ORIGINAL ARTICLE

Effects of rapid maxillary expansion in

hyperdivergent patients
Matthew W. Lineberger,a James A. McNamara,b Tiziano Baccetti,y Thomas Herberger,c and Lorenzo Franchid
Ann Arbor, Mich, Elyria, Ohio, and Florence, Italy

Introduction: This retrospective cohort study was performed to evaluate the skeletal and dental changes in the
short and long terms in hyperdivergent patients treated with rapid maxillary expansion and fixed appliances.
Methods: The sample consisted of 143 patients who had rapid maxillary expansion with a Haas-type
expander followed by edgewise therapy. Two groups were established: a normal vertical dimension group
(mandibular plane angle .20 and \27 ; n 5 52) and a hyperdivergent group (mandibular plane angle $27 ;
n 5 91). Lateral cephalograms were taken before treatment (average age, 11.5 years in both groups) and
after fixed appliance therapy (average age, 14.3 years in both groups). Subjects who exhibited opening or
closing in the mandibular plane angle during treatment greater than 1.5 (opening group, n 5 23; closing
group, n 5 26) were followed in the long term (average age, 20.3 years). Longitudinal changes in the
different groups were evaluated statistically as well as the prevalence rates of hyperdivergent patients in the
opening and closing groups. Results: No significant differences in treatment effects were found in any sagittal
or vertical dentoskeletal variables examined. The long-term evaluation of the patients at 5 or more years
posttreatment showed no significant skeletal changes. The prevalence rate of hyperdivergent patients in the
opening group was not significant. Conclusions: The results of this study indicate that rapid maxillary expansion
can be carried out successfully in patients with increased vertical dimensions without detrimental effects on
the vertical skeletal relationships. Thus, an increased mandibular plane angle is not a contraindication for rapid
maxillary expansion therapy. (Am J Orthod Dentofacial Orthop 2012;142:60-9)

