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CASE REPORT

A 22-year follow-up of the nonsurgical expansion


of maxillary and mandibular arches in a young
adult: Are the outcomes stable, relapsed, or
unstable with aging?
 Valladares-Neto,a Karine Evangelista,b Hianne Miranda de Torres,b Matheus Melo Pithon,c and
Jose
Maria Alves Garcia Santos Silvad
Goi^ania, Goias, and Jequie, Bahia, Brazil
Adult maxillary and mandible arch expansion without a surgical approach can be uncertain when long-term stability is considered. This case report describes the treatment of a 19-year-old woman with an Angle Class I
malocclusion with constricted maxillary and mandibular arches. The patient's main complaint was mandibular
anterior crowding. The treatment plan included expansion of the mandibular arch concurrent with semirapid
maxillary expansion. An edgewise appliance was used to adjust the nal occlusion. Smile esthetics and dental
alignment were improved without straightening the prole. This outcome was followed up with serial dental casts
for 22 years after treatment. At the end of that period, the occlusion and tooth alignment were clinically satisfactory, further supported by mandibular xed retention. However, the transverse widths were continuously and
gradually reduced over time, superposing orthodontic transverse relapse and natural arch constriction caused
by aging. (Am J Orthod Dentofacial Orthop 2016;150:521-32)

uccessful orthodontic treatment is also referred to


as long-term stability. However, orthodontic
relapse and physiologic changes with age can produce dental arch instability. Longitudinal studies have
shown that tooth position can be physiologically
changed with aging in untreated subjects because of
progressive arch constriction.1-3 These 2 phenomena
are probably superposed in treated subjects during the
postretention period.4

a
Adjunct professor, Division of Orthodontics, School of Dentistry, Federal University of Goias, Goi^ania, Goias, Brazil.
b
Postgraduate student (PhD), School of Dentistry, Federal University of Goias,
Goi^ania, Goias, Brazil.
c
Professor, Department of Orthodontics, School of Dentistry, Southwest Bahia
State University, Jequie, Bahia, Brazil.
d
Professor, Department of Stomatologic Sciences, School of Dentistry, Federal
University of Goias, Goi^ania, Goias, Brazil.
All authors have completed and submitted the ICMJE Form for Disclosure of
Potential Conicts of Interest, and none were reported.
Address correspondence to: Jose Valladares-Neto, Division of Orthodontics,
Federal University of Goias, Avenida Universitaria esquina com 1a Avenida, s/n,
Setor Universitario, CEP: 74.605-220, Goi^ania, Goias, Brazil; e-mail,
jvalladares@uol.com.br.
Submitted, May 2015; revised and accepted, October 2015.
0889-5406/$36.00
2016 by the American Association of Orthodontists. All rights reserved.
http://dx.doi.org/10.1016/j.ajodo.2015.10.030

As regards the transverse dimension, constricted arch


problems have been solved through expansion, and
increments in arch dimensions have been clearly
demonstrated.5,6 However, most studies on maxillary
and mandibular arch expansion have dealt with subjects
in the mixed and early permanent dentitions, and only a
few authors have studied long-term results.5,7-9 In
young adults, the prognoses for rapid maxillary
expansion and semirapid maxillary expansion (SRME) in
terms of palatal suture opening are uncertain due to the
rigidity of the skeletal components with advancing
maturity.10 This prevents or limits the extent of suture
opening and results in a greater dentoalveolar than a
skeletal response, with an unpredictable long-term
outcome.11 On the other hand, the response of mandibular arch expansion is only dentoalveolar, and it has
been recommended in the case of a constricted arch.6,8
Nevertheless, the changes in mandibular arch form have
controversial results and could adversely affect longterm stability and treatment outcomes.12 In contrast,
other studies have shown that mandibular arch forms
can be successfully expanded in the early stages.5,8,9
Because dental and skeletal long-term stability is a key
objective in orthodontics, and the tendency toward
relapse is a real problem superposed by changes caused
521

Valladares-Neto et al

522

Fig 1. Pretreatment photographs.

by aging, information on patients monitored over a long


period could be valuable and help to clarify this issue. We
present the treatment of an adult with a Class I malocclusion and constricted maxillary and mandibular arches.
The outcome of the expanded mandibular arch concurrent with SRME was followed for 22 years after treatment.
DIAGNOSIS AND ETIOLOGY

