Journal of Orthodontics/Vol.
28/2001/129–134
Rapid Palatal Expansion in Mixed Dentition
Using a Modified Expander: a Cephalometric
Investigation
PAO L A C O Z Z A , M . D ., D . D . S ., M . S .
A L D O G I A N C OT T I , D . D . S ., M . S .
A N TO N I A P E T R O S I N O , D . D . S .
Department of Orthodontics, University of Rome ‘Tor Vergata’, Via di Tor Vergata, 135-00173 Rome, Italy
Abstract. The aims of this investigation were to cephalometrically study the short-term skeletal and dental modifications
induced by rapid palatal expansion in a sample of 20 patients (10 male, 10 female), aged 6–10 years (mean age 8 years) in
mixed dentition with a uni- or bilateral posterior crossbite, a mild skeletal Class II malocclusion, and an increased vertical
dimension (FMA, SN^GoGn), and to compare them with an untreated matched control group of 20 subjects (10 male
and 10 female), mean age 8 years.
Cephalometric analysis showed that the maxilla displayed a tendency to rotate downwards and backward, resulting in a
statistically significant increase of the SN^PP angle (T0 9·95 degrees, T1 11·60 degrees, P 0·01) and the SN–ANS
linear value (T0 49·50 mm, T1 51·10 mm, P 0·05).
In addition, there was a statistically significant alteration of the anterior total facial height N–Me (T0 113·15mm, T1
114·15 mm, P 0·05) and for the dental upper molar measurement U6–PP (T0 19·70 mm, T1 20·30 mm, P 0·05).
The small alterations found in the anterior total facial height and in the sagittal angles agree with previous studies, and
suggest that RPE can be also used in subjects with a tendency to vertical growth and a skeletal Class II malocclusion.
Index words: Maxillary expansion, Mixed dentition, Cephalometric investigation.
Introduction 14–16 days of appliance activator. The maxilla displayed
a tendency to rotate downward and backward increasing
Rapid palatal expansion (RPE) performed in the early
the SN–PP angle value. The mandible rotated down and
stages of occlusal development has become an accepted
posteriorly.
orthodontic practice when orthopaedic opening of both
McNamara (1993) in a study of the effects induced by a
halves of the maxillary process is required (da Silva et al.,
RPE appliance observed that widening the maxilla lead to
1995).
a spontaneous forward posturing of the mandible during
Although the use of RPE procedures in the primary and
the retention period and that a spontaneous correction of
mixed dentition has been reported in the literature, and the
Class II relationship can be found after 6–12 months.
clinical indications have been proposed (Bell, 1982; Bishara
Velàzquez et al. (1996) in a long-term study regarding the
et al., 1987; Nicholson et al., 1989; Halazonetis et al., 1994),
effects of RPE reported that the modest, but potentially
relatively little has been published concerning the specific
unfavourable changes induced by the RPE device, such as
cephalometric alterations induced by this appliance. Haas
an open bite or mandibular postero-rotation, are reversible.
(1970) stated that once the mid-palatal suture opens, the
They found that, following termination of orthodontic treat-
maxilla always moves forward and downward, and this
ment, these undesirable effects were almost completely
causes a downward and backward rotation of the mandible,
resolved.
which decreases the effective length of the mandible and
This study aims to evaluate the short-term cephalometric
increases the vertical dimension of the lower face.
alterations induced by a new RPE appliance recently
Wertz (1970) suggested from his analysis of lateral
presented in the literature (Cozza et al., 1999), and specific-
cephalograms that the maxilla drops down consistently, but
ally used in subjects in the mixed dentition with a uni- or
rarely moves forward significantly. However, he had no
bilateral posterior crossbite, a mild skeletal Class II mal-
control group against which to assess the vertical changes.
occlusion and an increased vertical dimension.
This was later confirmed by da Silva et al. (1991), who
found that the maxilla did not show any statistically sig-
nificant alterations in the anteroposterior position over the
Subjects and methods
Correspondence: Dr Aldo Giancotti, Via Barnaba Tortolini 5, 00197 The sample comprised 20 patients (10 male and 10 female)
Rome, Italy with an age range of 6–10 years (mean age 8 years).