A
hyperdivergent patient with problems in the
transverse dimension (eg, posterior crossbite,
arch length discrepancy due to narrow arches)
is a particular challenge during orthodontic treatment.
Fear of creating a negative profile change due to rapid
a
Postgraduate student, Graduate Program in Orthodontics, Department of
Orthodontics and Pediatric Dentistry, University of Michigan, Ann Arbor.
b
Thomas M. and Doris Graber Endowed Professor of Dentistry, Department of
Orthodontics and Pediatric Dentistry, School of Dentistry; professor of Cell and
Developmental Biology, School of Medicine; research scientist, Center for Human
Growth and Development, University of Michigan, Ann Arbor; private practice,
Ann Arbor, Mich.
c
Private practice, Elyria, Ohio.
d
Assistant professor, Department of Orthodontics, University of Florence, Flor-
ence, Italy; Thomas M. Graber Visiting Scholar, Department of Orthodontics
and Pediatric Dentistry, School of Dentistry, University of Michigan, Ann Arbor.
y
Deceased.
Supported in part by funds from the Thomas M. and Doris Graber Endowed Pro-
fessorship, Department of Orthodontics and Pediatric Dentistry, University of
Michigan.
The authors report no commercial, proprietary, or financial interest in the prod-
ucts or companies described in this article.
Reprint requests to: James A. McNamara, Department of Orthodontics and
Pediatric Dentistry, University of Michigan, Ann Arbor, MI 48109-1078;
e-mail, mcnamara@umich.edu.
Submitted, August 2011; revised and accepted, February 2012.
0889-5406/$36.00
Copyright Ó 2012 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2012.02.019
60
maxillary expansion caused by downward and backward
rotation of the mandible can be a major concern to many
clinicians when planning treatment for a high-angle
patient with maxillary constriction.
The vast majority of the literature on rapid maxillary
expansion has documented the sagittal and vertical skel-
etal effects of expansion in the short term. These studies
describe downward movements of the maxilla in
response to rapid maxillary expansion that resulted in
posterior rotation of the mandible and opening of the
mandibular plane angle.1-8 These short-term results
seemed to indicate that hyperdivergent patients would
be affected negatively by rapid maxillary expansion in
the vertical dimension. Furthermore, the significance of
the findings in some short-term investigations appears
to be limited due to the large age range before treatment
(Wertz and Dreskin4; ages, 7-29 years), the limited sam-
ple sizes (Haas9; n 5 4; Inoue et al10; n 5 8), and, more
generally, the lack of control data.
Investigations on the long-term skeletal changes
produced by rapid maxillary expansion found that
the opening in the mandibular plane angle is mainly
a transient effect of rapid maxillary expansion.4,9,11-14
However, once again, most of these studies showed
some methodologic limitations, since they had small
Lineberger et al
sample sizes or lacked specific analyses of groups of
patients with hyperdivergent patterns.
Therefore, the aim of this study was to evaluate the
dentoskeletal changes in the short and long terms in
a large sample of hyperdivergent patients treated with
rapid maxillary expansion and fixed appliances, with
the ultimate goal of appraising whether an increased
vertical dimension can be a contraindication for rapid
maxillary expansion therapy.
MATERIAL AND METHODS
The sample analyzed in this retrospective cohort inves-
tigation consisted of 143 patients (58 boys, 85 girls) with
normal or hyperdivergent vertical skeletal pattern (man-
dibular plane angle .20 at an average age of 11 years).15
All patients underwent maxillary expansion with a Haas
expander and were treated in the same private practice.
Lateral cephalograms of good quality were taken of all pa-
tients at 2 time points (pretreatment [T1] and after fixed
appliance treatment [T2]) and, for a more limited sample
of 49 subjects, also at a posttreatment long-term observa-
tion (T3, more than 5 years posttreatment). The average
ages were 11.4 years 6 1.2 years at T1, 14.3 years 6
1.1 years at T2, and 20.1 years 6 1.6 years at T3.
The patients from the private practice of Drs Robert
and Thomas Herberger of Elyria, Ohio, enrolled in the
clinical trial had a nonextraction treatment protocol in-
corporating rapid maxillary expansion with a Haas-type
maxillary expander (Fig 1) turned twice per day at 0.25
mm per turn until the expansion screw reached 10.5
mm. As reported elsewhere, the average amount of max-
illary deficiency at the level of the first permanent molars
was 6 to 7 mm.16 The standardized expansion of 10.5
mm took into account the expected average postexpan-
sion relapse tendency of about 30%.17 The Haas ex-
pander was kept in place after active expansion for an
average of 65 days for retention. Full fixed orthodontic
appliances were placed immediately after the removal
of the Haas-type rapid maxillary expansion. No further
active expansion was obtained during the fixed appli-
ance phase and no adjuncts (eg, headgears or chincups)
other than intermaxillary elastics were used at any time.
An attempt was made to recall all patients who had
the treatment protocol described above. One hundred
forty-three patients agreed to have follow-up records
taken at about the age of 20 years. This sample of
patients, followed for 5 or more years after active treat-
ment, can be considered a type of “consecutively
treated” patient sample, in that treatment outcome
was not a basis for patient selection.
In the cephalometric analysis, serial films for a subject
were traced in 1 sitting by 1 investigator (M.W.L.) and
then verified for anatomic contour and landmark
American Journal of Orthodontics and Dentofacial Orthopedics
61
Fig 1. The Haas-type rapid maxillary expander.
identification and tracing superimpositions by a second
investigator (J.A.M.).
Regional superimpositions in each series were ac-
complished by hand, as previously advocated by Rick-
etts18 and McNamara,19 and in accordance with the
findings of the implant study of Bj€ ork and Skieller.20
Maxillary and mandibular fiducial markers used for
this purpose were placed on the T2 tracing and then car-
ried through to the T1 and T3 tracings (when appropri-
ate) in a series by way of maxillary and mandibular
regional superimpositions, respectively.
Tracings of the lateral cephalograms were digitized by
using a digitizing device (Numonics, Landsdale, Pa) and
digitizing software (DFP Plus 2.02; Dentofacial Software,
Toronto, Ontario, Canada). From the digitized tracings,
25 measurements were generated for each patient at
each time point. All lateral cephalograms had a magnifi-
cation from 6% to 8%. To standardize the data, all linear
measurements were converted to 8% enlargement.
The subjects were analyzed at T1, T2, and T3 with the
cervical vertebral maturational method, a reliable way to
assess skeletal maturity, as described by Baccetti et al.21
Blinded to the patient's age, 2 evaluators (T.B. and L.F.)
experienced in the cervical vertebral maturational
method determined each patient's stage. Any discrep-
ancies between the 2 evaluators were resolved by a third
experienced investigator (J.A.M.).
Statistical analysis
Means and standard deviations were calculated for
all cephalometric measures at the different time points.
Based on the initial mandibular plane angles, the
subjects were first divided into 2 groups: a normal
group (mandibular plane angle .20 and \27 ) and
July 2012  Vol 142  Issue 1
62
a hyperdivergent group (mandibular plane angle $27 ).
The average ages for the normal group were 11.5 6
1.1 years at T1, and 14.3 6 1.2 years at T2. The average
ages for the hyperdivergent group were 11.4 6 1.2 years
at T1, and 14.3 6 1.1 years at T2.
An exploratory Shapiro-Wilks test was performed on
all variables to test the normality of the samples, and
a Levene test was performed to evaluate the equality
of variances. The results were not significant and indi-
cated normality of distribution and equality of variances
for the examined parameters; therefore, parametric sta-
tistics were recommended. The Student t test was used
to compare statistically the starting forms at T1 and
the changes observed from T1 to T2 between the normal
and hyperdivergent groups.
The hyperdivergent group then was divided further
into 2 groups: moderately hyperdivergent (mandibular
plane angle $27 and \32 ) and very hyperdivergent
(mandibular plane angle $32 ). The average ages for
the moderately hyperdivergent group were 11.4 6 1.1
years at T1, and 14.3 6 1.0 years at T2. The average
ages for the very hyperdivergent group were 11.3 6
1.4 years at T1, and 14.2 6 1.3 years at T2. Analysis
of variance (ANOVA) with the Tukey post-hoc test was
used to compare statistically the starting forms at T1,
and the T1 to T2 changes in the 3 groups (normal vs
moderately hyperdivergent vs very hyperdivergent).
After the analysis of the treatment effects observed in
the first 2 headfilms (T2-T1), the patients were stratified
into 2 subgroups on the basis of changes in mandibular
plane angles during treatment. This further analysis
aimed to evaluate the changes in mandibular plane an-
gles as a result of the patients' responses to treatment in
addition to their vertical characteristics at T1. The clos-
ing group would comprise patients who had a substantial
closure (more negative than –1.5 ) of the mandibular
plane angle from T1 to T2, whereas the opening group
would comprise patients who from T1 to T2 experienced
a substantial opening of the mandibular plane angle
more positive than 1.5 . The value of 1.5 was chosen
based on the method error for the mandibular plane an-
gle measure (about 1 ). The prevalence rate of hyperdi-
vergent subjects was calculated in the 2 subgroups and
compared by using a z-test on proportions. Lastly, the
closing and opening groups were followed for the T3
observation of at least 5 years after the end of fixed ap-
pliances (average age, 20.3 years). The posttreatment
(T2-T3) changes in the opening and closing groups
were compared with the Student t test. Statistical signif-
icance was tested at the P \0.05 level for all statistical
tests, performed with statistical software (SPSS for Win-
dows, version 12; SPSS, Chicago, Ill; SigmaStat version
3.5; Systat Software, Point Richmond, Calif).
July 2012  Vol 142  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Lineberger et al
The power of the study was calculated on the basis of
the sample size of the groups and the effect size equal to
1, and it was greater than 0.90 for all comparisons.22
Thirty subjects from the sample were selected at random.
All films were retraced and redigitized, and cephalo-
metric variables were reassessed. Intraclass correlation
coefficients were calculated to compare within-subject
variability with between-subjects variability. Correlation
coefficients for the cephalometric measures were
extremely high; all correlation coefficients were greater
than 0.985. The errors in measurements for both linear
and angular variables were within 1.2 mm and 1.2 ,
respectively.
RESULTS
All groups (normal, hyperdivergent, and very hyper-
divergent) were well matched with regard to skeletal ma-
turity. Most subjects were in a prepubertal stage of
development (CS 1-3) at T1 and in a postpubertal stage
of development (CS 4-6) at T2. All subjects were fully
mature (CS 6) at T3.
Descriptive statistics for the normal and hyperdiver-
gent groups at T1 are presented in Table I. In the normal
group, the average mandibular plane angle value was
24.0 6 2.0 ; the hyperdivergent group had a mandibu-
lar plane angle of 31.0 6 3.0 (Table II). Lower anterior
facial height, measured from ANS to menton, was longer
in the hyperdivergent group than in the normal group
(12.3 mm). Posterior facial height, the distance from
condylion to gonion, was significantly shorter in the hy-
perdivergent group (–4.4 mm), indicating that decreased
posterior facial height in the hyperdivergent group was
a significant factor in the steepness of the mandibular
plane angle. The gonial angle also was greater in the hy-
perdivergent group than in the normal group (16.3 ).
No differences in the angle between the palatal plane
and the Frankfort horizontal or in upper facial height
(Na-ANS) were noted (Table I).
The common observation that could be made in the
sagittal starting form was the relative retrusion of both
the maxilla and the mandible in the hyperdivergent
group compared with the normal group. When the sag-
ittal position of the maxilla relative to the mandible was
evaluated, however, no differences between the 2 groups
were noted.
Similarly, there were no differences in interdental re-
lationships, including overbite, overjet, molar relation-
ship, and interincisal angle. The only significant dental
measurement was the relationship of the mandibular in-
cisor to the mandibular plane (IMPA). The mandibular
incisor was significantly more upright (–5.6 ) in the hy-
perdivergent group with respect to the normal group.
Lineberger et al 63

