RAPID MAXILLARY EXPANSION

Introduction:

Expansion is a space gaining procedure in orthodontics. It was in early 1940’s

that expansion of dental arches as a means of eliminating irregularities was recognized
by orthodontists.
In class I malocclusions, it was possible to eliminate the irregularities but
the teeth were moved into abnormal stress positions and into muscle forces. However
in class I malocclusion where there is tooth size and basal arch discrepancy between
the amount of tooth material and the available basal bone and where the patients
already has normal muscle activity, the movement of teeth away from basal bone into
functional forces is not likely to produce a stable orthodontic results.
Therefore the limitation of expansion techniques in the treatment of class I
malocclusions must be recognized.
In class II malocclusions, expansion is still a valid treatment objective,
because of concomitant change in muscle function and jaw relation ship and indeed
restoration of normal function is a prime treatment objective.
A great number of class II div. 1 cases exhibit a constricted upper arch which
needs expansion if co-ordination in class I relationship is to be achieved.
That transverse descrepancies in the dental arch must be resolved prior to
corrective anteroposterior mechanics.
Expansions can be done by two ways :
1. Slow expansion with the help of expansion appliances with expansion screws.
2. Rapid expansion.

RME or Palatal expansion, occupies a unique niche in dentofacial therapy.

A belief in the orthodontic principles that :

1) All expansion is fated to relapse.

2) That, changes in basal bone cannot be influenced by orthodontic treatment, has
found restrain acceptance among some orthodontists.

This may be true, when tooth is moved by light forces using conventional therapy BUT
UNDER HEAVY FORCES USED IN RME or distinctly different form of movement is
accomplished.
 Many orthodontists restrict their observations of lateral expansion to linear
increments in dental arch width, which is also to the detriment (harm) of RME.
A more meaningful picture emerges if other dimensions are included to realize
the full maxillary spatial changes.
A lateral force is a reshaping force and the morphological reaction of dental & maxillary
elements to this input thrust is regulated by certain mechanisms.
The more important mechanisms are demonstrated by their resultant patterns.
(eg.) VIZ
1) RATE OF EXPANSION
2) FORM OF APPLIANCE
3) AGE OF PATIENT
Rate of Expansion:

 Most important factor in expansion & key to RME

 By expanding at rates of 0.3 to 0.5mm / day active expansion is completed in 2-4
weeks, leaving little time for the cellular response of osteoclasts & osteoblasts seen
in slow expansion.
 In RME the Maxillary dental arch is widened by tilting the teeth buccally and partly
by moving the maxillae apart, opening the midpalatal suture.
 In complete palatal clefts, the cleft itself is opened in the absence of the suture.
 Forces employed is heavy compare to slow expansion.
 THE EFFECT OF EXPANSION OF THE DENTAL ARCH ON THE MAXILLARY
BASES INCREASES AS THE RATE OF EXPANSION IS INCREASED.

FORM OF THE APPLIANCE:

As the thrust is delivered to the teeth at the inferior free borders of the maxillae,
EXPANSION MUST REACH TO THE BASAL PORTIONS.
The form of the appliance will play an important role in this effort, according to its
Rigidity or flexibility in Anchorage or Control of dipping.
Even different forms of appliance in slow expansion will effect the basal width
slightly by stimulating (or not) growth at midpalatine suture)
THE EFFECT OF EXPANSION OF THE DENTAL ARCHON THE MAXILLARY
BASES INCREASES AS THE RIGIDITY OF APPLIANCE (ANCHORAGE) IS
INCREASED.

AGE OF THE PATIENT:

The increasing rigidity of facial skeleton with advancing age restricts bony
movements. Except during pre-pubertal and pubertal spurt.
THE EFFECT OF EXPANSION OF THE DENTAL ARCH ON THE MAXILLARY
BASES DIMINISHES AS AGE ADVANCES.
A natural consequence of RME IS THE DILATION OF NASAL AIR PASSAGES,
thereby creating an increase in available airflow.
Eg: Anterior nasal stenosis patients.
 In some cases respiration may be the only reason for carrying out RME.
 Patient should be viewed from both medical & dental standpoints.

HISTORICAL BACKGROUND:

The Narrow maxilla has been recognised for thousands of years & Hippocrates
referred to it, but for obvious scientific reason, no effective treatment was possible until
recently.

