ARCH EXPANSION

PRESENTED BY : DR SAAD IBNAE YAKUB

IS-36
DEPARTMENT OF ORTHODONTICS AND DENTOFACIAL
ORTHOPEDICS
SAPPORO DENTAL COLLEGE & HOSPITAL
GOOD MORNING
INTRODUCTION

 Arch expansion is a method of gaining space.

 An apparently complex yet relatively simple procedure in orthodontics is palatal

expansion.

 The correction of transverse maxillary deficiency can be an important component

of an orthodontic treatment plan.

 Expansion of palate was first achieved by Emerson C.Angell in 1860.Ever since

numerous expansion appliance have been described with varying force levels &
duration of treatment.
CLASSFICATION
A. Expansion of the dental arches can be classified
as:
1. Dento-alveolar expansion
2. Skeletal expansion

B.They can also be classified broadly as:

1. Rapid expansion
2. Slow expansion
Further…
C.1.Anterior expansion
2.posterior expansion
D.1.Unilateral expansion
2.Bilateral expansion
RAPID MAXILLARY EXPANSION(R.M.E)

 Rapid maxillary expansion is also known by the

terms rapid palatal expansion or split palate.

 It is skeletal type of expansion that involves the

separation of mid-palatal suture & movement of
the maxillary shelves away from each other.
PHILOSOPHY FOR THE USE OF RME
APPLIANCES

• The Rapid Maxillary expansion(RME) appliance is essentially

a dentofacial orthopedic appliance,which tends to produce
its changes by splitting the mid-palatal suture.The rationale
being that if extreme forces are applied on to the palatal
shelves,the interlying suture splits and results in true
skeletal changes.The teeth are generally used for the
purpose of transmitting the onto the maxillary bone proper.
 INDICATIONS FOR RME USE
RME appliances are ideally indicated in growing
individuals with severely constricted maxillary arches ,
involving airway impairment or mouth breathing
tendencies. They are also indicated in other cases of:
• Posterior cross bites with real or relative maxillary
deficiency
• Cleft patients
• Along with facemask therapy
• Class III cases with minor maxillary deficiency
• As part of interceptive orthodontics

 Medical indications : nasal stenosis, septal

deformities ,recurrent ear & nasal infection , allergic
rhinitis , D.N.S…etc
CONTRAINDICATIONS OF R.M.E

• 1. Single tooth crossbites

2. Un-cooperative patients
3. After ossification of mid-palatal suture unless it is accompanied by
adjunctive surgical procedures
4. Skeletal asymmetry of maxilla & mandible & adult cases with severe
antero-posterior skeletal discrepancies
5.As the posterior teeth are used as anchors to move the bones apart,the
procedure is not indicated in a periodontally weak dentition
DIAGNOSTIC AIDS

 The routine diagnostic aids such as :

Case history

Clinical examination & study models

Maxillary occlusal view radiograph – to see mid-

palatal suture

P.A cephalogram – to estimate the amount of

expansion that has taken place Occliusal
radiograph
 TYPES OF RAPID MAXILLARY EXPANSION APPLIANCES
Over the years numerous types of RME appliances
have been used. They can be best classified as:
• Removable appliances
• Fixed appliances
— Tooth-borne
— Tooth and tissue-borne

Examples of tooth borne appliances include:

i. Isaacson type

ii. Hyrax type

Two of commonly used tooth & tissue borne appliances are :
i. Derichsweiler type
ii.Hass type
 REMOVABLE RME APPLIANCES
The efficiency of removable RME appliances is
doubtful. The appliance basically consists of a screw
in the midline with retentive claps on the posterior
teeth. The acrylic plate is split in the middle and
activations of the screw forces the two halves apart to
result in the desired expansion.
This appliance is more effective when used in the
early mixed dentition phase. Its efficiency in the late
mixed dentition and older patients is suspect because
of the ossification of the mid-palatal suture and the resulting
delay in splitting causes the retention of the appliance to get
compromised. Patient compliance is paramount to all
removable appliances.
 FIXED RME APPLIANCES

Isaacson type
This appliance has a special spring loaded screw
called a MINNE expander,consists of a coil spring
having a nut that can compress the spring
It is soldered directly to the bands
No acrylic is used
Easy to fabricate
Expander is activated by closing the nut so that the
spring gets compressed.
HYRAX RME APPLIANCES

This type of appliances makes use of the HYRAX

screw, named after the ability to keep it clean (the
hygienic rapid expander).
The screw has heavy wire extensions, which can be
adapted to follow the contour of the palate and are
soldered to either metal bands or cast cap splints or
a wire framework that has acrylic splints or
embedded in acrylic splints
DERICHSWEILER TYPE

 The first premolars & first molars are banded

 Wire tags are soldered onto the palatal aspect of

 the bands
These wire tags get inserted into a split palatal
acrylic plate incorporating a screw at its centre.
HASS TYPE
 The first premolar & molar of either side are banded

 A thick stainless steel wire of 1.2mm diameter is

soldered on the buccal & lingual aspects connecting
the premolar & molar bands

 Lingual wire is kept longer so as to extend past the

bands both anteriorly & posteriorly

 Free ends turned back and embedded in acrylic.