A 19-year-old woman, complaining mainly of tooth


crowding, came for orthodontic treatment at a private
ofce. She reported being satised with her facial
appearance and had no serious medical impairment. A
facial analysis showed a well-balanced face, a mesocephalic growth pattern, and a straight prole. The ratio
of lower to upper facial heights was normal. The patient
had competent lips and the nasolabial angle was within
the normal range, but considering her slightly hooked
nose and retruded upper lip, the mentolabial sulcus

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was somewhat deep, and her lower lip was slightly


thicker than the upper lip although it did not impair
the relationship between them. She had a high smile,
exposing more than 2 mm of gingivae, and increased
buccal corridors.
An intraoral evaluation showed a Class I molar relationship with maxillary and mandibular atresic dental
arches. A crowding discrepancy of 5.0 mm was present
in the anterior segment of the mandibular arch and was
responsible for the irregular gingival alignment. The
maxillary anterior teeth showed a buccal proclination
with a slight midline diastema because of the central
incisor divergence. On the right side, the canine had a
Class II relationship. A single dental crossbite was
present between the second premolars on the left side.
A deep overbite was detected, with the maxillary incisors
covering 60% of the mandibular incisors, and overjet
was 6 mm (Figs 1-3). No intermaxillary tooth-size
discrepancy was found before treatment.

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Fig 2. Pretreatment dental casts.

Fig 3. Pretreatment radiographs: A, panoramic; B, lateral cephalometric; C, cephalometric tracing.

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Table. Cephalometric measurements


Variable
Skeletal ( )
ANB
SNA
SNB
SN.GoGn
FMA
Dental
1.NA ( )
1-NA (mm)
1.NB ( )
1-NB (mm)
IMPA ( )
Overjet (mm)
Overbite (mm)
Prole (mm)
S-Ls
S-Li

Norm

Pretreatment
19 y 11 mo (T1)

Posttreatment
22 y 11 mo (T2)

Postretention
44 y 9 mo (T4)

2.0
82.0
80.0
32.0
25.0

2.0
80.0
78.0
34.0
25.0

2.0
82.5
79.5
31.5
26.0

2.5
80.0
77.5
33.5
25.0

22
4
25
4
90
2-3
2-3

31.0
8.0
21.5
5.0
90.5
6.0
5.0

24.5
6.5
35.5
8.0
110.5
2.0
2.0

24.0
6
33.0
6
102.5
3.0
3.0

0
0

4.0
1.0

3.0
0.5

3.0
1.0

Fig 4. Progress photographs: slow maxillary expansion and mandibular dentoalveolar expansion
treatments.

Most of these morphologic changes were probably


related to her oral breathing developed with the increase
in upper airway resistance during infancy. The Table
shows the patient's cephalometric measurements.
TREATMENT OBJECTIVES

The aims of the treatment were to expand the maxillary and mandibular arches, resolve the mandibular
crowding, correct the dental crossbite, and obtain
normal overjet, overbite, and incisor inclinations.
TREATMENT ALTERNATIVES

In view of the treatment objectives, the following


treatment alternatives were presented to the patient:
(1) SRME with mandibular dentoalveolar expansion followed by an orthodontic xed appliance, (2) surgically
assisted rapid maxillary expansion and mandibular dentoalveolar expansion followed by an orthodontic xed

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appliance, (3) dental slice and xed appliance, and (4)


extraction of 4 premolars.
The rst option was selected because of the principal
problems and the patient's wishes.

TREATMENT PROGRESS

In the expansion phase, the patient was treated with a


Haas appliance and had her lingual arch expanded
(Fig 4). She was advised to activate the screw by 2 quarter
turns per day for the rst week, followed by a 1 quarter
turn every other day, characterizing the SRME. After
16 days, she showed a low orthopedic response observed
by a minimal median maxillary diastema and suspicions
of a buccal alveolar fracture in the left rst premolar.
Two-dimensional radiographic images have limited access to any vestibular fracture, and no action was taken.
The screw was then stabilized for retention. The 0.9-mm
lingual arch of stainless steel wire was expanded 3 times

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Fig 5. Immediately posttreatment photographs.

during the SRME retention. For the activation, the


lingual arch was rst removed, the bands were labially
torqued with a Weingart pliers, the lingual archwire
was symmetrically expanded by 3 to 4 mm each time,
and recemented. The aim of the active lingual arch
was to correct the collapsed mandibular arch until the
posterior teeth became upright, and thus contribute to
improving the morphology of the mandibular dental
arch. When both the Haas and the lingual arch expanders
were removed after 5 months, there had been gains in
the perimeters of the arches.
The xed appliance was bonded using a 0.022-in
edgewise prescription. The alignment phase included a
binary movement of the left second premolar to solve
the tooth rotation and dental crossbite problems. Alignment and leveling of the teeth took place over 8 months.
After we used rectangular wires, the maxillary anterior
proclination was corrected using lingual torque and
adding Class II elastics. The appliance was debonded
after 14 months of treatment.