 EMERSON.C.ANGELL in 1860, placed a screw appliance b/n maxillary premolars

for a girl aged 14 ½ years and widened the arch ¼” in 2 weeks. Patient was
provided with and asked to keep the shaft uniformly tight as possible.
By end of 2 weeks, jaw was widened leaving space between 2 central incisors
indicating maxillary bone have been separated.
It was the first time that a double jackscrew with opposing screw has been
described and used in orthodontics. (A landmark in dental science)

 In 1893, Professor Clarke.L.Goddard used an appliance with bands and a jackscrew

and claimed that maxillary separation had been collaborated by other professionals
including anatomists.

 Many E.N.T Surgeons who were concerned about effects of mouth breathing, felt
expansion as a means of relief of anterior nasal obstruction, as this method would
improve the nasal airflow by increased maxillary width.

 E.H.Angle (1910), V.H.Jackson (1904,1909) and A.H.Kitcham (1912) stood for

SLOW EXPANSION, which well known orthodontists such as, C.H.Hawley (1912),
H.A.Pubbon (1912) and M.Dewey (1913, 1914) opted for R.M.E.
(They were unsure of extent of the opening of the suture or the general effect)

 Angle was firm believer in the functional concept, the master of a technique which
left little or no scope for RME and was most influential in propagating his philosophy.

 In Europe, Germany was in forefront of orthodontics. The first work on RME was
published by R. Landsberger in 1908 and later paper (1909) appeared what was
probably the FIRST RADIOGRAPHIC PICTURE OF AN OPENED MID PALATAL
SUTURE.
ANATOMY

A) GENERAL Bones
Sutures

B) CHANGES WITH RME Bones

Sutures
Dental changes

A) GENERAL:

1) BONES:

Maxilla forms most of floor and lateral walls of the nasal cavity.
Articulating with maxilla are the following bones.

a) Cranial
 Frontal
 Ethmoid

b) Facial
 Nasal
 Lacrimal
 Inferior nasal concha
 Vomer
 Zygomatic
 Palatine
 Opposite maxilla.

Most of these bones bind the maxillae posteriorly and superiorly by sutural joints,
leaving the anterior and inferior aspects free.

 The Paired maxillae unite with a sutural joint at their palatine and alveolar
processes.
 The palatine bones have an intimate anatomical relationship with the maxillae, as
together they complete the hard palate or floor of nose and a greater part of lateral
walls of nasal cavity. Its articulation anteriorly with maxilla is by an extensive suture
along the palate (transverse) and up the lateral wall of the nasal cavity.

Posteriorly the articulation is with the pterygoid processes of the

sphenoid bone.

 The maxilla is in an exposed position, being supported at only part of its

circumference and is vulnerable to lateral displacement especially the anterior and
inferior portions, once the midpalatal sutures has been ruptured. Bilateral
displacement is therefore relatively easy as the required action is reciprocal and the
 teeth being deeply rooted in the alveolar processes of the maxilla, provides
convenient sites for the application of force.

2) SUTURES:

Since midpalatal suture plays a key role in RME, it should be examined in minute
detail if we are to understand what is happening and maintain full clinical control of the
operation.

Melsen (1975) had traced its development from birth to adulthood by histologic means
on material from human cadavers.

In Infancy, the suture in vertical coronal

section has a Y-shape and binds the vomer
and palatine processes.

In juvenile period, the junction between

three bones becomes higher and assumes
more of a ‘Y’ shape with interpalatal
section taking a serpentine course.

By adolescence, the oronasal course of the

suture may become so interdigitated that
mechanical interlocking as in a jigsaw
puzzle and islets of bone are formed.

Melsen stresses that this later development characteristic is unique to humane (animal
experimentation are invalid)

Histologic studies by Persson on timing and rates of ossification indicates (1977)

1) Earliest closure was in a girl aged 15 years while the oldest unossified suture was in
a women aged 27 years (indicate range of variation)
2) In general bony spiculus appear between age 15 years and 19 years (0.9% of
suture length) but these early bridges may be removed by osteoclasts to suit
physiologic requirements.
3) A greater degree of obliteration occurs posteriorly than anteriorly.
4) On average, 5% of the suture is closed by age 25 years.
(If this is accepted, 5% of sutural closure together with the mechanical interlocking
can be broken without surgical assistance, then the average age of 25 years may
be used only as a general guide)

 The timing of synostosis of circummaxillary sutures has not yet been established
satisfactorily, but as its rupture is unessential this is not important.
 Under some pathological conditions, the sequence and timing of synostosis is
abberant.
 Eg: vitamin D deficiency may disturb calcification.
B) CHANGES WITH RME

1) BONES:
In reaction to the application of an appropriate reciprocal force to the teeth laterally
across the palate, the maxillae will move apart with the BREAKDOWN OF
MIDPALATINE SUTURE.