 A screw is incorporated.
BONDED R.M.E
 Most of the RME appliances described earlier are banded appliances .They incorporate
bands on the first premolars & molars.

 An alternative design of the appliance would be to have a splint covering variable

number of teeth on either side to which the jackscrew is attached.

 Raymond Howe in 1982 developed this appliance

Clears the palate from acrylic

• No banding needed- can be used on malposed teeth where parallel path of insertion is
not possible

• Less error prone as bands don’t have to be placed in impression

• Easy to make on deciduous teeth.

INSTRUCTION ON HOW TO EXPAND
(ACTIVATION SCHEDULE)
 Schedule by Timms :
i. Upto age of 15 years:90 degree rotation in the
morning & evening.
Ii.Over 15 years:45 degree activation 4 times a day

 Zimring & Isaacson in 1965 :

i.Young growing patients : two turns each day for
the first 4-5 days & later one turn each day for
remainder of RME treatment.
Ii. Non growing adult patients : two turns each day
for the first two days & one turn each day for the
next 5-7 days & one turn every alternate day till
desired expansion is achieved.
RETENTION FOLLOWING RME THERAPY

Corrections achieved using the RME appliance are

likely to relapse unless sufficient time is given for
thereorganization of the concerned hard and soft
tissues.The occlusion is relatively deranged and
cannot beexpected to aid in retention. Usually the
same appliance can be used for retention after
immobilizing the screw using cold cure acrylic .
Alternatively the expansion can be maintained
using a transpalatal arch (TPA) or any of the other
appliances.
The TPA has the advantage that the fixed
appliance treatment can proceed unhindered.
EFFECTS OF RME

 Effect on maxilla

• Opening of the mid-palatal suture

• Downwards & forward maxillary movement

 Effect on maxillary teeth

• Midline spacing between the two maxillary central

incisors

• Maxillary posterior teeth show buccal tipping &

extrusion
 Effect on mandible

• Downward & backward rotation of the mandible

• Increase in face height

• Reduction in overbite

 Effect on nasal cavity

• Reduced resistance to nasal air flow

• ncrease in intra-nasal space

HAZARDS OF RME
Oral hygiene

Length of fixation

Dislodgement & breakage

Tissue damage

Infection

Pain or discomfort,dizziness,pressure at the bridge of nose etc

CLINICAL TIPS FOR RME

1.Oral hygiene instructions should be given to the patient and reinforced during the procedure.
2.Orthodontic movement of the anchor teeth should be avoided prior to rapid maxillary expansion,as
mobile teeth do not offer adequate anchorage for palatal split.Recently moved teeth tend to tip.
3.The patient should be trained to use the key.The key should be tied to a string and the free end should be
secured around the patient’s wrist to avoid accidental swallowing
4.Maxillary occlusal radiograph should be taken at regular intervals to monitor the expansion
SLOW EXPANSION

Slow expansion was the brainchild of the father of modern

dentistry, Pierre Fauchard. Slow expansion involves the use of
relatively lesser forces (2 to 4pounds) over longer periods (2 to
6 months) to achieve the desired results. Slow expansion has
been at times termed dentoalveolar expansion.

Slow Expansion Slow expansion has traditionally been

termed as dento-alveolar expansion ,although some skeletal
changes can be observed. The slower expansion have also
been associated with a more physiologic adjustment to the
maxillary expansion, producing greater stability & less relapse
potential than in rapid expansion procedures
INDICATIONS OF SLOW EXPANSION

• Correction of unilateral cross bites.

• Correction of ‘V’ shaped arches as in “thumb
suckers”.
• Preparation for bone grafts in cleft cases.
• Minimal crowding in the upper arch (1-2 mm).
• Elimination of a displacement
CONTRAINDICATIONS

• 1. Buccal or labial inclination of teeth

2. Bone loss on buccal aspect of teeth
 APPLIANCE USED FOR SLOW EXPANSION
Fixed
W arch
Quad helix
Ni-Ti arch wires

Removable

• removable screw appliances

• Coffin spring

Functional appliances

• Active

• Passive
FIXED

Quad helix
The quad-helix evolved from the coffin spring. The
appliance is a precursor to the tri- and the bi-helix
appliances. They are all named after the number of
helices incorporated in the appliance.

The quad-helix consists of two anterior and two

posterior helices. The portion of wire in between the
two anterior helices is called the anterior bridge and
that connecting the anterior helices and the posterior
helices is called the palatal bridge. The free wire ends
that are usually adapted close to the premolar teeth
are called the outer arms. The outer arms are soldered
to the molar bands.
CONTINUE....

