Original Article

Comparison of alveolar bone morphology after expansion with hybrid and

conventional Hyrax expanders
Ivan Silvaa; Felicia Mirandab; José Carlos da Cunha Bastosc; Daniela Garibd

ABSTRACT

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Objectives: To compare the buccal and palatal bone changes of maxillary posterior teeth pro-
duced by hybrid hyrax (HH) and conventional hyrax (CH) expanders in growing patients.
Material and Methods: A sample of 32 patients with posterior crossbites in the late mixed denti-
tion was recruited and randomly allocated into two groups. Group HH was composed of 18 individ-
uals with a mean age of 10.7 years (six female, 12 male) treated with a hybrid expander with two
anterior parasagittal miniscrews. Group CH was composed of 14 individuals with a mean age of
11.4 years (six female, eight male) treated with a conventional Hyrax expander. Cone-beam com-
puted tomography (CBCT) exams were obtained before expansion (T1) and after 11 months when
the expander was removed (T2). Buccal and palatal bone plate thickness and height of maxillary
posterior teeth were measured. Intergroup comparisons were performed using t or Mann-Whitney
tests (P , .05).
Results: The CH group showed greater decreases of the buccal bone plate height (mean change:
1.27 mm) at the maxillary first premolars compared to the HH group (mean change: 0.11 mm, P ¼
.001). No intergroup difference was found for changes in the buccal and palatal bone thickness.
Conclusions: Hybrid expanders showed a tendency to cause less negative impact on the buccal
bone plate height of first premolars compared to conventional Hyrax expanders. However, the differ-
ence was not clinically significant. Both hybrid and conventional Hyrax expanders are safe for the
alveolar bone morphology in the late mixed dentition. (Angle Orthod. 2024;94:414–420.)
KEY WORDS: Orthodontics; Palatal expansion technique; Imaging; Three-dimensional

INTRODUCTION appliance commonly used for RME.2 The Hyrax

expander concentrates the forces on the anchoring
Rapid maxillary expansion (RME) is an orthopedic pro-
teeth, causing orthopedic and dentoalveolar effects.2
cedure frequently performed during orthodontic treatment.
Buccal tip of maxillary posterior teeth can cause negative
RME is indicated to treat maxillary constriction in growing
periodontal effects including buccal bone dehiscence
patients, improving the transverse interarch relationship.1
and a decrease in the buccal bone plate thickness.3,4
The conventional Hyrax expander is a tooth-borne
Anchorage teeth are more prone to develop gingival
recession in the long term.4
a
Previous studies compared RME dentoskeletal and
PhD Student, Department of Orthodontics, Bauru Dental
periodontal effects between conventional Hyrax and
School, University of São Paulo, Bauru, Brazil.
b
Postdoctoral Fellow, Department of Orthodontics, Bauru Haas-type expanders using computed tomography
Dental School, University of São Paulo, Bauru, Brazil. images.5,6 Garib et al. demonstrated that both expand-
c
Maxillofacial Surgeon, Hospital for Rehabilitation of Craniofacial ers produced similar orthopedic effects.5,6 However,
Anomalies, University of São Paulo, Bauru, Brazil. conventional Hyrax expanders caused a greater reduc-
d
Professor, Department of Orthodontics, Bauru Dental School, tion of the buccal alveolar bone plate height of support-
Hospital for Rehabilitation of Craniofacial Anomalies, University of
ing teeth.5 The maxillary first premolars were affected by
São Paulo, Bauru, Brazil.
Corresponding author: Dr Ivan Silva, Department of more extensive buccal bone dehiscence than maxillary
Orthodontics, Bauru Dental School, University of São Paulo, first molars.5 Brunetto et al. associated the Haas-type
Alameda Octávio Pinheiro Brisolla 9-75, Bauru 17012-901, Brazil expanders to loss and reduction of height and thickness
(e-mail: ivandesouzaodonto@gmail.com) of maxillary first molar alveolar bone.7 In contrast,
Accepted: February 2024. Submitted: September 2023. Rinaldi et al. demonstrated that the Hyrax expanders led
Published Online: March 11, 2024 to dehiscence, fenestration, and exposure of the root at
Ó 2024 by The EH Angle Education and Research Foundation, Inc. the buccal aspect of maxillary first molars.8

