PALATAL EXPANSION

Orthopedic expansion
- changes occur mainly in the skeletal
structures
- less amount of dento alveolar
expansion
*** Rapid Maxillary Expansion (RME) is
an example of a true orthopedic expansion. It
causes separation of midpalatal suture and
also affects circumzygomatic and
circumaxillary sutures. After expansion, new
bone is deposited in the MPS.
Passive expansion
- result from the intrinsic forces
exerted by the tongue
-make use of buccal shields (e.g.
Frankel) to prevent labial and buccal
musculature from acting on the dentition
- results in widening of the arches
***forces from the tongue exert
expansible forces on the arches
- not achieved by mechanical
appliances but by the vestibular or lip shields
Rapid Maxillary Expansion
- involves split opening of the
maxillary suture and movement of the
palatal shelves away from each other
- forces are transmitted to the sutures
and the sutures open while the teeth move
minimally relative to the supporting bone
Brief history of RME
1860 RME was reported in dental literature
by Angell, but was initially opposed and
questioned by some
1961 RME was reintroduced by Hass (Hass
expander)
***Hass, Timms and Wertz stated that RME
produces true orthopedic expansion wherein
the changes are produced in the skeletal
structures rather than by the movement of
the teeth through the alveolar bone.

- formed by the junction of 3 opposing

pairs of bones (premaxillae, maxillae,
and the palatines) but often treated as
a single entity (MPS)
- Stages of development (Bjork &
Helm)
1st stage: infantile period
The suture is very broad and Y shaped
with the vomerine bone placed in a V
shaped groove between the two
halves of the maxilla.

2nd stage : Juvenile period

The suture is found to be more wavy.

3rd stage : Adolescent period

The suture is characterized by a more
tortuous course with increasing inter
digitations

ANATOMY
Midpalatal suture

CLASSIFICATION OF MAXILLARY
EXPANSION APPLIANCES
Slow expansion appliances

Removable: Active plate w/ screws,

Coffin spring, and active plate w/ Z
springs
Fixed: W arch, quad helix, bonded
expansion screws w/ fixed
appliance
Rapid expansion appliances
Banded RME: Haas expander,
Isaacson appliance, Hyrax and
Derichsweiler type
Bonded RME: Acrylic splints, cast
metal splints
Surgically assisted rapid maxillary
expansion

Slow Expansion
* Teeth alone are
supposed to move
* can transmit forces
from several oz. to 2
lbs
* rate of separation:
0.4 to 1.1mm/week
* intermolar width=
8mm
* requires 2-6mos.
* 16-30% total
skeletal change, vary
with age

Rapid Expansion
* major change in
basal structures of
Mn & Mx
* more than 5 oz.
* rate of separation:
0.2 to 0.5mm/day
* intermolar width=
10mm
* requires 1-4wks.
* 50% skeletal
changes

SLOW EXPANSION APPLIANCES

- basically produce dentoalveolar
expansion or changes
- rate of activation is less compared to
RME appliances
- usually provide few hundred grams
of force around 2 lb of pressure, with the
expansion carried out at the rate of
1mm/week
Removable Slow Expansion Appliances
1. Expansion Plates
- removable acrylic plate with jackscrew
in the midpalatal region
- Active plate: bec. It serves as a base in
which screws or springs are embedded
and to which clasps are attached
- expansion schedule: 1mm/week

2. Coffin Spring (Walter Coffin, 1875)

- consists of an omega-shaped wire of
1.25mm thickness, placed in the
midpalatal region
- free ends of omega wire are embedded
in acrylic
- spring is activated by pulling the 2 sides
apart manually

3. Removable Quad Helix

- same design as fixed quad helix
appliance, which is inserted into the
lingual attachment soldered to the molar
band
Fixed Slow Expansion Appliances
1. W Arch Appliance
- 0.036 SS wire is adapted in the form of
W, which extends from the first
permanent molar to the canine in the
anterior palate

- free ends of the W are adapted closely

to the palatal surfaces of premolars/1
molars
- appliance should be away from the
palatal or lingual mucosa to prevent
tissue irritation
Activation:
- by opening the apices of W for
anterior expansion, and opening the
anterior portion for posterior
expansion
- The appliance delivers proper force
levels when opened 3-4mm wider than the
passive width and should be adjusted to this
dimension before being inserted .
- Expansion should continue at the rate of
2mm per month until the cross bite is slightly
overcorrected.
2. Quad Helix Appliance
- general form is similar to Crozat
appliance and the W arch appliance,
later modified by Ricketts by adding loops
- incorporates 4 helices or coils to
increase flexibility
- constructed of 0.038 wire and soldered
to bands which are cemented to either
the maxillary 1st permanent molars or the
deciduous 2nd molars, depending on the
age of the patient

* An initial expansion of 8mm will produce

approximately 14 ounces of force
RAPID EXPANSION APPLIANCES
- RME occurs when the force applied to
the teeth and the maxillary alveolar
processes exceed the limits needed for
orthodontic tooth movement.
- The applied pressure acts as an
orthopedic force that compresses the
PDL, opens the MPS, moving the apices of
posterior teeth laterally

RME forces
- when viewed occlusally, studies by
Inoue and Wertz found that the palatine
processes of the maxillae separated
anteroposteriorly in a nonparallel that
is, in a wedge-shaped manner most of
the cases observed.