• The appliance is capable of producing

differential expansion, i.e. it can be activated to
produce different expansion levels in the
premolar and molar regions . It can be activated
prior to cementation of the bands by stretching
the molar bands apart or in the mouth with the
use of a three-prong plier. When the anterior
bridge is adjusted the molar expansion is
produced and when the palatal bridges are
activated, the premolar and canine region gets
expanded
W ARCH

•  0.9mm stainless steel wire soldered to molar

bands
 Patient cooperation not required
 Preferred in deciduous and mixed dentition
where mild to moderate expansion is required
 Activation : outside mouth,3mm wider than
passive width
NI-TI EXPANDER
• In 1993 Arndt developed a fixed –removable tandem
loop nickel-titanium maxillary expander which is
known by the names Ni-Ti expander or Nitanium
expander .This expansion appliance has the capacity
to rotate, upright,distalize and expand the anterior
and posterior arch with gentle biocompatible force.
this appliance is capable of a uniform , slow,
continuous force.

• The action of the Ni-Ti expander is made possible by

the properties of shape memory and transition
temperature.Shape memory is the ability to
constantly return to a set shape after deformation.
CONTINUE...

• The action of the Ni-Ti expander is made

possible by the properties of shape memory and
transition temperature . Shape memory is the
ability to constantly return to a set shape after
deformation.
• Nickel and Titanium form an alloy with a specific
thermal transition temperature(84* F).At
temperatures higher than the transition
temperature, interatomic forces bind the atoms
more tightly, producing a stiffer metal. At lower
temperature, the forces weaken , making the
metal more flexible.
REMOVABLE

• REMOVABLE APPLIANCES INCORPORATING

JACK-SCREWS

Various screws have been used for the

expansion of maxillary and the mandibular
arches. These screws have a smaller pitch and
are activated less frequently as compared to
screws used for RME appliances.
• ADVANTAGES

The main advantage of removable appliances is the fact that it can be removed for cleaning.

The other advantage includes the ability to have additional active components such as Z springs,finger
springs etc for additional tooth movement.

DISADVANTAGES

The main drawbacks of removable expansion appliances are the need for patient cooperation and
difficulty to obtain adequate retention in the mixed dentition
COFFIN SPRING

• This appliance is capable of producing slow

expansion , even though it has been shown to
split the palate especially when used in patients
in the early mixed dentition. It is an ideal
appliance to treat unilateral cross bites. It has an
advantage over screw appliances in that
differential expansion can be obtained in the
premolar and molar regions .
COMPARISON BETWEEN SLOW & RAPID
EXPANSION SLOW EXPANSION RAPID EXPANSION
Slow expansion
• 1. Type of expansion – both skeletal & dental
changes seen from beginning
2. Rate of expansion - slow
3. Type of tissue retraction - more physiologic
4. Force used –milder force (2-4 lbs)
5. Frequency of activation- less frequent (0.5-
1mm/week)
6. Duration of treatment- long
7. Type of appliance-either fixed or removable
8. Age-any age
9. Retention-lesser chance of relapse  9. More chance of relapse
R.M.E.
• 1. Predominantly skeletal changes initially,later
dental changes take place with skeletal relapse
2. Rapid
3. More traumatic
4. Greater force (10-20 lbs )
5. More frequent (0.5- 1mm/day)
6. Short
7. Mostly fixed appliance
8. Before fusion of mid- palatal suture
EXPANSION OF CLEFT PALATE CASES
 Excessive anterior collapse coupled to little or no posterior
collapse

 More fan wise expansion needed to restrict posterior

expansion.Screws of longer thread of upto 18mm
expansion

 More difficult to retain due to clinical crowns not

developed properly

 Unilateral expansion both cap splints & bands can be used

 Formation of fistula could be a complication

EXPANSION OF MANDIBULAR ARCH

 Stable expansion is difficult to attain in the lower

arch

 Present studies state that expanding the upper

arch allows for spontaneous expansion of the
lower arch to some extent.
OTHER METHODS OF EXPANSION
 Surgically assisted RME
patients who exhibit unusual resistance to separation of the
palatine bones may require surgical intervention.This usually
occurs in female patients over 16 years and male patients
over 18 years of age in whom the mid-palatal suture has
ossified.

 Transpalatal arch

 Magnets

 Ultra rapid expansion

Though these methods are not used frequently.

CONCLUSION

• Expansion of the arches has seen its ups & down since the past.More & more documentation of the
effects & stability of this procedure has thrown a new light on its clinical application.

Whether It is slow or rapid expansion,proper diagnosis & case assessment is very essential to ensure
consistent results.As more & more cases are being treated without extractions due to profile
considerations ,Expansion of the arches formsa valuable adjunct to treat a wide variety of clinical
presentations.
BIBLIOGRAPHY

• 1. Contemporary Orthodontics,5th edition by William R.Proffit,Henry W.Fields,David M.Sarver

2. Textbook of Orthodontics ,third edition by GURKEERAT SINGH
3. Kharbanda Orthodontics text book,5th edition
4. Orthodontics text book by S.I. Bhalaji,6th edition
THANK YOU