded by the fact that with growth, the resistance to expansion from
the buttressing lateral bones may increase, blurring the status of the
suture.
Potential dentoalveolar hazards of overexpansion
To reduce dental tipping and favour skeletal expansion, the surgi-
cally or mini-screw assisted rapid palatal expansion (SARPE or MARPE)
was recommended to overcome the resistance to expansion. SARPE is
illustrated in the records of a 15-year-old patient shown n Fig. 12A. An
expansion corresponding to the width of one incisor was performed
without any damage to the periodontium of the central incisors
(Fig. 12B). To maintain the arch widening, a .019” x 021” stainless steel
wire was inserted in the brackets and 0.036” transpalatal arch was
placed anchored on the first molars. A gradual closure of the suture was
observed. However, a CBCT reconstruction demonstrated that the maxil-
lae moved medially in relation to the teeth and the teeth did not move
with the bone or in relation to the bone (Fig. 12 D,E). The roots of the
teeth were maintained by the transpalatal arch and were clearly outside
the buccal bone.
The same effects were demonstrated in another patient with failing
bone coverage shown on CBCT imaging and verified by a flap surgery
(Fig 13). This finding counters the claim by pro-widening advocates that
the threshold of the radiograph could be changed to demonstrate bony
coverage of the expanded teeth that was too thin to be seen on the
image.
Gaps: While overexpansion is accepted with tooth-bone expansion
devices, guidelines based on high-level evidence are absent, leading to
a wide margin of variation among clinicians with irreversible effects,
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Fig. 10. A. Graphic illustration of the split of a heavily interdigitated suture when subjected to expansion. A fracture occurs across the interdigitations. B. A histological
image of a suture biopsy 3 weeks after expansion demonstrating not only formation but also resorption (yellow arrow) taking place. Red arrows point to true island
(fractured extensions) C. Biopsy at 9 weeks showing healing of the fracture. D. The suture (red arrows) has closed, but the sutural tissue can still be distinguished below
the consolidated bone. White arrow: Bony island in the middle of the suture Note the lamellar bone (blue arrows) and adjacent woven bone formed during the closure
(orange arrow).

probably related to suture closure and longer time of retention of the
appliance, at times requiring the reverse treatment strategy (e.g. cross-
bite elastics). In addition, overexpansion with bone-borne expansion is
subject to different also yet to be established evidence-based guide-
lines.
apnea through premolar extraction has not been supported in an elec-
tronic health records review.24
Gaps: Further exploration is needed by assessing the volumetric
changes in the oral cavity when the adaptive sutural contribution in the
pubertal period is prevented.

Maintenance of results: role of soft tissues

Potential breathing hazards of overexpansion
What is the impact on breathing of early sutural closure that may
affect the width of the nasal airways? Claims have been raised regarding
the effect of maxillary premolar extractions and associated constriction
of the maxillary arch, or the aggressive use of headgear and maxillary
distalization on normal breathing. The generation of obstructive sleep
The observations underscore the role of the soft tissues in maintain-
ing the expansion-induced changes in skeletal pattern, including the
tongue and cheek at rest and in function. The long-term outcome is asso-
ciated with the orofacial function. Sarn€as et al25 reported that maxillary
expansion leads to traumatic sutural damages and the healing process
along with the restoration of a soft tissue balance can cause a relapse of

Fig. 11. Frontal radiographs constructed from CBCT images before (A), after (B) and 3 months following expansion in a child with full deciduous dentition. A. before
expansion. B. Open suture after expansion. Apposition on buccal side. C. 3 months later, additional bone apposition is observed on the buccal side. ( The CBCT was
taken as part of a treatment for a patient suffering from a syndrome ).

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Fig. 12. A. Clinical photograph of a 15-year-old girl showing the significant diastema developed following a surgical assisted rapid palatal expansion. B. Intraoral
radiograph demonstrating that the expansion occurred without periodontal damage C. An artificial tooth was connected to the archwire in the diastema. Subsequently,
the tooth was gradually slenderized to allow for the closure of the space. D. CBCT image before expansion, demonstrating the presence of bilateral cross bites. Note the
apices of the molars penetrating the buccal bone, ( white arrows). E. Six weeks following the expansion, the molars were held with a transpalatal bar and the maxillary
halves approximated, indicating the medial movement of the bone with respect to the teeth. Accordingly the roots of the teeth held by the palatal bar are completely
outside of the bone(grey arrow).

the expansion. They also put in question the rationale for rapid maxillary
expansion unless normal growth and a change in function during treat-
ment generate a new balance. Thereby they confirmed the observation
of Isaacson,11 although either group of researchers did not refer to the
biopsy material17 demonstrating the fractures occurring when the suture
is interdigitated.
Gaps: While the displacements of hard tissues (teeth and bone) are
measurable, the influence of the neuromuscular envelope is not predict-
able. The adaptive potential of soft tissues varies individually, confound-
ing the issue of maintainability of the arch width expansion, let alone
the occurrence of side effects such as those illustrated in Figs. 12 and 13.
Missing is the answer to this question: what is the effect of a long-stand-
ing retention protocol of an over-corrected maxillary expansion on the
periodontium and on the transverse dimension if a closed suture main-
tains an overexpanded maxillary basal bone and the tongue does not
support it?
Conclusion
The combination of research and clinical observations on arch wid-
ening addressed in this paper indicate the following principles under-
scoring the presence of numerous gaps of knowledge:
1 Orthodontic widening should be performed before the suture
becomes highly interdigitated to avoid fracture and fusion. Clinical
or radiographic diagnostic tools to determine the amount of interdi-
gitations within the suture or suture closure are not available.
2 Early intervention in the mixed dentition and prepubertal years is
more dependable for palatal suture opening but may not anticipate
the feasibility or success of additional future expansion if needed.
Sutural opening is unpredictable individually in pubertal or postpu-
bertal years and becomes limited or questionable, requiring MARPE
or SARPE as indicated for the specific malocclusion and patient age,
notwithstanding the fact that skeletal expansion also presents vari-
ous limitations.
3 Maxillary arch expansion in the period when the suture is highly
interdigitated results in a sutural reaction comparable to a fracture
healing, possibly leading to fusion of the suture that may prevent fur-
ther growth of the suture and its adaptive escort of the growth of sur-
rounding structures. Consequently, the transversal development of
the upper airways may be reduced, and normal breathing affected.
High level evidence is warranted in this area.
4 Maintenance of the widened arch depends on removing the etiol-
ogy (e.g., mouth breathing) and preserving the soft tissue bal-
ance, particularly tongue posture. A low tongue posture may
prevent the maintainability of a maxillary expansion. This bal-
ance is a determining factor of successful and maintainable
results, irrespective of the rationale for the expansion, including
the correction of a crossbite and the reduction of “black
corridors” to achieve a wider smile.
5 The indications and extent of palatal expansion should be revisited,
and appropriate guidelines developed taking into consideration the
biological limits of the health and function of the oral tissues and
long-term maintainability of results.

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Fig. 13. A. Intraoral x-rays constructed from CBCT. When researchers claimed that the expansion can be iatrgenic the response was that the lack of buccal bone was
related to the threshold used . B. Clinical photograph demonstrates that the expansion indeed perforated the bone.

Declaration of Competing Interest
None.
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