The patient used a wraparound retainer in the maxillary jaw throughout the day over the rst 6 months and
only at night during sleep for the next 6 months. The
mandibular xed retainer from canine to canine has
been maintained up to the present.
TREATMENT RESULTS

The treatment resulted in signicant improvements


in dental alignment and smile, without straightening
the prole. A proper morphologic occlusion, with normal
overbite and overjet, and a good occlusal relationship
between the posterior teeth, were achieved with treatment, and both the maxillary and mandibular arches
were expanded. The expansion effect included proclination of the mandibular incisors, by increasing the IMPA
(initial, 90.5 ; nal, 110.5 ). The extent of gingival
recession after treatment was only what was adequate
for tooth alignment. Anterior and lateral occlusal guidances were also checked at the end of treatment. No

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Fig 6. Immediately posttreatment dental casts.

Fig 7. Final treatment radiographs: A, panoramic; B, lateral cephalometric; C, cephalometric tracing.

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Fig 8. Photographs 6 years after treatment.

Fig 9. Dental casts 6 years after treatment.

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Fig 10. Photographs 22 years after treatment.

Fig 11. Dental casts 22 years after treatment.

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Fig 12. Radiographs 22 years after treatment: A, panoramic; B, lateral cephalometric; C, cephalometric tracing.

signicant root resorption was observed, and root parallelism was well established (Figs 5-7). The 6-year and
22-year follow-up evaluations showed stable alignment
and occlusion, with normal radiograph images
(Figs 8-12).
Serial dental casts made on 4 occasions were available: pretreatment (T1), after expansion and xed appliance therapy (T2), and at the long-term observations
after 6 (T3) and 22 years (T4) posttreatment. Increases
in intercanine, interpremolar, and intermolar widths
were noted due to treatment in both arches. In the
maxillary jaw, the intercanine, interpremolar, and intermolar widths increased by 2.47, 4.09, and 3.75 mm,
respectively, after treatment. The mandibular arch
increased by 3.35, 3.05, and 3.65 mm, respectively, for
the same groups of teeth. During the evaluation at
6 years after treatment, a slight decrease in the transverse dimension was observed, and this tendency was

gradually maintained until the evaluation at 22 years after treatment, without returning to the initial width. The
maxillary width decreased by 0.42, 1.30, and 0.37 mm
after 6 years, respectively, for the intercanine, interpremolar, and intermolar widths; and by 0.97, 1.7, and
1.03 mm from 6 to 22 years after treatment, respectively.
The mandibular widths decreased by 0.0, 0.25, and
0.5 mm after 6 years, and by 0.0, 0.43, and 1.49 mm
after 22 years, respectively.
The cephalometric superimpositions showed no
change in the vertical dimension, and overjet was corrected because of maxillary retrusion concomitant to
mandibular protrusion (Fig 13). Overbite was basically
corrected by mandibular incisor protrusion. The longterm outcome showed a slight movement of these teeth
in the direction of the pretreatment position (Table). Our
case report showed increases in the transverse dimensions that remained clinically stable for 22 years after

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Fig 13. Cephalometric superimpositions: A, effect of treatment (pretreatment, black lines; nal treatment, red lines); B, effect of long-term outcomes (nal treatment, red lines; 22 years posttreatment,
green lines). Total (on the sella-nasion plane at sella), maxillary (on the palatal anterior curve), and
mandibular (on the mandibular plane at internal cortical symphysis) superimpositions.

Fig 14. Maxillary and mandibular arch widths at the canines (A), rst premolars (B), and rst molars
(C) during the 4 stages: pretreament (T1), immediately after treatment (T2), 6 years (T3), and 22 years
(T4) posttreatment.

treatment. However, as shown in Figure 14, a reduction


in the transverse width was detected in the long term,
without resulting in clinical disarrangement.
DISCUSSION

Although this case report is not unusual and


represents a perplexing clinical situation, it presents a
serious issue. It deals with the outcome of the treatment
of an adult, who simultaneously had maxillary and
mandibular nonsurgical expansions followed by a xed
edgewise appliance and who was followed for 22 years
posttreatment. This issue makes this report unique and
interesting.
A posterior crossbite is not an essential clinical
condition for undertaking maxillary expansion. In the

