Long-term Skeletal Changes with

Rapid Maxillary Expansion: A Review

of the Literature
Steve D. Marshall and Bhavna Shroff

Evidence-based dentistry is currently a high priority in the clinical practice of

orthodontics. Treatment decisions are made using evidence-based informa-
tion whenever it is available to the clinician. The focus of this article is to
evaluate the current literature available on the long-term stability of rapid
maxillary expansion. The literature was reviewed from 1979 to 2009, and all
systematic reviews and meta-analyses were included in this evaluation.
Clinical trials, retrospective or prospective, were also reviewed, even though
they did not always meet the inclusion criteria set forth. This review of the
literature shows that, based on the evidence provided by 2 trials, there is a
lack of strong evidence of the long-term stability of maxillary expansion in
adolescent patients with posterior crossbites at the initiation of orthodontic
therapy. Factors responsible for this include high attrition rates, lack of
adequate control groups, unclear diagnosis and ill-defined study end points,
and lack of standardization of studies. The conclusions that can be drawn
from our review are as follows: there is a clear need for well-designed and
well-controlled retrospective or prospective clinical trials for the evaluation
of stability of maxillary expansions. At the present time, orthodontists must
accept that some treatment modalities do not yet have a high level of evidence
for treatment effectiveness. (Semin Orthod 2012;18:128-133.) © 2012 Elsevier
Inc. All rights reserved.

xpansion of the maxilla, by the use of fixed
E or removable expansion appliances, is a
widely used orthodontic treatment in the correc-
tion of malocclusion. It is primarily used for the
correction of posterior crossbites occurring as a
result of insufficient maxillary width.1 It is par-
ticularly important in eliminating mandibular
functional shift, a finding commonly associated
with deficient maxillary arch width in early den-
tition development, which, if left untreated, may
Visiting Associate Professor, Department of Orthodontics, Uni-
versity of Iowa, Iowa City, IA; Professor and Graduate Program
Director, Department of Orthodontics, Virginia Commonweath Uni-
versity, Richmond, VA.
Address correspondence to Bhavna Shroff, DDS, MDentSc,
MPA, Department of Orthodontics, Virginia Commonwealth Uni-
versity, 520 North 12th St, Ste 111, Richmond, VA 23298. E-mail:
bshroff@vcu.edu
© 2012 Elsevier Inc. All rights reserved.
1073-8746/12/1802-0$30.00/0
doi:10.1053/j.sodo.2011.10.011
have undesirable consequences on facial symme-
try2 and temporomandibular joint function.3-10
Other applications for maxillary expansion found
in the orthodontic literature include increasing
arch perimeter (in the absence of posterior cross-
bite) to facilitate nonextraction edgewise treat-
ment,11 and improving Class II interarch relation-
ships by spontaneous mandibular growth or
positioning.12 The purpose of this article is to re-
view the long-term stability of maxillary expansion
using an evidence-based approach to evaluate the
research available on this topic.
Evidence-Based Information and
Orthodontic Treatment
During the past 20 years, the dental profession
and orthodontics have been increasingly influ-
enced by evidence-based medicine. Today, prac-
ticing evidence-based orthodontics requires that

128 Seminars in Orthodontics, Vol 18, No 2 (June), 2012: pp 128-133

 Skeletal Changes with Rapid Maxillary Expansion
orthodontic treatment decisions be made from
evidence-based information whenever feasible.
In the hierarchy of evidenced-based research,
the experimental design providing the highest
level of evidence for the effectiveness and effi-
ciency of treatment is the randomized clinical
trial.13 Systematic reviews and meta-analysis are
additional evidence-based tools that reduce bias
in the interpretation of data on treatment out-
comes. For a particular treatment question,
these methods assess the quality of the studies
and exclude low-quality research. They summa-
rize treatment efficiency and efficacy by strin-
gent evaluation of clinical trials for a particular
treatment effect. When a treatment is evaluated
by multiple randomized trials and examined by
systematic review or meta-analysis, these evi-
dence-based tools provide the highest level of
evidence by the careful selection and pooling of
treatment outcome data from multiple indepen-
dent investigations.