Table I. Comparison of starting forms: normal vs hyperdivergent

Hyperdivergent (n 5 91) Normal (n 5 52)
P value
Cephalometric measurement Mean SD Mean SD Difference (t test)
Cranial base
Ba-S-N ( ) 129.0 4.7 127.9 4.2 11.1 0.151
Maxillary AP skeletal
SNA ( ) 79.0 3.0 80.6 2.9 1.6 *
Co-Point A (mm) 86.6 3.6 89.5 4.5 2.9 y
Point A-Na perp (mm) 1.9 2.8 0.3 2.6 1.6 *
Mandibular AP skeletal
SNB ( ) 75.7 2.7 77.6 2.6 1.9 y
Co-Gn (mm) 111.3 5.4 113.8 5.8 2.5 z
Pg to Na perp (mm) 8.6 4.1 4.3 3.9 4.3 y
Intermaxillary
ANB ( ) 3.3 2.3 3.0 1.8 10.3 0.360
Maxillomandibular difference (mm) 24.8 4.1 24.3 3.7 10.5 0.518
Wits appraisal (mm) 1.2 2.8 0.4 2.5 0.8 0.102
Vertical skeletal
FH to PP ( ) 0.6 3.0 1.1 3.0 0.5 0.285
MPA ( ) 31.0 3.0 24.0 2.0 17.0 y
Go angle ( ) 131.2 5.3 124.9 4.4 16.3 y
N-ANS (mm) 51.2 3.3 51.0 3.5 10.2 0.840
ANS-Me (mm) 67.3 4.5 65.0 5.0 12.3 *
Co-Go (mm) 47.8 3.6 52.2 4.1 4.4 y
Interdental
Overbite (mm) 3.3 1.9 3.5 1.9 0.2 0.584
Overjet (mm) 5.3 1.8 4.7 2.0 10.6 0.070
Interincisal angle ( ) 130.4 8.0 129.5 9.1 10.9 0.523
Molar relation (mm) 1.6 1.4 1.4 1.3 10.2 0.427
Dentoalveolar
U1-Point A vert (mm) 4.3 1.6 4.7 1.2 0.4 0.135
IMPA ( ) 87.5 5.3 93.1 5.6 5.6 y
Soft tissue
Upper lip to E-line (mm) 3.0 2.3 3.1 2.4 10.1 0.840
Lower lip to E-line (mm) 0.1 2.4 0.7 2.3 10.8 0.050
NL angle ( ) 115.7 12.7 114.1 13.8 11.6 0.476

AP, Anteroposterior; NL, nasiolabial; perp, perpendicular; vert, vertical.