As the maxillae articulates superiorly and posteriorly, the general movement may be
likened to the opening of a fan, the most anterior and inferior points moving the greatest
distance with a fulcrum somewhere within the nasal airway (evident on Radiograph
from frontal or occlusal aspect)

 Although the force is not applied directly to the palatine bones, as they are not tooth
bearing, it would appear that they do move with the maxillae and thus maintain their
anatomical contiguity. This means that the INTERPALATINE SUTURE or
POSTERIOR PORTION OF MIDPALATAL SUTURE IS OPENED.

 Pterygoid processes of the sphenoid bone which articulate with the posterior of the
palatine bones are also splayed slightly. (measured by increase in width between
pterygoid hamuli i.e. ½ of increase in intermolar arch width.
 Soon after the commencement of expansion, the effect is translated to the maxillae
proper and the midpalatal suture begin to open, earlier in juvenile ( 1- 2 days) and
later in adults ( 3 – 4 days). After one week, with the dental arch width increased by
2 – 3 mm, the suture may be open 50% of this.

 Examination of the skull in its lateral aspect has shown some interesting changes
with RME.
 There is slight downward and forward movement of the maxillae (Wertz 1977)
 In 1970 Haas showed an increase in opening of pterygo maxillary fissure.
 Many of the bony changes brought about by the RME are of a transformative nature
and are effected to a certain extent by bending of the bone. Under these conditions
the spatial changes accomplished will depend on type of appliance used.

A rigid appliance will exert a parallel

opening and produce expansion at a
greater distance from the appliance than
one which is flexible and produces
expansion mainly by lateral inclination.

2) SUTURES: [Changes in Sutures]

There will be initial period of hypermia, there is osteoblast activity with new bone
appearing at the ends of the palatal processes and along the fibre bundles. This
type of response is common when osteogenic fibers come under tension and occurs
 in both animals and humans.
Melsens’ (1972) report suggests that, human biopsy material showed similarity
with animals up to a certain age (up to period of maximal pubertal growth)

Patients above this age showed bone islands, areas of resorption with
osteoclastic activity. This increased complexity in man is attributed to the
excessively serpentine course of suture attained by adolescence and multiple
microfractures are required before the palatal processes can be separated.

 Healing followed RME in older age group may result in bony bridges between the
maxillae and the soft tissue portion is much narrower. Time scale for healing is
within 2 –3 months.
Radiographic examination indicate a general mineralization.

3) DENTAL CHANGES:

The force of expansion is applied to the teeth in the first place and these will
move laterally apart with their respective maxillae.

 Since the movement is basically rotational, the teeth will gradually increase their
buccal inclination to a degree conditioned by the rigidity of the appliance and there
will be component of force along the axis of the teeth resulting in a slight extrusion.
 With opening of midpalatal suture a midline diastema is seen within few days and
will continue to increase until expansion is completed.
 If central incisors are not included in the appliance, they return to position occupied
before expansion by recoil of stretched transseptal fibers.

EXPECTED PHENOMENA DURING RME:

(AJO 1975 : 57/3) : 219-55)

1. Anteroposteriorly, the opening of midpalatal suture is parallel, inferosuperiorly the

opening is triangular with apex in nasal cavity.
2. The alveolar process bend and more laterally with the maxillae, while the palatal
processes swing inferiorly at their free margins. The effect is dental arch expansion
and increase in intranasal capacity.
3. The central incisors react as expected. As the sutures open the crowns coverage
and the roots diverge due to pull of transseptal fibers when the crowns come into
contact the continued pull of the filers causes the roots to converge toward their
original axial inclination. This cycle takes nearly 4 months.
4. When midpalatal suture opens, the MAXILLA ALWAYS MOVES FORWARD AND
 DOWNWARD (Probably due to disposition of maxillocranial sutures)
5. The change in maxillary posture invariably causes a downward and backward
rotation of mandible, which decreases the effective length of mandible and
increases the vertical dimension of the lower face.
There fore OPEN BITE CASES ARE ADVERSELY AFFECTED BY MAXILLARY
EXPANSION.

