Treatment

of

Transverse Discrepancy

Thornthan Songvejkasem
Patamaporn Bunjerdjin
 Maxillary Transverse Discrepancy

Surgically
Slow Rapid Assisted
Maxillary Maxillary Rapid
Expansion Expansion Maxillary
Expansion

Maxillary expansion treatments have been used for more than a century to correct
maxillary transverse deficiency.
• combination of orthopedic and orthodontic tooth movements
Agarwal, 2010
 Maxillary Transverse Discrepancy

Slow maxillary expansion

• Less tissue resistance

→ Improve bone formation
→ Eliminate or reduce the limitation of RME
• Promote greater post-expansion stability
• Constant physiologic force
→ 10 to 20 newtons of force should be applied to the maxillary region
only 450 to 900 gm of force is generated
→ 1 mm / week
• Maxillary arch width increase ranged 3.8-7.8 mm

Agarwal, 2010
 Maxillary Transverse Discrepancy

Slow maxillary expansion

Removalble plate W arch Quadhelix

Agarwal, 2010
 Maxillary Transverse Discrepancy

Surgically
Slow Rapid Assisted
Maxillary Maxillary Rapid
Expansion Expansion Maxillary
Expansion

Maxillary expansion treatments have been used for more than a century to correct
maxillary transverse deficiency.
• combination of orthopedic and orthodontic tooth movements
Agarwal, 2010
 Maxillary Transverse Discrepancy

Rapid maxillary expansion

• Heavy and rapid forces are applied

to the posterior teeth
↓
Minimum dental effect
Maximum skeletal movement

Agarwal, 2010
 Maxillary Transverse Discrepancy

Rapid maxillary expansion

2 quarter turns = 0.5 mm/ day

↓
≥10 mm in 2-3 weeks
with 10-20 pounds of pressure across suture

Agarwal, 2010
 Maxillary Transverse Discrepancy

Rapid maxillary expansion

• The space created at the suture is

filled initially by tissue fluid and
haemorrhage. <<unstable
→ The expansion device must be
stabilized for 3-4 months
• Not only affect maxilla but also
associated with 10 bones in the face
and head

Agarwal, 2010
 Maxillary Transverse Discrepancy

Rapid maxillary expansion

Infancy Juvenile Adolescence

 Maxillary Transverse Discrepancy

Rapid maxillary expansion

ü Maxillary constriction, ü Single tooth crossbite

transverse discrepancy ≥4 mm
ü Skeletal asymmetry of maxilla and mandible
ü Facilitate maxillary protraction in class III
treatment ü Passed the growth spurt

ü Cleft lip and palate patients with ✓ ✗ ü Recession on the buccal aspect of the molars
collapsed maxillae ü Anterior open bite
ü Gain arch length in patients, who have ü Steep mandibular plane
moderate maxillary crowding
ü Convex profiles
ü Reducing nasal resistance and providing
a normal breathing pattern ü Poor compliance

Agarwal, 2010
 Maxillary Transverse Discrepancy

Rapid maxillary expansion

Type of RME
1. Banded RME
• Tooth borne
• Tooth-tissue borne
2. Bonded RME

Agarwal, 2010
 Maxillary Transverse Discrepancy

Rapid maxillary expansion Banded RME

Tooth-tissue borne : “Hass” Tooth borne : “HYRAX” Agarwal, 2010

 Maxillary Transverse Discrepancy

Rapid maxillary expansion Banded RME

Not irritate palatal mucosa

Easy to keep clean
11-13mm sutural separation
0.2 mm/screw activation

Tooth borne : “HYRAX” Agarwal, 2010

 Maxillary Transverse Discrepancy

Rapid maxillary expansion Banded RME

Irritate palatal mucosa

More parallel expansion
Less relapse
Greater nasal cavity and apical
base gain
More favorable relationship of
the denture bases in width and
frequently in the A-P plane
More mobility of the maxilla
instead of teeth.
Tooth-tissue borne : “Hass” Agarwal, 2010
 Maxillary Transverse Discrepancy

Rapid maxillary expansion Bonded RME

Easily cemented during the mixed

dentition stage, when retention
from other appliances can be poor
Number of appointments are
reduced.
Reduced posterior teeth tipping
and extrusion, Improves the
vertical control
Provide bite block effect

Agarwal, 2010
 Maxillary Transverse Discrepancy

Rapid maxillary expansion

Cranial and
circumaxillary Nasal cavity
sutures

Mandible Dentoalveolar
Agarwal, 2010
 Maxillary Transverse Discrepancy

Rapid maxillary expansion Cranial and

circumaxillary sutures

• Opening of midpalatal suture

• Outward tilting of maxillary halves
• Lowering of palatal vault

Ghoneima, 2011, Agarwal, 2010

 Maxillary Transverse Discrepancy

Rapid maxillary expansion Cranial and

circumaxillary sutures

1, Frontonasal; 2, Frontomaxillary; 3, Frontozygomatic; 4, Internasal; 5, Nasomaxillary;

