ARCH EXPANSION

Types of Expansion
It is well known that expansion of the dental arches can be produced by a variety of orthodontic
treatments, including those that incorporate fixed appliances. The types of expansions produced can
be divided arbitrarily into three categories.
Orthodontic Expansion
Orthodontic expansion, produced by conventional fixed appliances as well as by various removable
expansion plate and finger spring appliances, usually results in lateral movements of the buccal
segments that primarily are dentoalveolar in nature. There is a tendency toward a lateral tipping of
the crowns of the involved teeth and a resultant relative lingual tipping of the roots. The resistance
of the cheek musculature and other soft tissue remains, providing forces that may lead to a relapse
or rebound of the achieved orthodontic expansion.40,41
Passive Expansion
When the forces of the buccal and labial musculature are shielded from the occlusion, as with the
FR-2 appliance of Fränkel, 42 a widening of the dental arches often occurs. This passive expansion
is not a result of the application of extrinsic biomechanical forces but rather by intrinsic forces such
as those produced by the tongue. Brieden and coworkers,43 in an implant study conducted in
patients treated with the FR-2 appliance ofFränkel, have demonstrated that bone deposition occurs
primarily along the lateral aspect of the alveolus rather than at the midpalatal suture. A related type
of spontaneous arch expansion also has been observed after lip-bumper therapy.44
Orthopedic Expansion
Rapid maxillary expansion appliances (Fig. 16-18) are the best examples of true orthopedic
expansion, in that changes are produced primarily in the underlying skeletal structures rather than
by the movement of teeth through alveolar bone.45-47 RME not only separates the midpalatal
suture but also affects the circumzygomatic and circumaxillary sutural systems.48 After the palate
has been widened, new bone is deposited in the area of expansion so that the integrity of the
midpalatal suture usually is reestablished within 3 to 6 months.
Rationale for Early Orthopedic Expansion
The cornerstone of the early orthopedic expansion protocol used in the treatment of patients with
arch-length discrepancy problems is the actual RME itself. The use of RME is based in part on our
previous studies of the development of the dental arches in untreated individuals, both in the
permanent dentition and the mixed dentition.1,29,49
Permanent Dentition
When arches are crowded, what is the cause? Howe and coworkers49 carried out an investigation in
which the dental casts of patients with severe crowding were compared with the dental casts of
untreated individuals who were classified as having ideal or near-ideal occlusions. No statistically
significant differences in tooth size were noted between the uncrowded and crowded populations,
regardless of whether aggregate tooth size or the sizes of individual teeth were considered. In
contrast, there were statistically significant differences in arch width and arch perimeter.
Maxillary intermolar width was of particular importance as an easily measured clinical indicator. In
noncrowded male
patients, the average distance between the upper first permanent molars, measured at the point of
the intersection of the
lingual groove at the gingival margin, was about 37 mm, a value that can be compared with a
similar measure in the crowded males of 31 mm. Similar but slightly smaller measures and
differences were noted in the female sample.49 Howe and coworkers concluded that a transpalatal
width of 35 to 39 mm suggests a bony base of adequate size to accommodate a permanent dentition
of average size (of course, a larger aggregate tooth size requires a larger bony base and vice versa).
Mixed Dentition
Because Howe and coworkers’49 study was conducted using data from individuals in the
permanent dentition, it did not address the issue of the normal development of the dental arches.
This question was considered in a second study50 that examined the nature of normal changes in
maxillary and mandibular transpalatal width from the early mixed dentition to the permanent
dentition. Longitudinal changes in an untreated population from 7 to 15 years of age were
evaluated. The average increase in transpalatal width between the upper first molars was about 2.5
mm.49,50
One of the conclusions that can be drawn from the studies cited earlier concerning dental arch
development is that
by providing some mechanism of widening the bony bases and increasing arch width and perimeter,
more space can
be obtained for the alignment of the permanent dentition. Of course, the dental arches cannot be
expanded ad libitum
because of the physiologic limits of the associated hard and soft tissues. It seems reasonable,
however, to consider increasing arch size at a young age so that skeletal, dentoalveolar, and
muscular adaptations can occur before the eruption of the permanent dentition.
Orthopedic Expansion Protocols
Our appliance of choice for use in patients with mixed dentition is the bonded acrylic splint
expander (see Fig. 16-18).