*P \0.01; yP \0.001; zP \0.05

There were no significant differences in the 3 soft-tissue
measurements evaluated.
No significant differences were found for any dentos-
keletal or soft-tissue variables examined from T1 to T2
(Table II). Of particular interest were the changes in the
mandibular plane relative to the Frankfort horizontal
plane. The mandibular plane angle opened by only
0.3 6 1.8 in the hyperdivergent group; the same angle
in the normal group on average remained unchanged
(0.0 6 1.8 ).
The average mandibular plane angle in the moder-
ately hyperdivergent group was 29.3 6 1.4 ; the
same angle in the very hyperdivergent group was 34.7
6 2.0 ; the mandibular plane angle of the normal group
remained at 24.0 6 2.0 (Table III). Lower anterior fa-
cial height was 2.8 mm longer in the very hyperdivergent
group than in the moderately hyperdivergent group,
a difference that was statistically significant. There was
no difference in posterior facial height (Co-Gn) between
the 2 hyperdivergent groups, although the measurement
was statistically longer in both groups than in the normal
group. No differences among groups were seen in upper
facial height. The gonial angle in the very hyperdivergent
group was 5.4 greater than that of the moderately
hyperdivergent group and 10 greater than the gonial
angle of the normal group.
A similar pattern of maxillary and mandibular skeletal
retrusion relative to the cranial base was noted as the
mandibular plane angle increased (Table III). The maxilla
was more retruded in both hyperdivergent groups com-
pared with the normal group, but they were not different
from one another. There were no differences in any of
the 3 intermaxillary measures considered. No significant
differences were noted in any dental measurements,

American Journal of Orthodontics and Dentofacial Orthopedics July 2012  Vol 142  Issue 1
64 Lineberger et al

Table II. Comparison of T2-T1 changes: normal vs hyperdivergent

Hyperdivergent (n 5 91) Normal (n 5 52)

Cephalometric measurement Mean SD Mean SD Difference P value (t test)

Cranial base
Ba-S-N ( ) 0.1 1.6 0.1 1.6 10.2 0.707
Maxillary AP skeletal
SNA ( ) 0.5 1.4 0.4 1.3 0.1 0.681
Co-Point A (mm) 2.6 1.5 2.7 1.7 0.1 0.896
Point A-Na perp (mm) 0.8 1.4 0.6 1.3 0.2 0.331
Mandibular AP skeletal
SNB ( ) 0.1 1.5 0.2 1.3 0.1 0.647
Co-Gn (mm) 7.0 3.1 6.1 2.4 10.9 0.065
Pg to Na perp (mm) 0.1 2.7 0.5 2.3 0.4 0.301
Intermaxillary
ANB ( ) 0.6 1.5 0.6 1.1 0.0 0.980
Maxillomandibular difference (mm) 4.4 2.9 3.4 2.4 11.0 0.052
Wits appraisal (mm) 1.4 2.9 0.7 2.3 10.7 0.150
Vertical skeletal
FH to PP ( ) 0.6 1.6 0.5 1.6 0.1 0.620
MPA ( ) 0.3 1.8 0.0 1.8 10.3 0.424
Go angle ( ) 1.5 2.4 0.7 3.6 0.8 0.099
N-ANS (mm) 3.3 1.6 2.9 1.6 10.4 0.162
ANS-Me (mm) 4.3 2.4 3.7 2.4 10.6 0.150
Co-Go (mm) 3.8 2.5 3.3 3.9 10.5 0.332
Interdental
Overbite (mm) 1.8 1.8 2.1 1.9 10.3 0.425
Overjet (mm) 1.9 3.6 1.5 1.6 0.4 0.417
Interincisal angle ( ) 13.3 17.0 10.0 10.3 3.3 0.205
Molar relation (mm) 1.0 2.0 1.1 1.3 0.1 0.732
Dentoalveolar
U1-Point A vert (mm) 0.4 3.5 0.3 1.3 10.1 0.869
IMPA ( ) 7.1 5.5 5.8 5.5 11.3 0.182
Soft tissue
Upper lip to E-line (mm) 1.3 1.6 1.6 2.0 10.3 0.253
Lower lip to E-line (mm) 0.1 1.7 0.5 2.3 10.4 0.194
NL angle ( ) 0.1 12.1 1.0 12.2 10.9 0.697

AP, Anteroposterior; NL, nasiolabial; perp, perpendicular; vert, vertical.

except for IMPA, which was significantly smaller in both
hyperdivergent groups. No differences were noted in any
of the 3 soft-tissue measurements considered.
Similar to the comparison between the overall hyper-
divergent and normal groups, no significant differences
were found for any dentoskeletal or soft-tissue variables
examined from T1 to T2 for the 3 groups (Table IV).
A total of 24 patients had a decrease in the mandib-
ular plane angle greater than 1.5 from T1 to T2 and
comprised the closing group, and 33 patients had an in-
crease in the mandibular plane angle greater than 1.5
and comprised the opening group. These groups were
evaluated by analysis of the prevalence of hyperdiver-
gent subjects. In the closing subgroup, 58.3% were hy-
perdivergent; 72.7% of the patients in the opening
subgroup were hyperdivergent. A z-test was performed
on these groups, and no significant differences were
found in proportions (z 5 0.902; P 5 0.377).
The subjects in these 2 groups subsequently had their
T3 cephalograms analyzed for long-term data. Descrip-
tive statistics and statistical comparisons of the T2 to T3
changes in these subgroups are presented in Table V.
No significant differences were found between the
opening and closing groups in any cephalometric vari-
ables examined. In particular, the mandibular plane an-
gle decreased by –1.1 6 2.3 in the opening group, and
a similar closure (–1.2 6 2.3 ) was noted in the closing
group.
DISCUSSION
This retrospective cohort study examined the treat-
ment effects of rapid maxillary expansion followed by
full fixed appliances on a large group (n 5 143) of con-
secutively treated patients with specific facial types (hy-
perdivergent vs normal, with the hyperdivergent group
subdivided into very hyperdivergent vs moderately