6, Zygomaticomaxillary; 7, Intermaxillary; 8, Zygomaticotemporal; 9, Pterygomaxillary; 10, Midpalatal suture
Ghoneima, 2011
 Maxillary Transverse Discrepancy

Rapid maxillary expansion Cranial and

circumaxillary sutures

1, Frontonasal; 2, Frontomaxillary; 3, Frontozygomatic; 4, Internasal; 5, Nasomaxillary;

6, Zygomaticomaxillary; 7, Intermaxillary; 8, Zygomaticotemporal; 9, Pterygomaxillary; 10, Midpalatal suture
Ghoneima, 2011
 Maxillary Transverse Discrepancy
Cranial and
Rapid maxillary expansion circumaxillary sutures

Pre RME

Internasal Intermaxillary

Post RME
1, Frontonasal; 2, Frontomaxillary; 3, Frontozygomatic; 4, Internasal; 5, Nasomaxillary;
6, Zygomaticomaxillary; 7, Intermaxillary; 8, Zygomaticotemporal; 9, Pterygomaxillary; 10, Midpalatal suture
Ghoneima, 2011
 Maxillary Transverse Discrepancy
Cranial and
Rapid maxillary expansion circumaxillary sutures
Pre RME

Nasomaxillary

Post RME

1, Frontonasal; 2, Frontomaxillary; 3, Frontozygomatic; 4, Internasal; 5, Nasomaxillary;

6, Zygomaticomaxillary; 7, Intermaxillary; 8, Zygomaticotemporal; 9, Pterygomaxillary; 10, Midpalatal suture
Ghoneima, 2011
 Maxillary Transverse Discrepancy
Cranial and
Rapid maxillary expansion circumaxillary sutures
Pre RME

Frontonasal

Post RME

1, Frontonasal; 2, Frontomaxillary; 3, Frontozygomatic; 4, Internasal; 5, Nasomaxillary;

6, Zygomaticomaxillary; 7, Intermaxillary; 8, Zygomaticotemporal; 9, Pterygomaxillary; 10, Midpalatal suture
Ghoneima, 2011
 Maxillary Transverse Discrepancy
Cranial and
Rapid maxillary expansion circumaxillary sutures
Pre RME

Frontonasal

Post RME

1, Frontonasal; 2, Frontomaxillary; 3, Frontozygomatic; 4, Internasal; 5, Nasomaxillary;

6, Zygomaticomaxillary; 7, Intermaxillary; 8, Zygomaticotemporal; 9, Pterygomaxillary; 10, Midpalatal suture
Ghoneima, 2011
 Maxillary Transverse Discrepancy

Rapid maxillary expansion Cranial and

circumaxillary sutures

Nonparallel and triangular

opening
Anterior > Posterior
Pre RME Post RME Inferior > Superior

1, Frontonasal; 2, Frontomaxillary; 3, Frontozygomatic; 4, Internasal; 5, Nasomaxillary;

6, Zygomaticomaxillary; 7, Intermaxillary; 8, Zygomaticotemporal; 9, Pterygomaxillary; 10, Midpalatal suture
Ghoneima, 2011
 Maxillary Transverse Discrepancy

Rapid maxillary expansion Cranial and

circumaxillary sutures

1, Frontonasal; 2, Frontomaxillary; 3, Frontozygomatic; 4, Internasal; 5, Nasomaxillary;

6, Zygomaticomaxillary; 7, Intermaxillary; 8, Zygomaticotemporal; 9, Pterygomaxillary; 10, Midpalatal suture
Ghoneima, 2011
 Maxillary Transverse Discrepancy

Pre RME

Frontozygomatic Zygomaticomaxillary Zygomaticotemporal Pterygomaxillary

• Increased interdigitation and rigidity
• Disarticulation of the palatal bone from the pterygoid process is possible only on infantile and juvenile skulls

Post RME
 Maxillary Transverse Discrepancy

Rapid maxillary expansion Cranial and

circumaxillary sutures

Cranial sutures respond differently to the external orthopedic forces

according to their anatomic location and the degree of interdigitation.
Ghoneima, 2011
 Maxillary Transverse Discrepancy

Rapid maxillary expansion Nasal cavity

• Short-term effects
• Increased width of nasal cavity
• Increased in total nasal volume and nasal valve area
• Decreased nasal airway resistance
• Long-term effects
• Stable nasal airway resistance
• Increased nasal cavity volume and minimal cross-sectional area
• 61.3% : improvement in nasal respiration Ghoneima, 2011
 Maxillary Transverse Discrepancy

Rapid maxillary expansion Mandible

• Mandible is kept in a distal position relative to centric relation because the constricted
maxilla is holding it back
• The mandibular arch acts as a “foot” that moves forward after the “shoe” is widened
↓
widening the maxilla with RME
↓
spontaneous forward posturing of the mandible during the retention period.