This appliance, which incorporates a Hyrax-type screw into a framework made of wire and acrylic,
is used to separate the halves of the maxilla. It is widely recognized that maxillary expansion is
achieved easily in a growing individual, particularly in individuals with mixed dentition.51,52 The
acrylic-splint type of appliance that is made from 3-mm-thick, heat-formed Biocryl has the
additional advantage of acting as a bite block because of the thickness of the acrylic that covers the
occlusal surfaces of the posterior dentition. The posterior bite block effect of the bonded acrylic
splint expander prevents the extrusion of the posterior teeth,53 a movement often associated with
banded RME appliances,54 thus permitting the use of this type of expander in some patients with
steep mandibular planes. It also unlocks the occlusion, immediately aiding resolution of a functional
jaw shift into crossbite.
Maxillary Adaptations
The treatment protocol that involves the use of a bonded expander is illustrated by the following
example. The morphology of a patient in the mixed dentition with an idealized (e.g., 34 to 35 mm)
transpalatal width (Fig. 16-19) can be compared with a patient with a narrow (e.g., 29 mm)
transpalatal width (Fig. 16-20). A goal of the orthopedic treatment initiated in the mixed dentition is
to reduce the need for extractions in the permanent dentition through the elimination of arch-length
discrepancies as well as the elimination of bony base imbalances. In instances of restricted
transverse dimensions, a bonded RME appliance is placed. The screw of the expander is activated
one-quarter turn (90 degrees, 0.20 to 0.25 mm) per day until the lingual cusps of the upper posterior
teeth approximate the buccal cusps of the lower posterior teeth (Fig. 16-21). In contrast to Haas,47
who recommends full opening of the expansion screw to 10.5 to 11.0 mm (an action that can
produce a buccal crossbite), we advocate only as much expansion as is feasible while still
maintaining contact between the upper and lower posterior teeth.
After the active phase of expansion is completed, the appliance is left in place for an additional 5
months to allow for a reorganization of the midpalatal suture as well as other sutural systems
affected by the expansion and to maximize the effect of the posterior bite block. At the end of the
treatment time, the RME appliance is removed, and the patient is given a removable palatal plate to
sustain the achieved result (Fig. 16-22).
The active expansion of the two halves of the maxilla produces a midline diastema between the two
upper central incisors. During the period after the active expansion of the appliance, a mesial
tipping of the maxillary central and lateral incisors usually is observed. Such spontaneous tooth
movement is typical after RME, and this movement often is interpreted as being evidence of
“relapse” by the patient or the parents. The clinician should advise the family about the probability
of such spontaneous tooth migration. At 3 or 4 months after the initiation of RME treatment,
brackets often are placed on the upper incisors to close the midline diastema and align the anterior
teeth (Fig. 16-23). In limited instances, a utility arch is used to retract, intrude, or protract the upper
incisors, depending on the needs of the individual patient.
Mandibular Adaptations
In patients whose lower arch exhibits moderate crowding of the anterior teeth or in whom the
posterior teeth are tipped
lingually, two types of appliances can be used before RME: the removable Schwarz appliance and
the lip bumper. The use of these “decompensating” (i.e., expanding, uprighting) appliancesbegan as
a result of our initial experiences using the bonded RME appliances alone. We were able to produce
the expected changes in maxillary transverse dimensions with the bonded expander readily, but we
made no attempt to widen the lower dental arch actively. After evaluating RME in mixed dentition
patients over a 5-year period, we discovered that in some patients, a spontaneous uprighting and
“decrowding” of the lower teeth occurred, yet in others, there was no change in the position and
alignment of the lower teeth.
Because one of the cardinal rules of orthodontics was that one never should expand the lower arch,
we were reluctant to
do so. However, because expansion or uprighting was observed in the lower arch on a sporadic
basis using RME and because arch expansion was produced routinely by the FR-2 appliance of
Fränkel,42,55-57 we decided to attempt orthodontic expansion or uprighting of the lower dental
arch using either the removable Schwarz appliance or the lip bumper before orthopedic expansion
of the maxilla. We assumed that expansion of the lower arch would not be stable unless the
expansion was followed by maxillary orthopedic expansion.
Mandibular Dental Uprighting and Expansion
Appliances
The Schwarz Appliance
The Schwarz appliance is a horseshoe-shaped removable appliance that fits along the lingual border
of the mandibular dentition (Fig. 16-24). The inferior border of the appliance extends below the
gingival margin and contacts the lingual gingival tissue. A midline expansion screw is incorporated
into the acrylic, and ball clasps lie in the interproximal spaces between the deciduous and
permanent molars.
The lower Schwarz appliance is indicated in patients with mild to moderate crowding in the lower
anterior region and especially in instances in which there is significant lingual tipping of the
posterior dentition. The appliance is activated once per week, producing 0.20 to 0.25 mm of
expansion in the midline of the appliance. Usually the appliance is expanded for 4 to 5 months,
depending on the degree of incisal crowding, producing about 4 to 5 mm of arch length anteriorly.