The reaction of MANDIBULAR TEETH was studied by ANDREW J. HAAS (AJO

1961 : 31(2) : 73-89)

In the study it was found that mandibular teeth tended to follow the maxillary
teeth by increased buccal inclination.
The significant increase of buccal tilt was probably due to a combination of
several factors. The forces of occlusion were altered by the expansion so that the
normal lingual vector of force on the mandibular buccal teeth was lost and the lateral
movement of the maxillae widened the area of attachment of the buccal musculature.
This resulted in a change of balance between the tongue and buccal musculature.
As Brodie observed. “The interaction of forces of these two antagonistic muscle
masses would dictate the size and form of the arches as well as axial inclination of the
teeth”.
A diminishing influence of the buccal musculature would permit the tongue to
exert a relatively greater force from within , manifesting itself in an increased buccal
axial inclination of the mandibular teeth as well as an expansion of the arch.
There is also the possibility that the thickness of the appliance, which was up to
three-fourth of an inch caused a downward displacement of the tongue during rest as
well as occlusion, thus increasing its lateral force on the mandibular buccal teeth.

The expansion procedure carries the attachment of the buccinator muscles laterally to
a position where its crushing force on the mandibular teeth is diminished.
THE APPLIANCE:

A) DESIGN:

An objective approach to the design of a suitable appliance should be made by

preparing a list of criteria based on biomechanical requirements of RME.
List of criteria include,

i) RIGIDITY (Resistance to rotation)

 Is given the top priority, as RME is most likely to be applied to the permanent
dentition, where there is considerate resistance to maxillary separation.
 Resistance is found in area where expansion is required (Basal portion of maxillae),
yet the force is applied remotely to teeth at the free lower border.
 Nearly parallel opening by a rigid appliance is required or the dentoalveolar
elements will tilt too far buccally and curtail basal maxillae expansion.
(Eg: Flexible appliance)
 Fixed components for rigidity requirements includes: bands small area of
connection.
and cap splints extensive areas of connection. Therefore rigidity is increased.

ii) TOOTH UTILIZATION: (No. of teeth included in appliance)

a) Load distribution:

 As entire lower position of maxillae are to be moved laterally, it is desirable to use

AS MANY TEETH AS POSSIBLE and spread load over entire alveolar length. Less
tissue damage.
 Few teeth can be banded whereas splints can be adapted to all teeth.

b) Appliance retention:

 Depends on areas of adhesion or interface between the teeth and appliance,

Thickness of adhesive agent,
Shape of clinical crowns.

 Bends may be superior to splint with respect to their close adaptation. If short
clinical crown  bend may impinge gingival sulcus

iii) EXPANSION: (Dilating unit and action)

 Dilating mechanism can be screw or spring
 Screw with sufficient thread preferred
 Spring has reduced rigidity and control.

iv) ECONOMY:

i) Time: Cap splint keeps clinical time to minimum.

ii) Material: Least intrusion into oral space is well tolerated. Banded appliance has
distinct advantage over bulky cap splints.

v) HYGIENE:

 Given the lowest priority therefore any deleterious effects are superficial and
reversible in well managed patient.

 Cap splints are cast in silver / copper alloy. The palatal extension to receive the
acrylic are cast integral with them. A proprietory screw gives at least 10mm of
expansion. Acrylic acts as a connecting agent between cap splints and screws.

B) CONSTRUCTION:

1. STANDARD APPLIANCE
 The making of metallic appliance calls for some expertise in the techniques of
forming wax patterns and casting.
 The impressions are pored and based to the given bite. Duplicate of the upper is
made for record purpose and the original provides as a working model.
 The teeth are surveyed for undercuts and about one millimeter is removed from the
gingival crest. This lengthening of crowns will assure that the completed splints will
nowhere be short.
 The teeth are lightly covered with inlay wax, a thickening which makes the wax
pattern slightly over size and allows for contraction of metal during cooling following
the casting. The model is now ready to receive the investment. All teeth except
centrals are covered down till gingiva.
 The palatal extension are added to provide mechanical locking with the acrylic
connections to the screw.
 Sterling silver is used for casting.
 After removal of sprue the splints are sandblasted from inside and polished from
 out side.
 On palatal side, drainage holes for excess cement are drilled one per tooth.
 Ideally screw should be mounted as high in the palatal vault as possible.

1) Modifications for Deciduous and Early mixed dentitions :

The cap splints are cast without the palatal flanges, as acrylic is not used.
And screw is attached directly by a soldered joint.