Tollaro, 1996, Gianelly, 2003McNamara JJ, 2000

 Maxillary Transverse Discrepancy

Rapid maxillary expansion Mandible

With either bonded or

banded RME showed no
significant improvement of the
anteroposterior relationship at
both skeletal and occlusal level
Bonded RME has reduced
of the facial divergency and of
the gonial angle.

Lione, 2017
 Maxillary Transverse Discrepancy

Rapid maxillary expansion Dentoalveolar

• Opening of diastema between

maxillary central incisors
• Buccal inclination and extrusion
of posterior teeth
• Increased palatal width,
intercanine width, intermolar
width
• Increased arch circumferential
• External root resorption
Agarwal, 2010
 Maxillary Transverse Discrepancy

Rapid maxillary expansion Dentoalveolar

• Buccal inclination and extrusion of posterior teeth

Olmez, 2007
 Maxillary Transverse Discrepancy

Rapid maxillary expansion Dentoalveolar

• Buccal inclination and extrusion of posterior teeth

• Buccal tipping of the maxillary first premolars and molars in the bonded RPE
group was significantly less than in the banded RPE group

• When RPE is performed after the pubertal growth spurt, maxillary adaptation to
expansion therapy results in a shift from the skeletal to the dentoalveolar level

*6/RB: inner angle between the long axis of the maxillary first molar and the radiographic image of the bar (RB) on the mandibular appliance (guide).
*RB-6-VCP: distance from the vestibular cortical plate (VCP), to the apex of the palatal root of the upper first molar, perpendicular to the long axis of RB Olmez, 2007
 Maxillary Transverse Discrepancy

Rapid maxillary expansion Dentoalveolar

• External root resorption

External root resorption at the level of the dentin and cementum and partial cementum repair were found
in all first premolars 3 months after RME with no difference between banded or non-banded type.
Matin, 2016
 Maxillary Transverse Discrepancy

Rapid maxillary expansion Disadvantages

• External root resorption

• Bite opening
• Discomfort
• Traumatic separation of midpalatal suture
• Microtrauma to TMJ
• Inability to correct rotated molars
• Cooperation
• Relapse

Agarwal, 2010
Fan type
Fan-type RPE

Doruk et al, 2004 (4.)

Material and methods
Group 1 Group 2

The fan-type RME group The RME group

comprised 17 subjects, who comprised 17 other subjects, who

had an anterior constricted had a maxillary transverse
maxilla with a normal intermolar discrepancy with a posterior
width. crossbite.
Doruk et al, 2004 (4.)
Material and methods

Doruk et al, 2004 (4.)

Conclusion
There was significantly greater expansion in the intercanine than in
the intermolar width in the fan-type RME group as compared with
the RME group.

Downward and forward movement of the maxilla was observed in

both groups.

The upper incisors were tipped palatally in the RME group, but they
were tipped labially in the fan-type RME group.

There was significantly greater expansion in the nasal cavity and

maxillary width in the RME group as opposed to the fan-type RME
group.

Doruk et al, 2004 (4.)

2 Bands
vs
4 Bands
2 Band vs 4 Band RPE

Davidovitch et al, 2005 (11.)

Material and methods

Davidovitch et al, 2005 (11.)

 Material and methods

All subjects were instructed to

activate the RPE appliances at 12-hour
intervals, by a quarter turn of the hyrax
screw (0.24 mm).
Activation was discontinued when the
posterior crossbite reverted to a slight
scissors bite in the first molar region.

Davidovitch et al, 2005 (11.)

 Material and methods

Documentation was made at 3 times:

T1 = pretreatment
T2 = at end of RPE activation (ie, posttreatment);
T3 = T2 + 1 year (ie, postretention).
Edgewise appliances were placed during T3.

Davidovitch et al, 2005 (11.)

Material and methods

Davidovitch et al, 2005 (11.)

Material and methods

Davidovitch et al, 2005 (11.)

RESULTS

Davidovitch et al, 2005 (11.)

RESULTS 2 Band 4 Band

Davidovitch et al, 2005 (11.)

 Conclusion

The greater the skeletal resistance, the

smaller the sutural response but the greater the
dental response to RPE therapy.
4-band RPE is indicated when severe anterior
crowding is accompanied by a tapered arch
Form
2-band RPE is recommended in the mixed
dentition when mild crowding occurs with posterior
constriction.