July 2012  Vol 142  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Lineberger et al 65

Table III. Comparison of starting forms: normal vs hyperdivergent vs very hyperdivergent

Hyperdivergent Very hyperdivergent Normal
(n 5 62) (n 5 29) (n 5 52) Statistical comparisons
Cephalometric ANOVA
measurement Mean SD Mean SD Mean SD P value H vs VH H vs N VH vs N
Cranial base
Ba-S-N ( ) 129.2 4.7 128.6 4.8 127.9 4.2 0.296 NS NS NS
Maxillary AP skeletal
SNA ( ) 79.2 2.9 78.7 3.3 80.6 2.9 0.010 NS * *
Co-Point A (mm) 86.6 3.3 86.4 4.3 89.5 4.5 0.000 NS * *
Point A-Na perp (mm) 1.7 2.9 2.1 2.6 0.3 2.6 0.005 NS * NS
Mandibular AP skeletal
SNB ( ) 76.2 2.5 74.7 3.0 77.6 2.6 0.000 * * *
Co-Gn (mm) 111.3 4.8 111.4 6.5 113.8 5.8 0.051 NS NS NS
Pg to Na perp (mm) 7.5 3.9 11.1 3.4 4.3 3.9 0.000 * * *
Intermaxillary
ANB ( ) 3.0 2.2 4.1 2.3 3.0 1.8 0.051 NS NS NS
Maxillomandibular 24.7 4.0 25.0 4.3 24.3 3.7 0.763 NS NS NS
difference (mm)
Wits appraisal (mm) 1.1 2.8 1.4 2.9 0.4 2.5 0.245 NS NS NS
Vertical skeletal
FH to PP ( ) 0.9 2.8 0.2 3.3 1.1 3.0 0.155 NS NS NS
MPA ( ) 29.3 1.4 34.7 2.0 24.0 2.0 0.000 * * *
Go angle ( ) 129.5 4.8 134.9 4.4 124.9 4.4 0.000 * * *
N-ANS (mm) 50.8 3.1 51.9 3.5 51.0 3.5 0.370 NS NS NS
ANS-Me (mm) 66.4 4.2 69.2 4.6 65.0 5.0 0.001 * NS *
Co-Go (mm) 48.3 3.5 46.7 3.7 52.2 4.1 0.000 NS * *
Interdental
Overbite (mm) 3.3 1.9 3.3 2.0 3.5 1.9 0.845 NS NS NS
Overjet (mm) 5.1 1.7 5.8 2.0 4.7 2.0 0.046 NS NS *
Interincisal angle ( ) 130.5 8.1 130.4 8.1 129.5 9.1 0.814 NS NS NS
Molar relation (mm) 1.6 1.5 1.6 1.2 1.4 1.3 0.727 NS NS NS
Dentoalveolar
U1-Point A vert (mm) 4.6 1.6 3.9 1.8 4.7 1.2 0.035 NS NS *
IMPA ( ) 88.7 5.3 85.1 4.6 93.1 5.6 0.000 * * *
Soft tissue
Upper lip to E-line (mm) 3.1 2.5 2.8 1.9 3.1 2.4 0.880 NS NS NS
Lower lip to E-line (mm) 0.1 2.5 0.5 2.3 0.7 2.3 0.085 NS NS NS
NL angle ( ) 114.3 13.8 118.6 9.4 114.1 13.8 0.271 NS NS NS

AP, Anteroposterior; H, hyperdivergent; N, normal; NL, nasiolabial; NS, not significant; perp, perpendicular; vert, vertical; VH, very hyperdivergent.
*P \0.05.

hyperdivergent). All patients received a standardized
amount of rapid maxillary expansion with a Haas-type
expander (10.5 mm) regardless of vertical skeletal fea-
tures. The stages of cervical vertebral maturation, age,
and sex were well matched between the hyperdivergent
groups and the normal group. More in detail, patients
were mainly prepubertal or pubertal at T1, with only
21 patients postpubertal at T1, and no patient had
reached CS 6 at T1. At T2, they were mostly postpubertal,
with only 20 patients showing CS 3 or below. At T3, all
patients had completed their active craniofacial growth;
they all showed CS 6. This type of information cannot be
derived from any previous study looking at the vertical
skeletal changes in rapid maxillary expansion patients.
Beyond the obvious differences in mandibular plane
angles between the groups before treatment, both the
maxilla and the mandible were positioned more retro-
gnathically relative to the cranial base in the hyperdiver-
gent patients, especially in the patients in the very
hyperdivergent group. Because both the mandible and
the maxilla were retropositioned and were shorter in
effective length, however, intermaxillary measures that
gauge the position of the mandible relative to the max-
illa (eg, ANB angle, Wits appraisal) were not significantly
different between the groups. These morphologic fea-
tures in hyperdivergent subjects are consistent with the
classical concepts by Solow and Kreiborg,23 who
described the craniofacial morphogenetic role of soft-
tissue stretching on the vertical and sagittal skeletal
characteristics. The angle formed by the mandibular in-
cisor relative to the mandibular plane was significantly
smaller in both hyperdivergent groups when compared

American Journal of Orthodontics and Dentofacial Orthopedics July 2012  Vol 142  Issue 1
66 Lineberger et al

Table IV. Comparisons of T2-T1 changes: normal vs hyperdivergent vs very hyperdivergent