 Screw used is a p fast type (Dentaurum 4b) and is cut to correct length.
 Extensively used by Thorne (1956) Gray and Brogan (1970, 1972)
 Because of better hygiene preferred in younger children

2) BANDED APPLIANCES:

 Usually first molars and first premolars are banded

 Wires may be soldered to the buccal aspects of the bands to increase rigidity or
brachets may be welded and used to attach arch wires for the correction of teeth
not covered by the RME.
Some commonly used appliances are:

1) DERICHSWEILER TYPE:

Tags are welded and soldered to the palatal aspects of the bands to provide
attachments for the acrylic, which is also extended to the palatal aspects of all non-
banded teeth except the incisors.

2) HAAS TYPE:

A length of .045 inch (1.15mm) stainless steal wire is welded and soldered along the
palatal aspects of the bands. The free ends are turned back and embedded in the
acrylic base, which stops short of bands and teeth. A proprietary screw is set in the
midline of the split acrylic base.

3) ISAACSON TYPE:

The appliance uses a special spring loaded screw called a Minne expander, which
is adapted and soldered direct to the bands without the use of acrylic. The screw may
be reduced in length to suit narrow arches by shortening the spring, tube and rod.

4) BIEDERMANN TYPE:

The appliance required a special screw either

Hyrax (dentaurum 602-813)
 Leone 620
Or Unitek 440 -160.

These have extensions in heavy gauge wire, which are welded and soldered to
the palatal aspects of the bands.

The HYRAX or BEIDERMAN appliance is a common Type of Rapid maxillary

expansion appliance.

 It is tooth – borne and consists of a jack screw and on all metal frame-work which is
soldered to bands on first premolars and first molars.
 HYGIENIC APPLIANCE
 Tooth extrusion, dental tipping and an increase in vertical dimension are often
encountered.
 According to recent studies bonded RME appliances using interocclusal acrylic may
control the vertical dimension by exerting an intensive force to the maxillary and
mandibular teeth.
(AO 1997 : 67(1) : 15-22)
 A comparison of hyrax banded and hyrax bonded expansion appliance was done
and the following findings were noted,

1. Angular changes of teeth occurred in both Hyrax and bonded groups with no
statistically significant differences.

2. No difference in expansion pattern. The manner in which expansion occurred was

unpredictable and as symmetrical.
Brossman et. Al attributed this asymmetrical expansion to variation in the rigidity of
skeletal articulations between maxillary segments.

3. The probable factor for relapse were considered to be, accumulated forces in the
circummaxillary articulations, occlusal forces, the surrounding buccal musculature
and the stretched fibers of the palatal mucosa. To neutrlize these forces palatal
retainers, trans palatal bars or fixed appliances with expanded wires should be
 considered.
4. Following expansion, the Hyrax appliance resulted in slight anterior movement of
maxilla while bonded appliance showed posterior displacement of A POINT.

5. Vertically Hyrax responded in a predictable fashion. The maxillary segment moved

inferiorly causing an opening of bite with subsequent changes in the mandibular
plane angle.

6. The BONDED APPLIANCE showed less inferior movement of PNS. This may be
due to intensive force by interocclusal acrylic.

7. DEPENDING ON DESIRED TREATMENT OBJECTIVES, the ORTHODONTIST

MUST CONSIDER THE DESIGN OF EACH EXPANSION DEVICE.

For eg. :-
In treatment of patients with open bite Bonded appliance with occlusal
tendency and excessive vertical coverage would help to prevent
dimension
extrusion of maxilla or maxillary
teeth.
In treatment of patients with low Hyrax with its’s bite opening
mandibular plane angle, deep bite features is helpful.
and lower anterior face height.
(A.O 1997 : 67(1) : 15-22)

FORCES PRODUCES BY RME:

AJO 1964 : 34(4) : 256-271:

 One significant finding in this study is the magnitude is consistencies of the forces
exerted by the expansion- screw appliance.
 A single activation of the expansion screw produced from about 3 to 10 pounds of
force. (1359 – 4530 grams.) 1 pound = 453 grams.
 Facial skeleton increases its resistance to expansion significantly with increasing
maturity and age.
 The retention more probably relies on the creation of a stable relationship at the
articulations of the maxilla and other bones of the facial skeleton.
Even the deposition of new bone in the midpalatal suture doesn’t necessarily
insure the permanency of the treatment as long as forces are present at adjacent
maxillary articulations.
 Force decay immediately following an activation is rapid, but the role of decay
rapidly decreases within several minutes. Therefore it would appear that little
advantage is gained by allowing more than approximately five minutes between
several activation given on the first day of treatment.

Important Conclusions:

1. It is apparent that forces of this magnitude will readily displace a removable

expansion screw appliance, therefore removable appliance are not recommended
for this procedure.