0301-228X/01/020000+00$02.00 © 2001 British Orthodontic Society
130 P. Cozza et al. Scientific Section JO Vol 28 No. 2
All children showed either a uni- or bilateral posterior Vertical analysis
crossbite with a transverse deficiency, the average presented
a skeletal Class II malocclusion and a vertical growth FMA angle, SN^GoGn angle, PP^GoGn angle, SN^PP
pattern. angle, [Link].^FH angle, Ar–Go mm, PP–Me mm, (S–Go)/
Twenty subjects, 10 males and 10 females (mean age 8 (N–Me) per cent, S–Go mm, N–Me mm, SN–PNS mm (per-
years), with untreated uni- or bilateral posterior crossbites pendicular distance from sella–nasion plane to posterior
were selected from the files of the Department of Ortho- nasal spine), SN–ANS mm (perpendicular distance from
dontics of the University of Rome ‘Tor Vergata’ to com- sella–nasion plane to anterior nasal spine), GoMe–PNS
prise the control group. mm (perpendicular distance from gonion–menton plane to
The expansion procedure was carried out with a new posterior nasal spine), GoMe–ANS mm (perpendicular
RPE fixed appliance (Butterfly expander) routinely used distance from gonion–menton plane to anterior nasal spine)
by the authors in the mixed dentition for patients with (Figure 3).
transverse maxillary deficiency. In this expander, the screw
is assembled with two round stainless steel wires (arms),
soldered to bands placed on the second primary molars Dental analysis
(Figure 1)
IMPA angle, [Link].^FH angle, inter-incisal angle, U6–PP
Activation of the screw commenced immediately after
mm (perpendicular distance from palatal plane to mesial
the appliance was cemented in place with a complete turn
cusp tip of maxillary first molar), L6–MP mm (perpen-
of the screw (four one-quarter turns). The parents were
dicular distance from mandibular plane to mesial cusp tip
instructed to activate a one-quarter turn three times a day
of mandibular first molar) (Figure 4).
(morning, afternoon, evening). The activation period lasted
from 7 to 9 days depending primarily on the degree of
maxillary constriction. The lateral expansion of the upper
arch was deemed sufficient when the posterior crossbite Method error
was overcorrected by 2–3 mm for each side. The appliance
Each cephalogram was traced and measured by one of the
was left in situ passively for 6 months and its screw was
authors (P.C.). All measurements were repeated after a
sealed to prevent unwinding.
period of 7 days and the mean value of the two measure-
The alterations produced by the RPE appliances were
ments was used.
assessed on two lateral cephalometric radiographs (T0–T1).
All measurement error coefficients were found to be
The first cephalogram was taken before treatment and the
close to 1·00 and within acceptable limits (Table 1).
second immediately after removal of the RPE appliance;
the average time between radiographs was approximately
6 months.
Two radiographs were also taken in a control group and
the average interval was approximately 8 months. Linear
and angular cephalometric measurements were used for
this study.
Sagittal analysis
SNA angle, SNB angle, ANB angle, AO–BO mm, N perp.–
A mm (point A to nasion perpendicular), N perp.–Pg mm
(point Pg to nasion perpendicular), PTM–A mm (perpen-
dicular distance from point A to pterygomaxillary vertical
line) (Figure 2).
F I G . 2 Sagittal analysis: cephalometric landmarks. S (sella), N (nasion),
A (Downs A point), B (Downs B point), AO (point A to occlusal plane
perpendicular), BO (point B to occlusal plane perpendicular), Pg (pogonion),
PTM (pterygomaxillary fissure), FH (Frankfort horizontal plane), OP (occlusal
F I G. 1 ‘Butterfly’ fixed expander used for the maxillary widening. plane).
JO June 2001 Scientific Section Rapid Maxillary Expansion 131
TA B L E 1 Method error coefficients
Variables R
SNA (°) 0·99
SNB (°) 0·98
ANB (°) 0·98
AO–BO (mm) 0·99
N perp.–A (mm) 0·99
N perp.–Pg (mm) 0·99
PTM–A (mm) 0·97
FMA (°) 0·98
SN^GoGn (°) 0·98
PP^GoGn (°) 0·99
SN^PP (°) 0·97
[Link]. ^ FH (°) 0·99
Ar–Go (mm) 0·98
PP–Me (mm) 0·98
(S–Go)/(N–Me) (%) 0·97
S–Go (mm) 0·99
N–Me (mm) 0·99
SN–PNS (mm) 0·98
SN–ANS (mm) 0·98
GoMe–PNS (mm) 0·97
GoMe–ANS (mm) 0·97
IMPA (°) 0·99
[Link]. ^ FH (°) 0·99
Interincisal angle (°) 0·97
U6–PP (mm) 0·97
F I G . 3 Vertical analysis: cephalometric landmarks. S (sella), N (nasion), L6–MP (mm) 0·98
ANS (anterior nasal spine), PNS (posterior nasal spine), FH (Frankfort
horizontal plane), OP (occlusal plane), Ar (articulare), Go (gonion),
Me (menton), Gn (gnathion) .