Hyperdivergent (n 5 62) Very hyperdivergent (n 5 29) Normal (n 5 52)

Cephalometric measurement Mean SD Mean SD Mean SD ANOVA P value

Cranial base
Ba-S-N ( ) 0.1 1.6 0.0 1.6 0.1 1.6 0.883
Maxillary AP skeletal
SNA ( ) 0.4 1.4 0.5 1.5 0.4 1.3 0.912
Co-Point A (mm) 2.5 1.6 3.0 1.4 2.7 1.7 0.354
Point A-Na perp (mm) 0.8 1.4 0.8 1.3 0.6 1.3 0.625
Mandibular AP skeletal
SNB ( ) 0.1 1.5 0.1 1.6 0.2 1.3 0.899
Co-Gn (mm) 6.7 3.2 7.7 2.9 6.1 2.4 0.063
Pg to Na perp (mm) 0.2 2.7 0.1 2.7 0.5 2.3 0.544
Intermaxillary
ANB ( ) 0.5 1.6 0.6 1.2 0.6 1.1 0.950
Maxillomandibular difference (mm) 4.3 2.9 4.7 2.3 3.4 2.2 0.067
Wits appraisal (mm) 1.0 2.9 2.2 2.9 0.7 2.3 0.051
Vertical skeletal
FH to PP ( ) 0.6 1.6 0.6 1.7 0.5 1.6 0.883
MPA ( ) 0.2 1.9 0.5 1.6 0.0 1.8 0.615
Go angle ( ) 1.6 2.4 1.3 2.3 0.7 3.6 0.218
N-ANS (mm) 3.1 1.7 3.6 1.3 2.9 1.6 0.138
ANS-Me (mm) 4.0 2.3 5.0 2.5 3.7 2.4 0.071
Co-Go (mm) 4.0 2.6 3.6 2.3 3.3 3.9 0.527
Interdental
Overbite (mm) 1.9 1.9 1.7 1.7 2.1 1.9 0.636
Overjet (mm) 2.0 4.2 1.7 1.5 1.5 1.6 0.611
Interincisal angle ( ) 14.6 19.4 10.7 10.0 10.0 10.3 0.227
Molar relation (mm) 1.2 2.3 0.5 1.2 1.1 1.3 0.226
Dentoalveolar
U1-Point A vert (mm) 0.3 4.1 0.8 1.8 0.3 1.3 0.720
IMPA ( ) 7.2 5.5 6.8 5.5 5.8 5.5 0.387
Soft tissue
Upper lip to E-line (mm) 1.3 1.8 1.3 1.4 1.6 2.0 0.520
Lower lip to E-line (mm) 0.1 1.7 0.0 1.7 0.5 2.3 0.424
NL angle ( ) 1.5 11.1 2.9 13.7 1.0 12.2 0.246

AP, Anteroposterior; NL, nasiolabial; perp, perpendicular; vert, vertical.

with normal subjects, thus reflecting a dentoalveolar
compensation to the steepening of the mandibular
plane. This observation has been noted in the past by
ork and Skieller,24 Steiner,25-27 and Solow,28 among
Bj}
others.
The first and fundamental outcome of our study was
represented by the minimal changes in the mandibular
plane angles induced by treatment in all 3 groups
(0.0 in the normal group, 0.2 in the moderately hyper-
divergent group, and 0.5 in the very hyperdivergent
group). Therefore, the differences among groups in
terms of increase in the inclination of the mandibular
plane to the Frankfort horizontal were not statistically
significant, and they were within a 0.5 range. Therefore,
the rapid maxillary expansion protocol can be used
safely in hyperdivergent or even very hyperdivergent
patients. None of the other cephalometric dentoskeletal
parameters investigated in this study showed any
significant change induced by rapid maxillary expansion
when reevaluated after fixed appliance therapy. Rapid
maxillary expansion therapy does not induce any signif-
icant change in dental or skeletal, sagittal or vertical, or
hard-tissue or soft-tissue parameters investigated after
fixed appliance therapy, as already suggested in the
study by Chang et al13 on smaller samples of subjects.
The concern expressed by several short-term studies
that rapid maxillary expansion treatment would have
the side effect of increasing the vertical skeletal dimension
was not corroborated by our results.1-8 Other long-term
studies have agreed in reporting the lack of significant
changes in the mandibular plane angle after rapid maxil-
lary expansion.4,9,11,13 However, these studies did not
focus specifically on patients with increased vertical
dimensions before rapid maxillary expansion.
Another interesting observation derives from the
comparison of the absolute change in mandibular plane

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Lineberger et al 67

Table V. Comparison of long-term (T3-T2) changes: opening vs closing groups

Closing group (n 5 23) Opening group (n 5 26)

Cephalometric measure Mean SD Mean SD Difference P value (t test)