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case of simultaneous arch constrictions, a maxillary


and mandibular expansion phase is recommended to
improve the transverse dental arch dimensions before
or during xed appliance treatment.8 The nonextraction
treatment of a crowded and constricted dental arch
requires an increase in arch perimeter to allow for arch
alignment and leveling. Ricketts et al13 proposed that
1 mm of incisor advancement produces 2 mm of arch
length, and 1 mm of canine expansion produces 1 mm
of arch length, whereas 1 mm of molar expansion results
in an increase of 0.25 mm in arch length.
Our case report showed that maxillary and
mandibular arch expansion followed by a xed
orthodontic appliance led to increases in arch widths
from 3 to 4 mm in an adult patient. McNamara et al8
found similar results for maxillary arch expansion in

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children, whereas Handelman et al11 found the


amounts to be 4.5 to 5.5 mm for adults. In the mandibular arch, the sample of McNamara et al increased by
only 1 to 2 mm. This comparison must take the
difference in methodologic measurement into account,
since we measured from the tip of the canines, whereas
McNamara et al used lingual landmarks. This gain was
sufcient to increase the arch perimeter, correct the
enlarged overjet, and solve the mandibular crowding
problem in our patient.
Adult nonsurgical expansion has always been
contentious, and several adverse side effects have been
reported. Our patient reported the suspicion of a
painless buccal alveolar fracture in the left rst premolar
at the end of screw activation, but no gingival recession
developed afterward. Unfortunately, few well-designed,
long-term studies have addressed stability with adult
nonsurgical expansion. Handelman et al11 found a
signicant reduction (0.5-0.6 mm) in maxillary posterior
arch width 5 years after retention. In our patient's
follow-up register of 6 years after treatment, the
reduction in maxillary width ranged from 0.25 to
1.3 mm.
We observed a clinically favorable occlusion and
esthetic gain in our patient even at 22 years after treatment. However, as previously mentioned, the transverse
dimension was not mathematically stable, except in the
mandibular intercanine width that was permanently
retained. Permanent mandibular retention was opted
for because of the strong tendency toward arch width
relapse described in the literature.12,14 In addition,
mandibular crowding was the patient's main complaint
before treatment. But in general, the dental arch width
gradually decreased, between 14% and 40%, after
22 years of follow-up. These changes were due to the
superposition of the orthodontic relapse and the natural
arch constriction as a result of aging. The orthodontic
relapse probably superposed to the aging effect up to
T3; from then on, the changes were attributed to the
effect of aging alone (Fig 14). In general, natural
changes in dental arch dimensions have been reported
to be small (\1.0 mm) from the third to the fth
decades of life, with no difference between the sexes
or patients with a high vs a low mandibular plane
angle.3,15,16
Our patient showed an improvement in the gingival
leveling of the mandibular incisors because of
orthodontic alignment and protrusion, and no gingival
recession was detected in the long term. In the literature,
gingival recession associated with orthodontic treatment
is a controversial issue. Recently, Renkema et al17 found
no association between proclined teeth and gingival
recession after a 5-year follow-up. Gingival recession

531

could also be inuenced by gingival phenotype. The authors of a study found that where there is thickness of
more than 0.5 mm in the attached gingiva, the risk of
gingival recession is reduced.18
Overall, simultaneous maxillary and mandibular arch
expansion using a nonsurgical approach is a viable
procedure for young adults; in selected cases, it can offer
a clinically favorable result in the long term. First,
preference should be given to SRME because of
problems arising from rapid maxillary expansion in
adults. The rapid rate of expansion can cause pain and
discomfort.19 Second, a clear atresia of the mandibular
arch should be a morphologic condition that needs
expansion. In addition, the muscular balance should
also contribute to better stability. Our case report
showed a mathematical reduction in the transverse
dimension in a patient from 23 to 45 years of age,
with no clinical signicance, except at the mandibular
intercanine distance, which maintained its stability. No
periodontal disease occurred in this patient with good
oral hygiene.
CONCLUSIONS

1.

2.

Maxillary and mandibular dental arch expansion


followed by the use of a xed orthodontic appliance
increased the arch widths by 3 to 4 mm and
resulted in a clinically favorable occlusion in the
long term.
However, the transverse dimension gradually
reduced throughout the maximum follow-up period
of 22 years, except in the mandibular intercanine
width, which remained stable because of the
permanent retention. The later changes were
considered the superposition of the orthodontic
relapse, and the natural arch constriction was due
to aging.

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