Statistical method
Descriptive statistics including mean and standard devia-
tion. The mean differences in cephalometric measurements
at T0 and T1 were examined with Wilcoxon’s test. We used
a non-parametric test because the studied variables were
not normally distribuited.
Results
Table 2 shows a comparison between the initial cephalo-
metric values for the control group and the treated group.
No statistically significant differences were found although
several mean differences of clinically significant size are
found.
Table 3 shows the comparison for each cephalometric
measurement considered before (T0) and after treatment
(T1) with RPE and the four variables in which the RPE
procedure induced statistically significant (P < 0·05)
alterations.
Table 4 shows the mean and standard deviation for the
cephalometric measurement in the control group.
The RPE procedures induced statistically significant
alterations only in four cephalometric measurements:
SN^PP, SN–ANS, N–Me, and U6–PP. The SN^PP angle
value increased (T0 9·95,T1 11·60) as did the SN–ANS
linear value (T0 49·50, T1 51·10), which resulted in a
downward and backward displacement of the palatal plane
(the distance between the SN plane and point PNS also
increased, but not statistically).
An increase of the anterior total facial height N–Me
F I G . 4 Dental analysis: cephalometric landmarks. ANS (anterior nasal spine),
(T0 113·15, T1 114·15) and the dental molar measure-
PNS (posterior nasal spine), FH (Frankfort horizontal plane), OP (occlusal ment U6–PP (T0 19·70, T1 20·30) was noted, and this
plane), Go (gonion), Me (menton), Gn (gnathion), U6 (upper first molar), caused a downward and backward rotation of the man-
L6 (lower first molar). dible.
132 P. Cozza et al. Scientific Section JO Vol 28 No. 2
Discussion metric analysis adopted and the type of growth pattern of
the examined subjects.
A comparison between the results obtained from different
studies was difficult, due to the lack of data concerning the
age, the dental and skeletal Class relationship, the cephalo-
Antero-posterior alterations of the apical bases
TA B L E 2 Comparison between control group and treated group—initial In the present study it was found that there were no
values
statistically significant alterations in the antero-posterior
Variables T0 control SD0 T0 treated SD0 P position of the maxilla, which contradicts the conclusions of
group group Davis and Kronman (1969) and Haas (1970), but it is in
agreement with Byrom (1971), Sarver and Johnston (1989),
SNA (°) 80·25 1·36 78·02 3·61 NS and da Silva et al. (1991). No statistically significant changes
SNB (°) 76·25 1·38 74·47 3·27 NS were observed in the control group.
ANB (°) 4·00 0·75 3·80 2·68 NS
AO–BO (mm) 1·38 1·38 1·35 3·95 NS
N perp.–A (mm) 0·25 1·39 –1·15 2·87 NS
N perp.–Pg (mm) –3·75 2·49 –8·10 5·87 NS Vertical alterations of the apical base and facial height
PTM–A (mm) 48·62 1·99 49·63 4·32 NS
FMA (°) 26·75 1·66 28·60 4·86 NS Vertical changes raised from this study agree with those
SN ^ GoGn (°) 37·56 2·94 37·90 4·81 NS reported by Davis and Kronman (1969), Wertz (1970),
PP^GoGn (°) 28·19 1·46 28·05 5·52 NS Byrom (1971), Sarver and Johnston (1989), da Silva et al.
SN ^ PP (°) 8·62 2·98 9·95 3·76 NS
[Link]. ^ FH (°) 10·75 2·25 11·10 2·88 NS
(1991), Velàzquez et al. (1996), Asanza et al. (1997), and
Ar–Go (mm) 38·62 2·44 38·70 3·45 NS Akkaya et al. (1999).