Occlusal view

Indications:
- All cross- bites in which the upper arch
needs to be widened
- Mild expansion in the mixed dentition
which frequently exhibit lack of space for
the upper laterals and in which the long
range growth forecast is favorable.
- Class III Expansion needed
- Class II cases
- Thumb sucking or Tongue thrusting
cases Cleft palate conditions either
unilateral or bilateral

- when viewed frontally, the maxillary

suture was found to separate
superoinferiorly in a nonparallel manner.
It is pyramidal in shape with the base of
the pyramid located at the oral side of the
bone
- The magnitude of the opening varies
greatly in different individuals and at
different parts of the suture.
- In general, the opening is smaller in
adult patients. The actual measurement
ranges from practically no separation to
10 mm or more.

Frontal view

Effect on the Mandible:

- Activation of RME results in a downward
and backward rotation of the mandible
due to extrusion of maxillary posterior
teeth
Effect on Maxillary anterior teeth:
- From the patient's point of view, one of
the most spectacular changes
accompanying RME is the opening of a
diastema between the maxillary central
incisors
- It is estimated that during active suture
opening, the incisors separate
approximately half the distance the
expansion screw has been opened, but
the amount of separation between the
central incisors should not be used as an
indication of the amount of suture
separation

Effect on Maxillary posterior teeth:

- Hicks found that with the initial alveolar
bending and compression of the
periodontal ligament, there is a definite
change in the long axis of the posterior
teeth the angulation between the right
and left molars increased from 1 to 24
during expansion.
- Not all of the change, however, is
caused by alveolar bending, but is partly
due to tipping of the teeth in the alveolar
bone, and is usually accompanied by
some extrusion

Effect on Alveolar bone:

- alveolar bone bends bucally due to
compression of PDL fibers on activation of
RME
INDICATIONS OF RME APPLIANCES
1. Maxillary constriction (narrow
maxillary base or wide mandible),
dental or combination of both skeletal
or dental constrictions
2. Skeletal Class II division 1
malocclusions w/ or w/o posterior
crossbite
3. Class III malocclusions, borderline
skeletal Class III, Pseudo-Class III w/
posterior crossbite and/or constricted
maxilla
4. Patients with cleft lip and palate with
collapsed maxilla
5. To gain arch length in patients w/
moderate tooth size arch length
discrepancy (e.g. child w/ decreased
maxillary width and dental crowding)
6. To widen the maxilla to make the smile
more attractive
7. Poor nasal airway, septal deformity,
recurrent ear/nasal/sinus infection,
allergic rhinitis, asthma, and before
septoplasty
CONTRAINDICATIONS OF RME APPLIANCES
1. Poor patient compliance
2. Cases of single tooth crossbite
3. Skeletal asymmetry of maxilla and
mandible
4. Severe anteroposterior and vertical
skeletal discrepancies

ADVANTAGES OF FIXED RME APPLIANCES

1. Patient compliance is not required
2. Rapid changes are produced within a
short period of time
DISADVANTAGES OF FIXED RME APPLIANCES
1. Bulkiness of the appliance
2. Difficulty in cleaning the appliance
R.M.E and Nasal Airway Resistance
RME causes a relative reduction in
the nasal airway resistance by
disarticulating the maxilla from
other bone particularly Septal and
palatine bone
Banded RME Appliances
1. Haas-type Expander
- 0.045 (1.5) SS wire is soldered to palatal
aspect of the bands (on the right and left
permanent 1st molars and premolars)
- Free ends Turned back embedded in
acrylic short of bands
- jack screws are incorporated in the midline
into the 2 acrylic pads that closely contact
the palatal mucosa
- support wires also extend anteriorly from
the molars along the buccal and lingual
surface of the posterior teeth to add rigidity
to the appliance

2. Isaacson appliance
- a tooth borne appliance without any acrylic
palatal covering
- consists of bands on right and left 1st
permanent molars and 1st premolars
- metal flanges are soldered into the molar
and premolar bands on the buccal and
palatal sides
- Screw reduced in length for narrow arches
- Activation: by closing the nut so that the
spring gets compressed

3. Bidderman
- Special screw of either Hyrax , Leaone or
Unitek Heavy gauge extension are welded to
palatal aspect of bands

4. Derichsweiler type
- wire tags are welded & soldered to palatal
aspect of bands to provide attachment for
acrylic which is extended to palatal aspect of
nonbonded teeth
- jack expansion screw is incorporated in the
center (on the split portion of the acrylic)

Bonded RME Appliances

- used in deciduous and severely malposed
teeth
- reduced food deposition
Consists of:
Acrylic splint, covering variable
number of teeth on either side in

the maxillary arch, to which a jack

screw is attached
Wire framework may be adapted
around the teeth to reinforce the
acrylic

Procedure of placement of bonded

RME appliances:
1. complete scaling and polishing of
maxillary teeth
2. teeth to be included in bonded
maxillary expansion are etched using
30% phosphoric acid
3. evaluation of etching
4. bonded RME appliances are
cemented onto the etched teeth using
either GIC or other bonding adhesives
Removable RME Appliances
- produce skeletal expansion by the splitting
of MPS, when they are used in the deciduous
or early mixed dentition; highly questionable
when used in older adults
Consists of:
an expansion screw in the midline
with split acrylic plate

may also consist of retentive clasps

(C or Adams clasp) on posterior
teeth, and
labial bow on anterior teeth
Activation:
Placement of expansion screw key
in the central bossing of screw and
turning the key up 90 or 45
produce split of MPS and
movement of maxillary shelves
away from each other

References:
* Textbook of Orthodontics by Sridhar
Premkumar, page 581-588, Reed Elsevier
India Pvt. Ltd., 2015
* Orthodontics: Principles and Practice, BS
Phulari, page 310-317
*Clinical orthodontics: Current Concepts,
Goals and Mechanics, A Kharad, page 161