Clinicians frequently have experienced difficulty understanding the reasoning underlying the use of
the Schwarz appliance before RME. The following example illustrates the logic for this treatment
decision. Figure 16-25, A, is a schematic of a bilateral posterior crossbite, a condition that clinically
is recognized easily and for which RME is a generally accepted treatment regimen. In this example,
the mandibular bony base and dental arch are of normal width, and there is normal posterior dental
angulation, whereas the maxilla is constricted.
The example shown in Figure 16-25, B, is from a patient who has maxillary constriction but in
whom also there has been mandibular dentoalveolar “compensation” (i.e., the positionsof the lower
teeth have been influenced by the size and shape of the narrow maxilla). No obvious crossbite is
present. Even though maxillary width is the same as in Figure 16-25, A, the lower posterior teeth
have erupted in a more lingual inclination.
The palate appears narrow (in this example, a transpalatal width of 29 mm), and the arches are
tapered in form. Mild to
moderate lower incisor crowding also is present (not shown). In such a patient, mandibular dental
“decompensation” using a removable lower Schwarz appliance often is undertaken. The width and
form of the mandibular dental arch are made more ideal before the time that RME is attempted. By
decompensating the mandibular dental arch, greater arch expansion of the maxilla can be achieved
than when RME is used alone.58,59
Simply stated, the purpose of the Schwarz appliance is to produce orthodontic tipping of the lower
posterior teeth, uprighting these teeth into a more normal inclination (Fig. 16-25, C). This
movement is unstable if no further treatment is provided to the patient. A tendency toward a
posterior crossbite is produced that is similar in many respects to the posterior crossbite shown in
Figure 16-25, A.
Usually the Schwarz appliance is left in place until the maxillary orthopedic expansion phase is
completed (Fig. 16-25, D). As described earlier, the maxilla is expanded using a bonded acrylic
splint appliance until the upper lingual cusps barely touch the lower buccal cusps. After a 5-month
period of RME stabilization, which allows adequate time for the midpalatal suture and the adjacent
sutural systems to reorganize and reossify, both appliances are removed, and the patient is given a
simple maxillary maintenance plate (Fig. 16-26), with no retention provided in the mandible. In
instances of severe anterior malalignment in either arch, fixed appliances may be placed on the
incisors to align these teeth, and interim lingual arch retention may be used.
Lip Bumper
The lip bumper (Fig. 16-27) is a removable appliance that also can be used for mandibular dental
decompensation.44,60 The lip bumper is particularly useful in patients who have very tight or tense
buccal and labial musculature. The lip bumper lies away from the dentition at the gingival margin
of the lower central incisors and shields the teeth from the forces of the adjacent soft tissue. The
appliance usually is worn on a full-time basis and may be ligated in place. This appliance not only
increases arch length through passive lateral and anterior expansion but also serves to upright the
lower molars distally, adding to the available arch-length increase. Patients with lip bumper therapy
must be monitored to avoid impacting the erupting second molars.
From a neuromuscular perspective, the lip bumper theoretically creates a more desirable treatment
effect than does the
Schwarz appliance. (The Schwarz appliance simply produces orthodontic tipping of the teeth
through direct force application to the dentition and alveolus.) On the other hand, the lip bumper
shields the soft tissue from the dentition, allowing for spontaneous arch expansion as is seen with
the Fränkel and other soft tissue shielding appliances. We tend to favor the use of the Schwarz
appliance over the lip bumper, however, in most instances because of the predictability of the
treatment outcome and the ease of clinical management. Only in patients with very constricted
(tense) soft tissue is the lip bumper the appliance of choice.
SPONTANEOUS IMPROVEMENT OF SAGITTAL
MALOCCLUSIONS
The major focus of this section of the chapter thus far has been the resolution of intraarch tooth-
size/arch-size discrepancy problems. Interestingly, there is another phenomenon that has been a
serendipitous finding—“spontaneous” improvement of mild Class II and Class III malocclusions
after RME.
Class II Patients
There are many patients in the mixed dentition who not only have intraarch problems but also have
a Class II malocclusion or a strong tendency toward a Class II malocclusion. Generally, these
patients do not have severe skeletal imbalances but rather may be characterized clinically as having
either slight mandibular skeletal retrusion or an orthognathic facial profile with minimal
neuromuscular imbalances.
According to the routine protocol described previously, these patients undergo RME with or
without prior mandibular
dental decompensation. At the time of expander removal, these patients will have a buccal crossbite
tendency, with only the lingual cusps of the upper posterior teeth contacting the buccal cusps of the
lower posterior teeth (Fig. 16-28, A). A maxillary maintenance plate typically is used to stabilize
this relationship. Several appointments later, some interesting observations are noted: the tendency
toward a buccal crossbite has disappeared (Fig. 16-28, B), and the patient now has a significant
improvement in molar relationship, sometimes the establishment of a solid Class I sagittal occlusal
relationship.