PP–Me (mm) 56·13 3·64 61·15 4·41 NS Downward and backward (SNB, N perp.–Pg) displace-
(S–Go)/(N–Me) (%) 61·42 1·81 59·60 3·21 NS ment of the apical base results in a slight, and not significant
S–Go (mm) 64·87 2·64 67·55 4·66 NS rotation of the palatal and mandibular plane. The first is
N–Me (mm) 105·63 4·62 113·15 6·99 NS responsible for the statistically significant increase in
SN–PNS (mm) 40·62 1·60 41·40 2·37 NS
SN–ANS (mm) 49·50 3·42 49·50 3·34 NS
SN^PP angle value and linear distance SN–ANS, and the
GoMe–PNS (mm) 38·50 3·34 39·25 2·91 NS second for the increase in anterior total facial height N–Me.
GoMe–ANS (mm) 59·00 3·33 62·55 4·85 NS No statistically significant modifications of the skeletal
IMPA (°) 89·75 2·12 91·90 6·12 NS divergency angles (FMA, SN^GoGn) were found.
[Link]. ^ FH (°) 110·13 6·31 111·35 7·14 NS The minimum increase of the facial anterior heights is a
Interincisal angle (°) 136·13 5·69 126·80 11·69 NS direct effect of extrusion of anchoring primary upper molars.
U6–PP (mm) 17·62 2·02 19·70 2·02 NS
L6–MP (mm) 26·88 4·19 27·20 1·73 NS
No statistically significant changes were observed in the
control group.
TA B L E 3 Cephalometric changes with treatment in the RPE group
Variables T0 SD0 T1 SD1 Mean of SD of P
changes changes
SNA (°) 78·02 3·61 77·85 2·79 –0·17 1·77 NS
SNB (°) 74·47 3·27 73·90 2·75 –0·57 1·79 NS
ANB (°) 3·80 2·68 3·90 2·76 0·10 0·79 NS
AO–BO (mm) 1·35 3·95 1·45 3·06 0·10 1·55 NS
N perp.–A (mm) –1·15 2·87 –1·15 3·45 0·00 2·55 NS
N perp.–Pg (mm) –8·10 5·87 –8·45 5·72 –0·35 2·87 NS
PTM–A (mm) 49·63 4·32 50·36 3·77 0·74 1·59 NS
FMA (°) 28·60 4·86 28·25 5·11 –0·35 2·56 NS
SN ^ GoGn (°) 37·90 4·81 38·45 4·59 0·55 2·72 NS
PP^GoGn (°) 28·05 5·52 27·25 4·19 –0·80 2·69 NS
SN ^ PP (°) 9·95 3·76 11·60 3·25 1·65 2·64 **
[Link]. ^ FH (°) 11·10 2·88 10·70 3·74 –0·40 2·56 NS
Ar–Go (mm) 38·70 3·45 39·80 3·62 1·10 2·31 NS
PP–Me (mm) 61·15 4·41 61·90 4·77 0·75 1·97 NS
(S–Go)/ (N–Me) (%) 59·60 3·21 59·40 2·60 –0·20 2·02 NS
S–Go (mm) 67·55 4·66 67·75 3·80 0·20 1·82 NS
N–Me (mm) 113·15 6·99 114·15 6·88 1·00 2·18 *
SN–PNS (mm) 41·40 2·37 41·75 2·24 0·35 1·69 NS
SN–ANS (mm) 49·50 3·34 51·10 3·46 1·60 2·33 *
GoMe–PNS (mm) 39·25 2·91 39·70 3·26 0·45 2·28 NS
GoMe–ANS (mm) 62·55 4·85 63·05 4·65 0·50 1·88 NS
IMPA (°) 91·90 6·12 91·30 6·47 –0·60 4·01 NS
[Link]. ^ FH (°) 111·35 7·14 111·45 7·44 0·10 4·44 NS
Interincisal angle (°) 126·80 11·69 128·65 10·40 1·85 6·23 NS
U6–PP (mm) 19·70 2·02 20·30 2·20 0·60 1·14 *
L6–MP (mm) 27·20 1·73 27·55 2·25 0·35 1·14 NS
*P < 0·05; **P < 0·01.