Davidovitch et al, 2005 (11.)

Haas-type RPE
Haas-type RPE

Ugolini et al. , 2015 (7.)

Material and methods

Ugolini et al. , 2015 (7.)

Material and methods

Ugolini et al. , 2015 (7.)

Result

Ugolini et al. , 2015 (7.)

Conclusion
At T2, the net increase of maxillary intercanine distance
in GrE is still significant compared with Gr6, indicating a more
stable expansion on the anterior region of the arch.

Transverse maxillary deficiency can be successfully

corrected with RME on upper second deciduous molars,
avoiding undesirable periodontal effects on permanent teeth
when RME is anchored on the upper first permanent molars.

RME anchored on second deciduous molars was

clinically efficient when the root of the anchoring tooth had at
least the same length of the clinical crown at the
orthopantomogram rx examination.

Ugolini et al. , 2015 (7.)

MARPE

Bone-anchored maxillary expander

(BAME)

Tooth-bone-anchored expander
(MSE)
Bone-anchored maxillary expander

Lagrave`re et al, 2010 (8.)

Material and methods

Lagrave`re et al, 2010 (8.)

Conclusion

Both expanders showed similar results.

The greatest changes were seen in the transverse
dimension; changes in the vertical and
anteroposterior dimensions were negligible. Dental
expansion was also greater than skeletal expansion.

This study suggests that bone-anchored

maxillary expansion (BAME) can be considered as an
alternative choice for tooth-borne maxillary expansion
(TAME) .

Lagrave`re et al, 2010 (8.)

Maxillary Skeletal Expander

Cantarella et al, 2017 (2.)

Material and methods

Cantarella et al, 2017 (2.)

Results and
Conclusion
Midpalatal suture was successfully split by MSE in late
adolescents, and the opening was almost perfectly parallel in a
sagittal direction. Regarding the extent of transverse asymmetry of
the split, on average one half of ANS moved more than the
contralateral one by 1.1 mm.

Pterygopalatine suture was split in its lower region by

MSE, as the pyramidal process was pulled out from the pterygoid
process.

Remarkably, this study shows that the

pterygopalatine suture can be split by an orthopedic appliance
without the need of surgery in late adolescents

Cantarella et al, 2017 (2.)

 Maxillary Transverse Discrepancy

Surgically
Slow Rapid Assisted
Maxillary Maxillary Rapid
Expansion Expansion Maxillary
Expansion

Maxillary expansion treatments have been used for more than a century to correct
maxillary transverse deficiency.
• combination of orthopedic and orthodontic tooth movements
 Maxillary Transverse Discrepancy
Surgically Assisted
Adult with narrow palatal arch
Rapid Maxillary Expansion

1. Correct posterior crossbite when large amount (>7 mm)

of expansion to avoid the potential increased risk of
segmental osteotomies
2. Widen the arch
- creating space without premolar extraction
- following maxillary collapse associated with a
cleft palate
- extremely thin and delicate gingival tissue,
- presence of significant buccal gingival recession
in the canine-bicuspid region of the maxilla;
- significant nasal stenosis is found.
Agarwal, 2010
SARPE
Surgically assisted
rapid palatal
expansion
Kayalar et al. , 2019 (6.)
Findings

Kayalar et al. , 2019 (6.)

Conclusion

Both tooth-borne and hybrid devices led to

significant widening of the nasal soft and hard tissues,
both in the short term and 6 months after SARPE. Skeletal
nasal widening increased further during the retention
phase. The amount of widening did not differ significantly
between tooth-borne and hybrid SARPE.

Patients with a narrow and constrained nose

may benefit from the soft-tissue changes provided by
SARPE, and skeletal nasal widening may promote
respiratory improvements.

Kayalar et al. , 2019 (6.)

Kayalar et al. , 2017 (13.)
Material and methods

Kayalar et al. , 2017 (13.)

 Result

Of 487 articles retrieved from the 6

databases, 5 articles were included, 4 with
cone-beam computed tomographic (CBCT)
data and 1 with non-CBCT 3-dimensional cast
data. There was a significant difference in
skeletal expansion in favor of Bone-borne
rather than Tooth-borne appliances.
However, there was no significant
differencein dental expansion.

Kayalar et al. , 2017 (13.)

Conclusion

According to the literature, to achieve

more effective skeletal expansion and minimize
dental expansion after SARPE, a bone-borne
appliance should be favored.

Kayalar et al. , 2017 (13.)

 Transverse
discrepancy
Expansion of the maxilla
and the maxillary dentition may
be accomplished in numerous
ways. The type of skeletal
and dental pattern greatly
influences the type of expansion
chosen and the type of
expansion selected can greatly
facilitate the overall treatment
objectives.
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