2. Present day orthodontic mechanics are designed to produce constant gram loads
over long ranges of action in an attempt to produce physiologic response in the
bone and periodontal membrane.
Rapid mechanical expansion procedures on the other hand produce heavy
forces and are designed to produce minimal tooth movement and maximal
bone repositioning.
INDICATIONS:

1. Treatment of both surgical and non-surgical class III cases especially the non-
surgical ones.
2. Cases of Real and Relative maxillary deficiency.
3. Cases of inadequate nasal capacity exhibiting chronic nasal respiratory problem.
4. The mature cleft palate patient.
5. Cases where increase in width would give an excellent occlusion.
6. Prior to functional therapy.
7. As supplement to orthognathic surgery.

 For the establishment of a more favorable denture bast relationship, the maxillary
posterior teeth must be over expanded.

OBJECTIVES OF PALATAL EXPANSION:

1. The primary object of palate expansion is to coordinate the maxillary and
mandibular denture bases

2. To increase the transverse width of the maxillary dental arch at the apical base with
the minimal concomitant movement of posterior teeth within the alveolus.

C) REQUIREMENTS :-
1. The appliance should be designed to enhance the orthopedic movement and to
curtail orthodontic response.

Dental anchorage unit should be as strong as possible. Band all posterior teeth with
bands joined by buccal and lingual soldered bars.
CLINICAL MANAGEMENT OF RME:

 The clinician should explain the principles to patient and parent.

 Explain the nature of appliance, visits and time frame, show a appliance.
 If patient is a mouth breather and referred by an ENT surgeon, it should be noted
that widening increases nasal airway and may improve respiration.
 Only when commitment is fully realised by all parties, should the clinician proceed
with therapy.

Fitting the appliance:

 In case of cast cap splints, attention must be paid to cleanliness (especially the
fitting surface good adhesion.)
 Check the direction of the screw for opening, it SHOULD BE BACKWARDS WHEN
VIEWED FROM LINGUAL ASPECT.

Cementation:

Only when clinician is satisfied that the appliance fits accurately without causing
pain or discomfort should be proceed with cementation.

Instructions:

1) The usual inherent difficulties in speech and mastication must be mentioned.

2) Oral hygiene maintenance
3) Regime of screw rotation must be prescribed on basis of patients age and expected
degree of separation, and is classified into 3 age groups.

1) Up to age 15years
2) Age 15 – 20 years
3) Age over 20 years

1) Up to age 15 years:

 Most patients fall in this group.

 180° Daily rotation (90° in morning, 90° in evening) is Recommended.
 Long handled keys are used for this purpose by the person responsible to turn the
screw (parent)

2) Age 15 – 20 years
 Because of increased resistance to maxillary separation may cause force build up
and PAIN IN PATIENTS IN THIS AGE GROUP C turn of 90°
 It should be able to maintain to maintain the overall daily rotation of 180° by 4 turns
of 45° at 4 equal time lapses.
3) Age over 20 years:

 There can be a substantial build up of tension and probable painful symptoms,

therefore reduction of rate of expansion is necessary.
 90° Rotation (45° in morning and evening)

Persistent pain normally is the product of an unyielding midpalatal suture, because the
tension disperses and the pain disappears as the maxillae separate.

 Never should the appliance be activated for a period longer than 1 week against
unyielding suture in hope of achieving maxillary separation. This practice is
particularly dangerous when patient is sedated to relive pain.
 Suture opening is confirmed by looking at screw and looking at commencement of
median diastema

If patients reports episodes which indicate excessive force build up. Then following
adjustment can be made:

1) Reduce the angle of rotation, but increase the frequency. This will maintain the
overall rate reduces immediate build-up but residual force continues to accumulate.
2) Reduce the rate of expansion, which will stop the accumulation of residue.

How much to expand?

A general and convenient guideline is to stop when the maxillary palatal cusps are level
with the buccal cusps of the mandibular teeth.

 At the end of active expansion, the patient enters fixed retention for 3 months,
followed by removable retainer.

After Rapid Maxillary Expansion:

Anatomical Changes:
Bones:

 The end of active appliance expansion may not be the limit of bony expansion. As
flexure strain has built in the appliance, this brings extra basal expansion even
though the screw is no longer turned.
 Studies have shown that basal bone relapse was less compared to dental arch.

Sutures:
Histologically the mid palatal defect is invaded by bone cells, osteoid tissue is first laid
down and then converted to haversian system.
The suture is reconstituted.
Radiographically, the suture appears normal 3 months after expansion.
Dental:

The teeth with their respective maxillae rotate outwards.