However, in orthodontics, the number of ran-
domized clinical trials remains small.14 The rea-
sons for this are both practical and ethical; de-
nying treatment or choice of treatment to
patients, the difficulty faced in amassing large
subject samples and well-matched controls and
following them over long periods, and the sig-
nificant cost of randomized clinical trials are a
few factors contributing to the current small
number of randomized clinical trials. For certain
orthodontic treatments, evidence-based infor-
mation on treatment outcomes may not come
from randomized trials.15,16 Well-planned retro-
spective and prospective controlled trials will be
the primary evidence-based support that will
guide our profession on the effectiveness of
many of our treatments. Tightly focused system-
atic reviews that select retrospective and pro-
spective trials of the highest methodological
quality will provide second-level evidence that
will be the best evidence available to the clini-
cian.
Questions regarding the effectiveness of max-
illary expansion are an example of this issue. No
randomized clinical trials exist for characteriz-
ing the short-term effects or long-term stability
of expander therapy, but evidence-based sup-
port for the same has come from systematic
reviews of retrospective and prospective nonran-
domized trials.
129
Evidence-Based Information on the
Immediate Effects of Maxillary
Expansion
Since the first report on maxillary expansion by
Angell,17 the immediate and short-term effects
of rapid maxillary expansion (RME) with a fixed
appliance have been reported in a large number
of case reports that have independently con-
firmed that the maxilla responds to RME activa-
tion. The most current evidence-based informa-
tion regarding the immediate effect of 2-4 weeks
of RME activation comes from a meta-analysis
conducted by Lagravère et al.18 Three hundred
thirty-seven studies on the skeletal and dental
effects of RME, published between 1966 and
2004, were evaluated against the authors’ inclu-
sion criteria. Based on the authors’ determina-
tion of appropriate methodology for measuring
the immediate treatment effects of RME, 14 of
the 337 studies were chosen for the meta-analysis
and their data for changes in transverse dimen-
sion pooled. The results show that the immedi-
ate treatment effects of RME in the transverse
dimension are, on average, 60% dental and 40%
skeletal. The average intermolar width gains at
the tooth crown and root apex were 6.7 mm and
4.4 mm, respectively, and the average increase
in basal maxillary width (jugale-jugale) was 2.73
mm.
Evidence-Based Information on the
Long-term Stability of Maxillary
Expansion
What evidence is available concerning the long-
term change in maxillary transverse dimension
postexpansion (ie, the amount of expansion re-
maining ⬎5 years postretention)? We sought an
evidence-based answer to this question with a
search of the literature for meta-analyses and
systematic reviews through PubMed and Google
Scholar, using the key words palate expansion,
maxillary expansion, rapid maxillary expansion, and
slow maxillary expansion. Eight articles that sur-
veyed the literature between 1979 and January
2007 were identified.19-26 Additional trials pub-
lished between 2007 and 2009, and not part of a
systematic review or meta-analysis, are covered in
a separate section of this article. Each systematic
review or meta-analysis attempted to look at
long-term stability of maxillary expansion as one
130 Marshall and Shroff
of the treatment outcomes measured. Six of the
8 articles19-24 draw conclusions that are incon-
clusive, equivocal, or, at best, suggest weak indi-
rect evidence for long-term stability of maxillary
expansion. A 2001 Cochrane Review19 did con-
clude there is weak evidence of long-term stabil-
ity when crossbites are corrected in the primary
dentition by removal of premature contacts.
This was based on 3 of 12 studies included in the
systematic review. However, none of the in-
cluded studies followed long-term stability of
maxillary expansion after RME treatment. Shiff-
man and Tuncay20 surveyed 5000 articles on
expansion and chose 6 for meta-analysis based
on inclusion and exclusion criteria. Only 3 of
these 6 trials reported measurements of inter-
molar widths postexpansion and postretention.