Angle Orthodontist, Vol 94, No 4, 2024 414 DOI: 10.2319/092623-650.1

ALVEOLAR BONE MORPHOLOGY AFTER HH AND CH EXPANSION 415

RME with skeletal anchorage was first described in and III malocclusion; (4) need for RME either because of
2008 with the aim of preventing periodontal side posterior crossbite or in association with orthopedic max-
effects to posterior teeth.9 Wilmes et al.10 were the illary protraction. The exclusion criteria were: (1) patients
first to use orthodontic miniscrews as RME anchorage with a history of previous orthodontic treatment;
in growing patients. The hybrid Hyrax expander had (2) patients with systemic or neurological condi-
two parasagittal miniscrews in the anterior region of tions; (3) patients with cleft lip, cleft palate, and/or
the palate as an anchoring unit. In addition to achiev- other craniofacial anomalies.
ing favorable expansion in the region of premolars and
molars, these same teeth showed an increase in their Interventions
buccal inclinations as an effect of the therapy.10 The sample was allocated into two different groups.
A recent randomized clinical trial comparing hybrid

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HH group was composed of 18 patients (12 male, six
and conventional Hyrax expanders in growing patients female) with a mean age of 10.7 years treated with a
showed greater increases in the nasal cavity width, HH maxillary expander with two anterior miniscrews.
maxillary width, and buccal alveolar crest width for the CH group was composed of 14 patients (eight male, six
hybrid Hyrax expander.11 A previous study compared female) with a mean age of 11.4 years treated with a
the periodontal effects produced by conventional Hyrax CH maxillary expander (tooth-supported anchorage).
and hybrid expanders in growing patients. The hybrid In HH group, a premanufactured hybrid expander
Hyrax expander did not cause changes in the buccal (PecLab Ltda., Belo Horizonte, MG, Brazil) was anchored
bone plate thickness of the maxillary first premolars.12 on bands cemented to the maxillary first permanent
However, there was no standardization in the amount molars. Two miniscrews were placed in the anterior
of screw activation performed between groups.12 region of the palate at a parasutural position. The minis-
No previous study has evaluated changes in the crews of 1.8 mm diameter, 7 mm length, and 4 mm trans-
bone plate height after expansion with the hybrid Hyrax mucosal length were installed in the slots after placement
appliance. There is an assumption that the hybrid of the expander (Figure 1). In CH group, bands were
expander could prevent buccal bone dehiscence on the placed on the maxillary first molars (Figure 1).
anchorage teeth of adolescent patients. This informa- In both groups, the expander screw was activated
tion would better inform clinicians regarding the type of one-quarter turn twice a day for 14 days, achieving
expander to be chosen for adolescents, especially for 5.6 mm expansion. At the end of the active expansion
those patients exhibiting a thin periodontal biotype. period, the expander was maintained as a retainer for
11 months until maxillary protraction therapy was per-
Objective formed for a previous study.13 None of the 18 participants
The aim of this study was to compare buccal and pal- in the HH group analyzed in this study demonstrated
atal bone changes of maxillary teeth produced by the miniscrew instability. Patients and their parents received
Hybrid (HH) and Conventional Hyrax (CH) expanders in guidance on maintaining an appropriate level of oral
hygiene throughout the treatment period. Perimplant
growing patients. The hypothesis was that both expand-
chlorhexidine gel (2%) was prescribed twice a day during
ers would show similar impact on the alveolar bone mor-
active treatment. One patient from HH group showed
phology after treatment.
periimplantitis during the expansion retention phase and
the use of chlorhexidine was increased.
MATERIALS AND METHODS
Cone-beam computed tomography (CBCT) was per-
Trial Design and Settings formed with the i-CAT 3D system (Imaging Sciences
This was a secondary data analysis from a ran- International, Hatfield, Pa) before (T1) and after
domized clinical trial (RCT).13 The primary clinical 11 months when the expander was removed (T2). The
trial was registered under the number NCT03712007 protocol of 120 kVp, 8 mA, 0.25-mm voxel size, scan
at Clinicaltrials.gov. The study was approved by the Eth- time of 27 seconds and a field of view of 13 cm in height
ics in Research Committee of Bauru Dental School, Uni- and 16 cm in depth was used. Patients were positioned
versity of São Paulo, Brazil (CA: 48292721.9.0000.5417). in the device with a standardized head position, main-
This study was carried out at the Orthodontic clinic taining the Frankfurt plane parallel to the ground and the
sagittal plane perpendicular to the ground.
of the Bauru Dental School, University of São Paulo. A
sample of 32 patients aged between 9 and 13 years of
Outcomes
age with maxillary constriction was recruited and ran-
domly allocated into two study groups with a 1:1 ratio. The primary outcomes were evaluated in a previous
The inclusion criteria were: (1) patients of both sexes; study.13 The outcomes of this secondary data analysis
(2) late mixed or early permanent dentition; (3) Class I from the RCT were the thickness and height of the