The orthodontist traditionally has viewed a Class II malocclusion as primarily a sagittal and vertical
problem. Our experience with the post-RME correction of the Class II problem indicates that many
Class II malocclusions also have a strong transverse component. The overexpansion of the maxilla,
which subsequently is stabilized through the use of a removable palatal plate, disrupts the occlusion.
It appears that the patient becomes more comfortable by positioning his or her lower jaw slightly
forward, thus eliminating the tendency toward a buccal crossbite and at the same time improving
the overall sagittal occlusal relationship. In many respects, the teeth themselves act as an
endogenous functional appliance, encouraging a change in mandibular posture and, ultimately, a
change in the maxillomandibular
occlusal relationship.
The correction of a Class II tendency patient is illustrated in Figure 16-29. Figure 16-29, A, shows
the sagittal view of the skeletal and dentoalveolar structures of a Class II tendency patient who has
excessive overjet and a narrow maxilla. The placement of a bonded maxillary expansion appliance
immediately
causes an increase in the vertical dimension of the face because of the posterior occlusal coverage.
This change is beneficial in most patients, in that the temporary increase in the vertical dimension
prevents extrusion of the posterior teeth during the expansion process.53 This treatment also may
result in an upward and slightly forward displacement (Fig. 16-29, B) of the maxilla. (This
phenomenon will be discussed subsequently in the discussion of the spontaneous improvement of
Class III malocclusion.) During the post-RME period, during which a removable palatal plate is
worn (Fig. 16-29, C), the mandible is postured forward by the patient because of the overexpansion
of the maxilla. Thus, the spontaneous improvement of patients with a tendency toward a Class II
malocclusion does not occur during the active expansion period but rather during the time that the
maintenance plate is being worn.
Because of the perceived importance of this issue, we have conducted two prospective clinical trials
investigating this
phenomenon. Guest and coworkers61 contrasted the treatment results of 50 Class II or end-to-end
patients treated with
a bonded expander to 50 matched untreated control participants (Fig. 16-30). The analysis of serial
cephalometric films
taken 4 years apart indicated that the bonded RME had its greatest effects at the occlusal level,
specifically producing
highly significant improvement of Class II molar relationship and a decrease in overjet. The Class II
molar relationship
remained virtually unchanged in the control group, but the RME group showed an improved molar
relationship of more
than 1 mm in more than 90% of the expansion patients and more than 2 mm in almost 50% (see Fig.
16-30). The second
study61 on a larger group of patients (500 RME patients from the McNamara private practice; 188
control participants)
revealed similar results.
Thus, this improvement in Class II relations occurs with such frequency that it can be included as
part of the overall
treatment plan. If the resulting occlusion remains Class II at the time of phase II treatment, then
definitive Class II corrective procedures can be initiated.
Class III Patients
The use of a bonded RME appliance also can lead to a spontaneous occlusal improvement in a
patient with a tendency
toward a Class III malocclusion. At first glance, this phenomenon seems paradoxical, given the
previous discussion concerning the spontaneous improvement of Class II tendency problems. The
mechanism of Class III correction, however, is distinctly different from that described previously.
An examination of Figure 16-29, B, provides some explanation for this phenomenon. The
placement of an acrylic splint
expander that opens the bite vertically 3 mm not only provides an intrusive force against the
maxilla,53 presumably because of the stretch of the masticatory musculature, but also may produce
a slight forward repositioning of the maxilla. A slight forward movement of the maxilla after RME
has been documented in both clinical62 and experimental63 studies. In addition, the placement of a
bonded expander with acrylic coverage of the occlusion helps eliminate a tendency toward a
pseudo–Class III malocclusion.
As with the Class II tendency patients described previously, patients in whom a borderline Class III
malocclusion exists usually have a reasonably balanced facial pattern, often with only a slight
tendency toward maxillary skeletal retrusion. Obviously, in patients in whom Class III malocclusion
persists after expansion, more aggressive types of therapies are indicated, as will be discussed later.
When contrasting the spontaneous improvement of both Class II and Class III tendency patients, it
must be emphasized
that any spontaneous improvement of a Class III malocclusion usually occurs (if it does occur)
during the active phase
of treatment (within the first 30 or 40 days). The spontaneous correction of Class II malocclusion
usually is noted during the retention phase, after the bonded expander has been removed and the
maintenance plate has been worn for 6 to 12 months. When planning the treatment for a Class III
tendency patient, FM hooks may be attached to the expansion appliance to facilitate the use of an
FM if that treatment is deemed necessary from the original plan or at a later time.