During active RME, there was increased inclination to the vertical.
However after RME they returned slowly approximately to their original
inclinations.

Rapid Maxillary expansion of cleft palates:

Despite presurgical alignments and improved procedures for surgical closure, the
collapse of maxillary segments remains a common occurrence. RME can achieve
some of the best results.

 Slightly less force is required to separate maxillae in cleft palates.

 RME in cleft palates produces less discomfort then in normal palate, there is no
midpalatal suture to worry about.
 3 months retention period is advisable
 Bone grafting can be arranged mutually with the surgeon to avoid interference
with the orthodontic plan.
 The only undesirable situation, which may arise from RME, is the opening of
oronantral fistula.
Surgically assisted RME:

The inter dependence between orthodontist and oral surgeon may be because,

1) Orthodontist may approach oral surgeon to free the maxillae in order to carry out
RME in patients in whom there is excessive resistance to separation and thus
extend the age and range for this therapy.

2) The oral surgeon may approach the orthodontist for realignment of the dental
arches for satisfactory occlusion, when surgically correcting patients with maxillo
mandibular dysplasias and RME is recommended in such cases.

TECHNIQUES:

SURGICAL FREEING OF THE MAXILLAE

Resistance to seperation of maxillae may be due to:-
1. Midpalatal Synostosis (obliteration by calcified tissue)
2. Midpalatal interlocking :-
The serpentine course of the suture between nose and mouth which physically
locks the maxillae as in a jigsaw puzzle.
3. Circum maxillary rigidity:-
This is part of a skeletal aging or maturing process
 It is clinically prudent to consider surgical freeing of maxilla in patients above age of
25 years.
 Rapid expansion should never be continued for ore than one week unless sutural
opening is assured.
The failure of diastema to develop when screw has be turned for few days and there is
pain of continuous nature  INDICATE MAXILLAE NEEDS SURGICAL FREEING.

SURGICAL TECHNIQUES :-
 Some knowledge of level of synostosis over the length of midpalatal suture is
 needed.
 Studies mention that ossification is not constant, it begins posteriorly and more
posteriorly than anteriorly.

DENNIS VERO, a oral surgeon has developed a series of operations of increasing

stages of osteotomies to cope with midpalatal synostosis and the progressive rigidity of
the facial skeleton.

Stage 1 A :-
This is a palatal osteotomy used if the patient is aged 25 years or more or in
younger patients where RME has been tried is failed.
The soft tissue incision is made in the palate, behind the central incisors and
then straight back, parallel to the mid-line and the greater palatine vessels to the
posterior border of the hard palate.
A single flap of the palatal mucoperiosteum is reflected to expose the midline
region of the hard palate around and posterior to the incisive fossa, the connection
tissues over it being kept intact to preserve some of the nerves and vessels.
The bone is cut with a medium roe-head bur to one side of the midline to avoid
damage to the septum. Care is taken to avoid puncture of the nasal mucous
membrane.
This stage refers to unilateral cross bites where the bony incision is made on the
ipsilateral side to make dentomaxillary element do greater movement.
The flap is sutured back. The patient will be ready for RME after 7-10 days.
The advantages of the eccentric soft tissue incision over the usually described midline
one are:-
1. A single flap which is easier to handle and reposition.
2. Soft and hard tissue wounds are not contiguous, consequently the cut bone is
covered with fresh periosteum. Healing is better.

Stage 1 B :-
 Same as stage 1A but used in cases where there is bilateral buccal cross bites.
 Bilateral osteotomies of the hard palate are made.
 Enough exposure can be obtained from a flap raised from the same unilateral
eccentric soft tissue incision by funneling.

D) Stage 2 A :-

 Over the age of 30 years, lateral maxillary osteotomies are made in addition to
palatal ones.
 The soft tissue incision is made in the alveolar mucosa from the base of the
zygomatic arch forward to a point over the apex of the lateral incisor and down to
the gingiva of the central incisor.
 With this exposure of the lateral wall, the maxillary cut is made from the piriform
aperture, through the anterior and lateral walls of the antrum and across the
buttress at the base of the zygomatic arch, to stop at the tuberosity.
 In patients with unilateral buccal cross bites this technique is carried out on
ipsilateral side only.

E) Stage 2 B :-

In case of bilateral buccal cross bites, this operation is extended to both sides.