From these 3 trials, the authors determined that
postretention residual intermolar width was 2.4
mm, which is similar to transverse changes ex-
pected with growth. Ko et al21 selected 11 arti-
cles for meta-analysis, all of which were non-
randomized trials. Results for long-term stability
are inconclusive because the “long-term” time
point was not well defined in these articles, vary-
ing between immediate postretention and some
undefined period after retention. Additionally,
retention protocols were not well defined. Pe-
trén et al22 performed a systematic review on 12
trials to compare effectiveness of various maxil-
lary expansion treatments, including reduction
of cusp interferences in the primary dentition,
using a quad helix or expansion plate, or an
RME in the mixed dentition. They concluded
that there was no evidence to indicate that any of
these treatments were more effective in correct-
ing posterior crossbite. Further, they found no
studies that measured the long-term stability of
the correction. The authors expressed concern
that the trials selected for review had significant
problems, including lack of power, small sample
size, bias, and confounding variables. Lagravère
et al23 evaluated treatment outcomes for slow
versus rapid maxillary expansion using fixed ex-
pansion appliances. The selected studies for the
systematic review were found to be weak in
methodology. No information regarding long-
term maxillary expansion stability was included
or evaluated. Bondemark et al14 reviewed 2 spe-
cific orthodontic treatment outcomes: long-term
stability of orthodontic treatment and patient
satisfaction. Of the 38 articles that met the in-
clusion criteria, only 3 trials evaluated long-term
stability in the transverse dimension after maxil-
lary expansion. The authors confirmed that pos-
terior crossbite can be successfully corrected in
the primary dentition using selective grinding
(79%) and that the correction was maintained
after 5 years (no maxillary expansion is per-
formed). One of the 3 trials (a retrospective
study) showed posterior crossbite correction to
be successful and stable over the long-term when
using quad helix or expansion plate in the
mixed dentition. However, the authors express
caution in their analysis of these 3 studies be-
cause of large sample attrition, unclear diagnosis
and end points, and poorly defined patient ma-
terial. The authors concluded that because these
trials suffer from weak and inconsistent method-
ology, no meaningful evidence-based conclu-
sions could be made regarding long-term expan-
sion stability. The conclusions from these 6
evidence-based reviews are based on similar
methodological weaknesses found in the trials
evaluated, including lack of long-term data, lack
of control samples, lack of sample size, selection
bias, confounding variables, lack of method or
error analyses, lack of statistical analyses, and
lack of retention protocol.
Lagravère et al24 evaluated long-term stability
using skeletal landmarks on radiographs and
concluded that there is weak or secondary evi-
dence of long-term skeletal expansion stability
using fixed expansion appliances. The evidence
is secondary because only one study met the
inclusion criteria for this systematic review. The
included study provided data for only fixed
(Haas-type) expansion appliances. In a second
systematic review, Lagravère et al25 evaluated
stability of dental arch expansion using dental
casts and concluded that there is evidence of
long-term stability of dental arch expansion.
Given that the 2 qualifying studies in this system-
atic review were not randomized controlled clin-
ical trials, the scientific evidence is not the high-
est level attainable. The authors reviewed the
literature on the long-term dental arch changes
associated with RME treatment. They searched
for controlled clinical trials that included long-
term dental arch evaluations made from posterior-
anterior radiographs or dental casts. Long-term
evaluation was defined as expansion remaining
after more than 1 year postretention. Inclusion
and exclusion criteria resulted in only 3 controlled
 Skeletal Changes with Rapid Maxillary Expansion
clinical trials, each of which used Haas-type RME
appliances. Two of these studies measured long-
term changes on dental casts against untreated
controls; one was a retrospective study for an adult
treatment sample and the other was a prospective
study for an adolescent treatment sample. Based
on the analysis of these data, the authors
concluded that between 3.7 mm (adolescent
treatment) and 4.8 mm (adult treatment) of
expansion is retained in the long-term, when
compared with controls. The third included
study measured long-term changes on posteri-
or-anterior radiographs against untreated con-
trols, but without defining a retention proto-
col. The authors commented, “Therefore,
caution should be exercised in the interpreta-
tion of the long-term (expansion) effects ac-
cording to cephalometric analysis. . . Cephalo-
metric measurements regarding intermolar
width change are subject to magnification ef-
fect and without knowledge of the magnifica-
tion factor cannot be compared directly with
model measurements.”25
Recent Trials on the Long-term Stability
of Maxillary Expansion (2007-2009)
Recent studies on the long-term stability of maxil-
lary expansion have only provided limited addi-
tional information based on weak evidence.26-31
Most studies lack control samples and have fo-
cused on the comparisons of treatment outcomes
obtained from various maxillary expansion modal-
ities. Often, these studies do not always meet the
criteria defined for systematic reviews and only
provide limited scientific evidence.