Cranial base
Ba-S-N ( ) 0.3 1.9 0.5 1.3 0.2 0.579
Maxillary AP skeletal
SNA ( ) 0.6 1.6 0.1 1.4 10.5 0.175
Co-Point A (mm) 2.5 2.2 2.2 1.6 10.3 0.585
Point A-Na perp (mm) 0.4 1.3 0.0 1.1 10.4 0.236
Mandibular AP skeletal
SNB ( ) 0.9 1.6 0.6 1.6 10.3 0.563
Co-Gn (mm) 4.6 3.3 5.1 3.9 0.5 0.650
Pg to Na perp (mm) 1.7 2.7 1.3 2.5 10.4 0.552
Intermaxillary
ANB ( ) 0.2 1.6 0.6 1.3 10.4 0.382
Maxillomandibular difference (mm) 2.1 2.7 2.9 2.9 0.8 0.354
Wits appraisal (mm) 0.3 2.9 0.4 2.7 10.1 0.927
Vertical skeletal
FH to PP ( ) 0.5 2.2 0.2 1.4 0.3 0.448
MPA ( ) 1.2 1.7 1.1 2.3 0.1 0.880
Go angle ( ) 1.6 3.0 2.7 4.6 11.1 0.651
N-ANS (mm) 1.1 2.1 2.0 1.6 0.9 0.135
ANS-Me (mm) 2.8 1.8 2.9 2.3 0.1 0.863
Co-Go (mm) 3.3 4.1 3.8 4.2 0.5 0.770
Interdental
Overbite (mm) 0.5 1.3 0.3 1.5 10.2 0.711
Overjet (mm) 0.1 1.2 0.3 1.1 10.2 0.542
Interincisal angle ( ) 0.7 4.9 1.4 4.9 0.7 0.627
Molar relation (mm) 0.3 0.9 0.4 1.1 0.1 0.831
Dentoalveolar
U1-Point A vert (mm) 0.4 1.2 0.9 1.0 0.5 0.169
IMPA ( ) 0.7 4.1 1.0 3.0 0.3 0.770
Soft tissue
Upper lip to E-line (mm) 2.0 1.8 1.1 1.8 0.9 0.090
Lower lip to E-line (mm) 2.1 2.1 1.5 1.6 0.6 0.264
NL angle ( ) 2.5 8.6 3.3 10.5 15.8 0.051

AP, Anteroposterior; NL, nasiolabial; perp, perpendicular; vert, vertical.

angles in the groups of patients we evaluated in this
study with the growth changes expressed by untreated
controls with a tendency toward high-angle facial pat-
terns in the literature. The changes in the mandibular
plane angles in the moderately hyperdivergent and
very hyperdivergent patients in this study (0.2 6 1.9 ,
and 0.5 6 1.6 , respectively) are similar to those of
untreated controls along with growth during a period
comparable to our T1 to T2 interval (–0.3 6 2.3 in
the study of Chang et al13; –0.7 6 2.2 in the study
of Baccetti et al29). The differences are not statistically
significant (P .0.05), especially once the error for ceph-
alometric measurements is taken into account.
The prevalence rates of patients showing no change
in the mandibular plane angle (within 1.5 ) in the nor-
mal and hyperdivergent samples were similar (Fig 2;
63% and 58%, respectively). Also the prevalence rates
of patients with closure or opening of the mandibular
plane angle (.1.5 in either direction) were compara-
ble in the 2 groups. In terms of the tendency to closure
of the mandibular plane angle, the comparison be-
tween the hyperdivergent and normal subjects was
insignificant (z 5 0.537; P 5 0.592); in terms of the
tendency to opening of the mandibular plane angle,
the comparison was also insignificant (z 5 1.154;
P 5 0.248). Moreover, the prevalence rates of hyperdi-
vergent subjects in the groups with closure of the man-
dibular plane angle greater than 1.5 (closing group) vs
opening of the mandibular plane angle greater than
1.5 (opening group) during rapid maxillary expansion
and fixed appliance treatment were not significantly
different.
This means that a hyperdivergent patient treated
with rapid maxillary expansion followed by fixed appli-
ances has similar probabilities of closure or opening of
his or her mandibular plane angle during treatment,