Stage 3 A :-

 In patients order than 40 years, stage 1 and stage 2 are supplemented to anterior
maxillary osteotomies.
 The horizontal incision in the alveolar mucosa is made as in stage 2 but the
downward portion is made obliquely across the midline to give access to the
anterior nasal spine.
 The bone is cut from the piriform aperture to the midline beneath the anterior nasal
spine and is continued down between the central incisors.
 It may be carried back along the floor of nose but it does not have to meet palatal
incisors.
 The cortex only should be cut in the vicinity of the incisor and deep incision avoided
between the central incisors.
 If transseptal fibers between the centrals are cut. The median diastema will not
close spontaneously and orthodontist is lets with additional and unnecessary work.
 Stage 3 B :-

Where there is Bilateral buccal cross bite, the osteotomies are made bilaterally.
RME AS A SUPPLEMENT TO ORTHOGNATHIC SURGERY :-
 Maxillo mandibular dysplasia today are corrected by surgical repositioning of the
whole or part of maxillary or mandibular components. Eg. of cases which need
presurgical expansion
1. Mandibular retrognathism with an existing buccal cross bite which becomes worse
when mandible is repositioned forwards.
Mandibular protrusion in which maxillary arch is so deficient in width that even when the
mandible is moved back, a buccal cross bite remains.

COMPARISON BETWEEN SLOW EXPANSION AND RAPID MAXILLARY

EXPANSION.
1. By expanding at rates of 0.3 – 0.5 mm per day, active expansion is completed in 2 –
4 weeks, leaving little time for cellular response of osteoclasts and
osteoblasts as seen in slow expansion.
2. As the thrust is delivered to the teeth at the inferior free borders of the maxillae,
expansion must reach to the basal portions. Form of appliance plays a important
role in this effort in Anchorage or control of tipping.
Even different forms of appliances in slow expansion will affect the basal arch
width slightly by stimulating (or not ) growth at the midpalatal suture (Skieller
1964 : Chaconas et. al 1975)
3. The substantial increase in maxillary base width is brought about by RME in
contrast to slow expansion.
4. A natural consequence of RME is the dilation of nasal air passages, so creating an
increase in the available air flow. Eg. In patients with anterior nasal stenosis and
habitual mouth breathers. In certain cases respiration may be the only or primary
reason for carrying out RME.
The wider ambit of RME must be appreciated by the clinician and the patient must be
viewed from both medical and dental standpoints.
Slow expansion has more physiologic stability and less potential for relapse than
with rapid expansion.
5. The characteristic teeth movement associated with RME and slow expansion is
shown in simplistic diagram below.

Hazards of RME :-
1. Oral Hygiene :-
 The bulk of the appliance is not a threat to oral hygiene.
 Tongue wrinkle out trapped debris.
 Mild anti-bacterial mouth wash may be used.

2. Length of fixation :-
 The usual period is up to 4 months.
 Palate covered by the appliance may become spongy and hemorrhagic but will
return to normal state after few days.

3. Dislodgement and Breakage :-

 Loose appliance should be recemented
 Breakage is rare and usually involves the screw.

4. Tissue damage :-
 To avoid damage to the deeper tissues especially midpalatal suture area Zeibe
(1930) advised limiting the rate of expansion to 0.5mm /day which he based on his
histological studies.
 All RME involves heavy forces which probably occludes the blood vessels on the
compression side in the periodontal membrane.
 Histological studies show resorption lacunae on the roots and the alveolar bone,
largest being near the crest.
 On the apical third there was small areas of excessive deposition of cementum.
 Reversal lines were evident and the bays of resorption were being refilled with
osteoid tissue.
 After some time normality would return to the teeth and periodontium.

5. Infection :-
 An immersion of pathogenic organisms in mouth represents a true hazard in RME,
especially if appliance used consists of cap splints and covers large portion of
palate.
 Beneath such appliances organisms flourish.
 Most common infection is acute ulcerative gingivitis.
 In such condition appliance should be removed to permit clearing.

6. Failure for suture to open :-

Pain is a symptom of force build-up, which may be due to :-
 Unyielding maxillae (synostosis and interlocking)
 General skeletal rigidity.

Damage is done if expansion is carried out against unyielding suture and the appliance
is driven into the alveolar.
 Pain appear when the screw is turned and when the force decays away with the
opening of the suture, the pain will also subside.
WHEN SUTURE IS NOT OPENING  FORCE WILL NOT DECAY  CONSTANT
PAIN.

 EXPANSION SHOULD NOT BE CONTINUED FOR MORE THAN ONE WEEK

AGAINST UNYIELDING SUTURES.