The long-term stability of maxillary expansion
was recently revisited in a comparative study of
rapid versus slow maxillary expansion in early
and late mixed dentition.26 No control group
was included in the design, and the study was
retrospective. The follow-up period was only of 2
years after the completion of active treatment.
The results from this study supported that the
long-term stability of corrected posterior cross-
bites was observed in 79% of the patients who
were treated. The amount of relapse was nearly
the same in all the groups, regardless of the
treatment modality used or stage of dentition.
The level of evidence provided by this study was,
again, limited because of intrinsic flaws with the
experimental design.
131
In a retrospective randomized controlled
study, posterior crossbite correction was also
shown to be effective and stable for 1 year after
initiating treatment when using quad helix or
expansion plate in the mixed dentition.27 Quad
helix treatment was 100% successful, whereas
removable expansion plate treatment showed a
66% success rate. Both maxillary tooth surface
composite onlay (reduction of occlusal interfer-
ences) and no treatment were not effective in
correcting posterior crossbite. Treatment proto-
col for the study included correction, but not
overcorrection, of the crossbite occlusion. The
expansion was retained for 6 months after treat-
ment, and stability of expansion was measured at
1 year after initiating treatment. The length of
the postretention period was unclear. The au-
thors intend to follow these subjects and report
on stability for a longer postretention period.
The outcomes of slow and rapid maxillary
expansion were examined in conjunction with
Class II correction in a sample of 70 consecu-
tively treated patients.28 In this retrospective
study, slow maxillary expansion was performed
by expanding the inner bow of a cervical head-
gear and not using a removable plate, as in
previous studies, and the assignment to either
group was based on the severity of the transverse
discrepancy. Results were reported per group
rather than in a comparative manner because of
the limitation in this experimental design. The
study supported that both slow and rapid max-
illary expansion offered long-term stability (10
years postretention) in the treatment of Class II
skeletal patients.
The long-term stability of maxillary expansion
performed in the mixed dentition was recently
examined in 2 prospective longitudinal clinical
studies.29,30 Geran et al29 examined 51 consecu-
tively treated patients and compared them with a
group of 26 untreated control patients for the
University of Michigan Growth Study. Patients
were treated with an expander and fixed appli-
ance therapy, and the outcomes were measured
at 3 time points on dental casts: pretreatment,
immediately post-treatment, and 5 or more years
after completion of the phase II of treatment.
The type of appliance used was an RME with
acrylic splint. Three orthodontists treated all pa-
tients, and the inclusion criteria to enter the
expansion study included the presence of crowd-
ing, lingual crossbite, an esthetic concern, or a
132 Marshall and Shroff
tendency toward Class II malocclusion. The re-
sults from this study showed that maxillary ex-
pansion can be achieved successfully during the
mixed dentition and is stable over the long-term
(5 years or more). However, the amount of
space created in the arches, as reflected by the
changes in arch perimeter, can only alleviate
mildly crowded arches effectively. As a result, the
authors concluded that maxillary expansion
could be effectively used for the correction of
transverse discrepancies and was stable over the
long-term. However, the long-term stability of
the increase in arch perimeter in the maxilla
(3.8 mm) needed to be considered with caution.