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416 SILVA, MIRANDA, BASTOS, GARIB

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Figure 1. (A) Hybrid Hyrax. (B) Conventional Hyrax.

buccal and palatal alveolar bone plates measured on 0.63 mm in first premolar buccal bone plate height,15 a
CBCT scans. minimum sample of eight patients was required for
Measurements were performed using NemoScan each group.
software by Nemotec (Nemostudio Nx Pro, version
8.8, 2 uv 8, Madrid, Spain). Before measurements Randomization
were made, the head position was standardized in
Randomization was performed electronically using the
three planes of space using the multiplanar recon-
randomizarion.com website. Random block sizes were
struction screen. A bispinal line in the axial and sagittal
used. The allocation was performed using sequentially
planes was positioned perpendicular and parallel to
numbered, opaque, and sealed envelopes. The randomi-
the horizontal plane, respectively. In the coronal sec-
zation list generation, allocation concealment, and imple-
tion, the infraorbital line was positioned parallel to the
mentation process were performed by different operators.
horizontal plane.14
An axial section passing through the right maxillary
Blinding
first permanent molar trifurcation was used to evaluate
the thickness of the buccal and palatal bone plates of No blinding was accomplished considering operator
maxillary posterior teeth (Figure 2A). Parasagittal sec- and patient were aware of the type of treatment per-
tions passing through the center of the roots of poste- formed. The CBCT scans were de-identified during
rior teeth in the axial section were used to measure the assessment to ensure blinding during measure-
the buccal and palatal bone plate heights of maxillary ment and data analysis.
posterior teeth (Figure 2B). For the first molar, three
parasagittal slices were generated passing through Statistical Analysis
the center of the mesiobuccal, distobuccal, and palatal After 1 month, 30% of the sample was randomly
roots. In each parasagittal section, the height from selected and remeasured by the same examiner. The
buccal and palatal bone plates to the cusp tip of the reliability of repeated measures was assessed by the
corresponding side was measured. intraclass correlation coefficient (ICC) and Bland-Altman
(B-A) limit of agreement.
Sample Size Calculation
Shapiro-Wilk test was used to verify normal distribu-
Sample size was calculated to provide a test power tion. Intergroup comparison of the interphase changes
of 80% and a significance level of 0.05. For an inter- was performed using t or Mann-Whitney U-test, depend-
group difference of 1 mm and a standard deviation of ing on the data normality. The analyses were performed

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ALVEOLAR BONE MORPHOLOGY AFTER HH AND CH EXPANSION 417

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Figure 2. Variables measured on the CBCT images. (A) Buccal and palatal bone thickness were measured in an axial section passing
through the trifurcation of the maxillary right first molar. BBPT indicates buccal bone plate thickness; PBPT, palatal bone plate thickness.
(B) Buccal and palatal bone plate heights were measured in a cross-section passing through the center of maxillary premolars and the first
molar. BBPH indicates buccal bone plate height; PBPH, palatal bone plate height.

using Jamovi software (The Jamovi project Version 2.3, group and three patients in the CH group) were not
2022). A significance level of 5% was regarded. considered in the analysis.
Good to excellent reproducibility of repeated measure-
ments was found for all variables, with ICC varying from
RESULTS
0.757 (second premolar bone plate palatal thickness) to
The final sample of the HH group comprised 18 0.964 (first premolar bone plate buccal thickness). The
patients (six female and 12 male) with a mean initial variable with the greatest limits of agreement was the
age of 10.8 years (SD ¼ 1.04). The mean treatment mesiobuccal bone plate height of first molars (1.46
time for the HH group was 11.3 months. The sample and 2.09). The variable with the smallest limits of agree-
of the CH group comprised 14 patients (six female ment was the buccal bone plate height of first premolars
and nine male) with a mean initial age of 11.4 years (0.44 and 0.34).
(SD ¼ 3.98). The mean treatment time was 11 Similar characteristics regarding sex, initial age, and
months. Group HH was composed of 5% of Class I treatment time were found for both groups (Table 1).
patients and 95% of Class III patients. Group CH had Both groups were compatible before treatment (T1)
14% Class I patients and 86% Class III patients. regarding all variables (Table 2). All patients in both
According to a previous classification by Angelieri groups demonstrated a midpalatal suture split and
et al.,16 61% of patients in the HH group were at pala- posterior crossbite correction.11
tal suture maturational stage B, 22% were at matura- The buccal bone plate thickness of posterior teeth
tional stage A, and 17% were at maturational stage C. decreased after expansion similarly in both groups
In CH group, 72% were at palatal suture maturational
Table 1. Baseline Characteristics of Groups and Treatment Timesa
stage B, 14% were at maturational stage A, and 14%
were at maturational stage C. Group HH had 55% of Variable Group HH Group CH P Value
patients in the early permanent dentition and 45% in Sex, n .928b
the late mixed dentition. Group CH had 50% of Male 10 8
Female 8 6
patients in the early permanent dentition and 50% in Total, n 18 14
the late mixed dentition. All patients in the mixed denti- Mean age, y (SD) 10.80 (1.04) 11.44 (1.26) .102
tion had complete eruption of the maxillary first premo- Treatment time, mo (SD) 11.38 (3.98) 11.00 (3.78) .782
lars. Measurements for second premolars that were a
CH indicates conventional hyrax; HH, hybrid hyrax.
b
not erupted or fully erupted (four patients in the HH Chi-square test (sex); t-test (age and treatment time).