JO June 2001 Scientific Section Rapid Maxillary Expansion 133
TA B L E 4 Cephalometric changes in the control group over the observation period
Variables T0 SD0 T1 SD1 Mean of SD of P
changes changes
SNA (°) 80·25 1·36 80·37 1·16 0·12 1·73 NS
SNB (°) 76·25 1·38 76·19 1·36 –0·6 1·84 NS
ANB (°) 4·00 0·75 4·18 1·03 0·18 0·69 NS
AO–BO (mm) 1·38 1·38 1·69 1·62 0·31 1·64 NS
N perp.–A (mm) 0·25 1·39 0·06 1·52 –0·19 2·31 NS
N perp.–Pg (mm) –3·75 2·49 –2·85 3·77 0·9 2·56 NS
PTM–A (mm) 48·62 1·99 48·62 2·11 0·00 1·46 NS
FMA (°) 26·75 1·66 26·94 1·52 0·19 2·61 NS
SN ^ GoGn (°) 37·56 2·94 37·56 3·09 0·00 2·70 NS
PP^GoGn (°) 28·19 1·46 28·06 1·52 –0·13 2·70 NS
SN ^ PP (°) 8·62 2·98 8·75 3·02 0·13 2·58 NS
[Link]. ^ FH (°) 10·75 2·25 10·75 2·24 0·00 2·44 NS
Ar–Go (mm) 38·62 2·44 38·69 2·55 0·07 2·22 NS
PP–Me (mm) 56·13 3·64 56·06 3·62 –0·07 2·11 NS
(S–Go)/ (N–Me) (%) 61·42 1·81 61·29 2·99 –0·13 1·99 NS
S–Go (mm) 64·87 2·64 65·00 2·93 0·13 1·81 NS
N–Me (mm) 105·63 4·62 106·06 4·57 0·43 2·16 NS
SN–PNS (mm) 40·62 1·60 40·75 1·69 0·13 1·56 NS
SN–ANS (mm) 49·50 3·42 49·50 3·42 0·00 2·31 NS
GoMe–PNS (mm) 38·50 3·34 38·50 3·34 0·00 2·15 NS
GoMe–ANS (mm) 59·00 3·33 58·93 3·21 –0·07 1·75 NS
IMPA (°) 89·75 2·12 90·13 2·15 0·38 3·99 NS
[Link]. ^ FH (°) 110·13 6·31 110·19 6·41 –0·06 4·29 NS
Interincisal angle (°) 136·13 5·69 135·75 6·04 –0·38 6·11 NS
U6–PP (mm) 17·62 2·02 17·50 1·41 –0·12 1·12 NS
L6–MP (mm) 26·88 4·19 26·94 4·20 0·12 1·18 NS
Conclusions Asanza, S., Cisneros, G. J. and Nieberg, L. G. (1997)
Comparison of Hyrax and bonded expansion appliances,
Based on the cephalometric alterations observed after Angle Orthodontist, 67, 15–22.
RPE during mixed dentition, the following can be con- Bell, R. A. (1982)
cluded: A review of maxillary expansion in relation to rate of expansion and
patient’s age,
1. No statistically significant changes were observed in American Journal of Orthodontics, 81, 32–37.
the sagittal analysis.
2. No statistically significant changes were observed in Bishara, S. E. and Staley, R. N. (1987)
Maxillary expansion: clinical implications,
FMA and SN^GoGn angle. American Journal of Orthodontics, 91, 3–14.
3. The palatal plane displayed a slight downward and
backward rotation altering: SN^PP, SN-ANS. Byrom, A. G. (1971)
Evaluation of anterior-posterior and vertical skeletal changes in
4. A statistically significant increase of the dental molar rapid palatal expansion cases as studied by lateral cephalograms,
measurement U6–PP was noted. American Journal of Orthodontics and Dentofacial Orthopedics, 60,
5. A statistically significant increase in the anterior total 419.
facial height (N–Me) was observed as a direct effect of Cozza, P., Giancotti, A. and Petrosino, A. (1999)
the vertical displacement of the palatal plane and the Butterfly expander for use in mixed dentition,
upper molars. Journal of Clinical Orthodontics, 33, 583–587.
In all subjects a satisfactory resolution of the maxillary da Silva, O. G., Villas Boas, M. C. and Capelozza, L. (1991)
constriction was obtained, which indicates that this pro- Rapid maxillary expansion in the primary and mixed dentitions: a
cedure can also be used in patients with a tendency to cephalometric evaluation,
American Journal of Orthodontics, 100, 171–181.
vertical growth, considering the minimum increase of the
N–Me verified. Davis, M. W. and Kronman, J. H. (1969)
Anatomical changes induced by splitting of the midpalatal suture,
6. Previous studies would suggest that these modest Angle Orthodontist, 39, 126–132.
short-term changes are reversible. Haas, A. J. (1970)
Palatal expansion: just the beginning of dentofacial orthopedics,
American Journal of Orthodontics, 57, 219–255.
Halazonetis, D. J., Katsavrias, E. and Spyropoulos, M. N. (1994)
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