American Journal of Orthodontics and Dentofacial Orthopedics July 2012  Vol 142  Issue 1
68
Fig 2. The prevalence rates of patients with different
amounts of change in the mandibular plane angle in the
normal and hyperdivergent samples.
and that these probabilities are similar to those that sub-
jects with normal vertical relationship would experience.
When the long-term changes were analyzed for the
opening and closing groups, no significant differences
were found between them for any of the cephalometric
variables under investigation. The mean change in the
mandibular plane angles for both groups combined
was –1.1 , a change that is within normal limits when
compared with long-term growth changes in untreated
subjects with a hyperdivergent tendency reported in
the literature.13,29 Both Garib et al14 and Chang et al13
found physiologic closings of the mandibular plane an-
gle in the long-term evaluation of normative samples,
with average values of –0.7 and –0.9 , respectively.
Therefore, the skeletal changes produced by rapid max-
illary expansion and full fixed appliances are statistically
and clinically insignificant and cannot be distinguished
from normal growth. Because of the lack of any detri-
mental effect of rapid maxillary expansion and fixed
appliance therapy on the vertical skeletal relationship
at the end of the active treatment period, a continued
favorable growth trend in the vertical dimension can
be expected in the long-term posttreatment appraisal.
CONCLUSIONS
In this retrospective cohort study, we examined the
short-term and long-term skeletal effects of rapid max-
illary expansion and full fixed appliances on different fa-
cial types, with a focus on the subjects with increased
vertical dimensions. Our findings are as follows.
1. The protocol of rapid maxillary expansion followed
by full fixed appliances had no significant skeletal
effects in the vertical dimension in hyperdivergent
subjects (both very hyperdivergent and moderately
July 2012  Vol 142  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Lineberger et al
hyperdivergent) compared with patients with nor-
mal vertical relationships.
2. No significant differences in the prevalence rates of
hyperdivergent patients were found between those
who experienced opening vs closing of the mandib-
ular plane angle at the end of treatment. The prev-
alence rates of opening vs closing mandibular plane
angle were similar in the hyperdivergent and
the normal patients. Therefore, a hyperdivergent
patient treated with rapid maxillary expansion fol-
lowed by fixed appliances has similar probabilities
of showing closure or opening of the mandibular
plane angle during treatment, and these probabili-
ties are similar to what a subject with a normal ver-
tical relationship would experience.
3. With regard to the mandibular plane angle, the
long-term changes in response to rapid maxillary
expansion appear favorable because they express
a tendency toward reduction in the angle, they are
statistically insignificant, and they are indistin-
guishable from normal growth.
4. Rapid maxillary expansion can be used effectively in
patients with increased vertical dimensions without
detrimental effects to the dental and skeletal struc-
tures. An increased mandibular plane angle is not
a contraindication for rapid maxillary expansion
therapy.
REFERENCES
1. Davis WM, Kronman JH. Anatomical changes induced by splitting
of the midpalatal suture. Angle Orthod 1969;39:126-32.
2. Haas AJ. Palatal expansion: just the beginning of dentofacial
orthopedics. Am J Orthod 1970;57:219-55.
3. Wertz RA. Skeletal and dental changes accompanying rapid
midpalatal suture opening. Am J Orthod 1970;58:41-66.
4. Wertz R, Dreskin M. Midpalatal suture opening: a normative study.
Am J Orthod 1977;71:367-81.
5. Chung CH, Font B. Skeletal and dental changes in the sagittal,
vertical, and transverse dimensions after rapid palatal expansion.
Am J Orthod Dentofacial Orthop 2004;126:569-75.
6. da Silva Filho OG, Montes LA, Torelly LF. Rapid maxillary expan-
sion in the deciduous and mixed dentition evaluated through post-
eroanterior cephalometric analysis. Am J Orthod Dentofacial
Orthop 1995;107:268-75.
7. Byrum AG Jr. Evaluation of anterior-posterior and vertical skeletal
change vs. dental change in rapid palatal expansion cases as stud-
ied by lateral cephalograms. Am J Orthod 1971;60:419.
8. Cozza P, Giancotti A, Petrosino A. Rapid palatal expansion in
mixed dentition using a modified expander: a cephalometric inves-
tigation. J Orthod 2001;28:129-34.
9. Haas AJ. Long-term posttreatment evaluation of rapid palatal
expansion. Angle Orthod 1980;50:189-217.
10. Inoue N, Oyama K, Ishiguro K, Azuma M, Ozaki T. Radiographic
observation of rapid expansion of human maxilla. Bull Tokyo
Med Dent Univ 1970;17:249-61.
Lineberger et al
11. Linder-Aronson S, Lindgren J. The skeletal and dental effects of
rapid maxillary expansion. Br J Orthod 1979;6:25-9.
12. Velazquez P, Benito E, Bravo LA. Rapid maxillary expansion.
A study of the long-term effects. Am J Orthod Dentofacial Orthop
1996;109:361-7.
13. Chang JY, McNamara JA Jr, Herberger TA. A longitudinal study of
skeletal side effects induced by rapid maxillary expansion. Am J
Orthod Dentofacial Orthop 1997;112:330-7.
14. Garib DG, Henriques JF, Carvalho PE, Gomes SC. Longitudinal
effects of rapid maxillary expansion. Angle Orthod 2007;77:
442-8.
15. Broadbent BH Sr, Broadbent BH Jr, Golden WH. Bolton standards
of dentofacial developmental growth. St Louis: Mosby; 1974.
16. McNamara JA Jr, Baccetti T, Franchi L, Herberger TA. Rapid max-
illary expansion followed by fixed appliances: a long-term evalua-
tion of changes in arch dimensions. Angle Orthod 2003;73:
344-53.
17. McNamara JA Jr, Brudon WL. Orthodontics and dentofacial ortho-
pedics. Ann Arbor, Mich: Needham Press; 2001.
18. Ricketts RM. A four-step method to distinguish orthodontic
changes from natural growth. J Clin Orthod 1975;9:208-15,
218-28.
19. McNamara JA Jr. A method of cephalometric evaluation. Am J
Orthod 1984;86:449-69.
American Journal of Orthodontics and Dentofacial Orthopedics
69
20. Bjork A, Skieller V. Normal and abnormal growth of the mandible.
A synthesis of longitudinal cephalometric implant studies over
a period of 25 years. Eur J Orthod 1983;5:1-46.
21. Baccetti T, Franchi L, McNamara JA Jr. The cervical vertebral mat-
uration (CVM) method for the assessment of optimal treatment
timing in dentofacial orthopedics. Semin Orthod 2005;11:119-29.
22. Cohen JA. A power primer. Psychol Bull 1992;112:155-9.
23. Solow B, Kreiborg S. Soft-tissue stretching: a possible control fac-
tor in craniofacial morphogenesis. Scand J Dent Res 1977;85:
505-7.
24. Bjork A, Skieller V. Facial development and tooth eruption. An im-
plant study at the age of puberty. Am J Orthod 1972;62:339-83.
25. Steiner CC. Cephalometrics for you and me. Am J Orthod 1953;39:
729-55.
26. Steiner CC. Cephalometrics in clinical practice. Angle Orthod 1959;
29:8-29.
27. Steiner CC. The use of cephalometrics as an aid to planning and
assessing orthodontic treatment: report of a case. Am J Orthod
1960;46:721-35.
28. Solow B. The dentoalveolar compensatory mechanism: back-
ground and clinical implications. Br J Orthod 1980;7:145-61.
29. Baccetti T, Franchi L, Schulz SO, McNamara JA Jr. Treatment tim-
ing for an orthopedic approach to patients with increased vertical
dimension. Am J Orthod Dentofacial Orthop 2008;133:58-64.
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