Angle Orthodontist, Vol 94, No 4, 2024

418 SILVA, MIRANDA, BASTOS, GARIB

Table 2. Intergroup Comparisons at T1 Before Expansion (t-Test and Mann-Whitney U-Test)a

Group HH Group CH 95% CI
Variable Mean (SD) Mean (SD) Lower, Upper P Value
Bone plate thickness (BPT)
First premolars B 1.25 (1.03) 1.08 (0.39) 0.26, 0.29 1.000
P 3.22 (1.22) 3.37 (1.65) 0.90, 1.20 .774
Second premolars B 2.17 (0.98) 2.12 (0.77) 0.70, 0.60 .888
P 3.23 (1.13) 3.65 (1.07) 0.38, 1.23 .290
First molars MB 1.90 (0.93) 1.81 (0.88) 0.75, 0.57 .778
DB 2.79 (0.79) 2.66 (0.85) 0.66, 0.53 .690
P 2.55 (0.55) 2.42 (0.76) 0.64, 0.19 .296
Bone plate height (BPH)

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First premolars B 9.76 (0.86) 9.02 (1.26) 1.51, 0.03 0.059
P 7.99 (0.84) 7.58 (1.68) 0.76, 0.41 0.837
Second premolars B 8.80 (0.88) 8.06 (1.03) 0.11, 1.59 0.087
P 8.62 (0.73) 8.32 (0.77) 0.37, 0.96 0.368
First molars MB 7.90 (0.63) 7.68 (0.80) 0.74, 0.29 0.384
DB 7.98 (0.51) 7.61 (0.67) 1.79, 0.06 0.090
P 8.44 (1.10) 8.52 (0.85) 0.65, 0.80 0.830
a
Statistically significant at P , .05, t-test; B indicates buccal aspect; DB, distal buccal root; MB, mesialbuccal root; P, palatal root/palatal aspect.

(Table 3). The palatal bone plate thickness of posterior including the alveolar bone crest level, with high sensi-
teeth slightly increased in most regions, with no inter- tivity.15 The CBCT protocol was chosen based on the
group differences. lowest possible radiation dose while offering sufficient
The conventional Hyrax expander produced a sharpness for identification of the bone structures to
greater reduction in the buccal bone plate height of be evaluated, following the ALARA (as low as reason-
maxillary first premolars compared to hybrid expand- ably achievable) principle. The assessment of the
ers (Table 3). No intergroup difference was found for alveolar bone morphology through CBCT scans per-
changes in the buccal bone plate height of maxillary mitted the analysis of RME consequences on anchor-
second premolars and first molars (Table 3). The pala- ing teeth. Previous studies recommended a smaller
tal bone plate height remained stable after expansion voxel size to evaluate delicate structures such as buc-
with no difference between groups (Table 3). cal bone plate.17,18 The voxel size in this study was
0.25 mm and the images had high definition and
sharpness. When the alveolar bone thickness is thinner
DISCUSSION
than the voxel size, the bone-height measurements are
The use of CBCT allowed the visualization and likely to be overestimated.19 For this reason, results
quantification of buccal and lingual bone structures, should be considered with caution in regions with a

Table 3. Intergroup Treatment Change Comparisons (t-test and Mann-Whitney U-Test)