The second prospective trial evaluated the
association of a maxillary expansion device with
the use of a mandibular Schwartz plate in the
mixed dentition.30 A total of 50 patients were
included in this study along with a control group
of 16 untreated subjects obtained from the Uni-
versity of Michigan Growth Study. Three groups
of patients were compared in this study: the first
group was treated with an RME only (27 pa-
tients), the second group was treated with an
RME and a mandibular Schwartz plate (23 pa-
tients), and the third group was a control group
derived from the University of Michigan Growth
Study (16 patients). The treatment outcomes
were measured on dental casts at 4 time points:
before treatment, after the expansion, after
completion of treatment, and at least 3 years
after the completion of treatment. The study
showed that the use of an RME only allows for
the correction of a transverse discrepancy with a
limited long-term increase in the arch perimeter
(⬍3 mm). When an RME was combined with a
mandibular Schwartz plate, the long-term in-
crease of the mandibular arch perimeter al-
lowed for an acceptable correction of moderate
tooth size arch length discrepancies (3.8 mm).
This result was comparable with what was re-
ported in a previous study,29 which used an
acrylic splint RME. It is to be noted that these 2
latter studies focused on the long-term stability
of arch length gained after maxillary expansion
rather than maxillary expansion alone.
Sokucu et al31 reported on maxillary expan-
sion stability 2 years post-treatment (1 year
postretention) for patients treated with RME
and surgically assisted RME. Thirteen subjects
with bilateral posterior crossbite, mean age of 12
years, underwent an RME treatment protocol
involving activation of bonded maxillary ex-
panders with an occlusal coverage at the rate of
1 turn per day to an unknown end point (“until
the desired suture opening was achieved”29).
The expanders were then used as removable
retainers for 6 months. A transpalatal arch was
included for subsequent fixed edgewise therapy.
Removable retainers were delivered at de-band-
ing and worn for 1 year. Follow-up records were
taken 1 year later, thereby allowing measure-
ment of expansion 1 year postretention com-
pared with expansion at de-banding. Of the 2.8
mm of intermolar expansion gained from pre-
treatment condition, no significant loss of ex-
pansion was seen 1 year postretention.
From the review of the recent literature, it is
still apparent that evidence supporting the long-
term stability of maxillary expansion is limited.
The primary reasons for the low-to-moderate
value of this evidence are generally based on the
fact that studies have analyzed retrospective
rather than prospective data, they have not al-
ways included a control group of patients (for
reasons cited earlier in this article), the diagno-
sis and end points of the observations are un-
clear or ill-defined, and the patient groups are
often poorly defined. This has resulted in a lack
of standardization of the studies and difficulty in
comparing their results.
Conclusions
In summary, from the evidence-based point of
view, the evidence on whether maxillary expan-
sion is stable over the long-term comes from one
retrospective controlled trial on adult subjects
and one prospective controlled trial on adoles-
cent subjects. In the adolescent study, posterior
crossbite was not an initial condition for any
subject. In the adult study, 83% of the subjects
began expansion therapy with posterior cross-
bite. Thus, the evidenced-based answer pertains
directly to these conditions. Although many cli-
nicians can assert, on the basis of their experi-
ence, that RME treatment is a stable procedure,
there remains a lack of strong evidence for long-
term stability of maxillary expansion in adoles-
cent subjects, in whom posterior crossbite is the
pretreatment condition. To bolster the evidence
for maxillary expansion stability, well-designed
retrospective and prospective controlled trials
are needed. Future trials should include well-
 Skeletal Changes with Rapid Maxillary Expansion
defined retention protocols and the use of un-
treated control groups to factor out normal
transverse changes anticipated with growth. Sys-
tematic review and meta-analysis will provide
stronger evidence for treatment effectiveness.
From this review of evidence-based literature, it
is apparent that, at present, orthodontists must
accept that there are treatments for which a high
level of evidence for treatment effectiveness is
not yet available.
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