Group HH Group CH Mean 95% CI
Variable Mean (SD) Mean (SD) difference Lower, Upper P Value
Bone plate thickness (BPT)
First premolars B 0.14 (0.41) 0.08 (0.51) 0.06 0.28, 0.41 .716
P 0.13 (1.21) 0.50 (1.02) 0.63 0.20, 1.48 .134
Second premolars B 0.20 (0.65) 0.17 (0.56) 0.25 0.20, 0.89 .224
P 0.24 (1.46) 0.27 (1.12) 0.06 0.84, 0.94 .822
First molars MB 0.18 (0.50) 0.47 (0.51) 0.30 0.69, 0.12 .193
DB 0.33 (0.55) 0.56 (0.51) 0.17 0.58, 0.21 .498
P 0.73 (0.70) 0.40 (0.27) 0.33 0.74, 0.07 .108
Bone plate height (BPH)
First premolars B 0.11 (0.66) 1.27 (1.12) 1.15 0.49, 1.82 .001*
P 0.25 (1.15) 0.21 (1.32) 0.24 0.61, 1.05 .597
Second premolars B 0.02 (0.63) 0.69 (0.84) 0.51 1.09, 0.01 .056
P 0.40 (1.13) 0.02 (0.86) 0.02 0.76, 0.48 .949
First molars MB 1.14 (1.44) 0.74 (1.46) 0.40 1.47, 0.66 .447
DB 0.64 (0.66) 0.32 (0.61) 0.32 0.79, 0.14 .173
P 0.02 (1.00) 0.10 (0.94) 0.07 0.79, 0.64 .829
* Statistically significant at P ,.05, t-test; B indicates buccal aspect; DB, distal buccal root; MB, mesial buccal root; P, palatal root/palatal aspect.

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ALVEOLAR BONE MORPHOLOGY AFTER HH AND CH EXPANSION 419

very thin alveolar bone plate. Adequate reproducibility to HH group. The error analysis showed that this mea-
was found for all variables in agreement with a previous surement was precise and reliable, exhibiting the
study that reported excellent intraexaminer reproduc- smallest limits of agreement. No previous study evalu-
ibility of the bone morphology assessment in CBCT.19 ated buccal bone dehiscence formation using hybrid
In this study, CBCT images were clinically used for expanders. Since the hybrid expander was anchored
planning miniscrew installation at T1 and planning com- on anterior palatal miniscrews, the forces delivered to
prehensive orthodontic treatment at T2. the first premolars were decreased. Consequently,
The HH used in this research has a design modifica- there was decreased buccal tipping of maxillary first
tion compared to that described by Wilmes.10 Palatal premolars and a smaller buccal bone height change
extensions and buccal c-clasps were added to all occurred. However, the mean change in buccal bone
appliances for both groups, making their design com- height was small (1 mm) and not clinically relevant. In

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patible and comparable. The palatal extensions were other words, both CH and HH expanders can be used
made so that, during the activation phase, the premo- in the late mixed dentition. At later ages of adoles-
lars could follow the expansion movement, simplifying cence (15 to 18 years), the impact of use of a hybrid
the subsequent phase of the orthodontic treatment. expander on buccal bone height of first premolars
The buccal c-clasps were added to increase the resis- might be more relevant.
tance of the appliance. Future studies should evaluate the periodontal out-
The hybrid expanders share the expansion load come of hybrid expander use in late adolescence to
between posterior teeth and palatal miniscrews.11
understand the ideal type of expander indicated for
Regarding the skeletal effects, previous prospective
use during the later stages of the adolescent growth
and retrospective studies have not found differences
spurt, when the orthopedic effects of expansion appli-
between hybrid and conventional expanders.12,20 On
ances may become more limited.
the other hand, two randomized clinical trials demon-
strated a greater increase of the nasal cavity and max-
CONCLUSIONS
illary width with hybrid expanders.11,21 Regarding the
dental effects, previous studies reported less buccal
• Hybrid expanders showed a tendency to produce a
tipping of first premolars with hybrid expanders.12,21
Considering that the HH expander might produce an lesser decrease of buccal alveolar bone height of
increased skeletal effect and more limited dental side first premolars compared to conventional expanders.
effects compared to conventional Hyrax expanders, it However, the difference was not clinically significant.
• Clinically, HH and CH expanders are safe, consider-
is logical to speculate that the impact on the buccal
and palatal bone plates would be different between ing their effects on alveolar bone morphology in the
the two expanders. late mixed dentition.
HH and CH expanders produced a similar reduction in
the buccal bone plate thickness of posterior teeth. These ACKNOWLEDGMENTS
findings were in disagreement with previous studies, This study was financed in part by the Coordenação de
since a smaller decrease of the buccal bone thickness of Aperfeiçoamento de Pessoal de Nível Superior - Brasil
maxillary first premolars with the HH expander was (CAPES) - Finance Code 001.
found.12,20 The possible explanation are differences in
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Angle Orthodontist, Vol 94, No 4, 2024