A stu,dy of basal mowme&

with Tapid maxillary expamk

Donald J. Timms, L.D.S., D.Orth.R.C.S.(Eng.)‘~
Prc~.stor?. El?~/atld

Key words: Interhamular width. rapid maxillary expansion

I
f a lateral force with reciprocal action is applied across the maxillary arch, not
only will the arch be widened, but the maxillary bones will be reshaped. The extent of this
transformation will depend upon a number of factors, one of which is the rate of expan-
sion. When the rate is increased, less time is allowed for physiologic movement based on
osteoblastic and osteoclastic activity and the maxillary bones move apart by disarticulating
along their common midpalatal suture.
The extradental expansion or basal movement has, in the past, been investigated
almost exclusively by the analysis of teleradiographic frontal head films. From the litera-
ture, the works of Krebs” ’ and Hershey and associates” are noteworthy for their precision
and analytical content. However, this procedure shows only basal movement in the
vertical plane, that is above the application of force, and yet the effect of rapid maxillary
expansion (R.M.E.) is carried not only upward but backward.
To date there is very little information on the movements of the bones posterior to the
applied force, and what can be found is largely speculative. Wertz,” after scrutinizing
occlusal radiograms which showed the typical triangular opening of the midpalatal suture
with R.M.E., came to the conclusion that the suture did not open throughout its entire
length and that it was doubtful whether the palatine bones separated. Later he revised his
theory and considered that the suture did open completely.”
Lines6 stated that the effects of R.M.E. were carried only as far back as the

*Consultant Orthodontist, Northwestern Regional Health Authority.

500 0002.9416/80/050500+08$00.80/0 0 1980 The C. V. Mosby Co.

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Basal movement with rapid ma.rillary expansion 501

Fig. 1. Anatomic drawing showing relationship of maxilla (Max.), palatine bone (Pal.), and pterygoid
process of spheroid bone (Pt.).

pterygopalatine suture and that slippage at this junction would prevent movements of the
pterygoid processes of the sphenoid bone.
In the field of experimental animal work, West’ found that the application of R.M.E.
to monkeys disarticulated the maxillae from their contiguous bones and thus restricted the
effect of expansion. It must be borne in mind that the results of animal experiments should
never be assumed to apply equally to human beings.
If we turn back the pages of history, and R.M.E. is long in this dimension, it would
seem that more enterprise was displayed nearly three quarters of a century ago, when
Federspiel ,8 m order to check that the midpalatal suture had opened, was not against
reflecting a flap of the palatal mucosa. Prices used a more simple method and passed a
sharp probe between the separated palatal processes after anesthetization with cocaine.
An investigation into the movements produced by R.M.E. on the bones posterior to
the maxilla calls for an examination in the horizontal rather than the vertical plane, and
here one runs into difficulties with a radiographic technique. Intraoral occlusal films are
useless, and basilar or vertex view present problems in landmark definition because of the
overlapping bones. Therefore, I chose a method that avoided the inherent difficulties in a
radiographic analysis and the errors of applying the findings of animal experiments to
human beings.

Method
The ideal way to measure any dimension of the skeleton is to take the measurement
directly, but in the living subject this is usually impracticable for reasons of accessibility.
The only favorable anatomic landmark of hard tissue in the region under investigation,
with a reasonable degree of accessibility, is the pterygoid hamulus.
This useful datum point is at the inferior extremity of the pterygoid process of the
 Fig. 2. Appliance. Cast-silver cap splints with screw before addition of acrylic resin.

sphenoid bone and is paired with its laterally opposing member, so that any changes in the
interhamular width would indicate basal movement. The pterygoid processes are not
strictly circummaxillary structures, as the palatine bones are interjacent between them and
the maxillae (Fig. 1). Furthermore, it should be noted that, although they are paired, they
are both parts of one and the same bone.
In most patients, the hamuli may be palpated in the upper corners of the mouth,
between the soft palate and the lateral walls. The technique for measuring the interhamular
width was as follows: With the patient’s mouth wide open and the overlying soft tissue
stretched, the hamuli were palpated and the spots were marked with a pencil. A pair of
blunt calipers was then introduced and adjusted to correspond with the hamuli; the marks
acted for general guidance as the hamuli may be felt with calipers. The interhamuli width
was then recorded to the nearest millimeter.
There are arguments against this method on the grounds of the level of accuracy,
because of (1) the thickness of the overlying tissues and (2) movement of the subject due
to mucosal sensitivity.
The difficulties are admitted, but against them must be set the fact that the mea-
surements are taken directly from the skeleton and not from an agency, such as a radio-
graphic plate.
All measurements were taken by the same clinician and using the same technique.
Also recorded were the intermaxillary dental arch widths. These were taken from the
study models, using the lingual cervical margin of the first permanent molars, or of the
second molars if the first ones were missing.
As the basal movements may be varied by the form of the appliance and the rate of
expansion, R.M.E. was standardized by using a rigid, high anchorage appliance (Fig.
2).‘O This consisted of cast-silver cap splints, with a Glenross Mark VI screw attached
with acrylic resin and cemented to all the maxillary teeth with the exception of the central
incisors.
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Table I. Results of rapid maxillary expansion, giving increases in interhamular

and intermolar arch widths (I.M.)

Paiient Increase in Increase in lnterhamular

(percent)
NO. .%X Age interhamular width intermolar width Intermolar

I F 8.2 6 8.0 75
2 F 8.9 8 9.0 89
3 F 8.9 7.5 53
4 M 9.4 5 8.5 59
5 F 10. I 4 8.0 50
6 M 11.0 5 8.0 62
7 M 11.1 7.0 57
8 F 11.3 4 8.0 50
9 F Il.6 7.0 57
10 F 11.6 9.5 53
II F Il.9 9.5 74
12 F 12.0 7.5 40
13 F 12.2 9.0 56
14 F 12.4 9.5 63
15 M 12.8 4 9.0 44
16 M 12.9 9.0 55
17 F 13.0 9.0 78
I8 F 13.1 4 6.5 61
19 M 13.3 4 8.0 50
20 M 13.4 8.0 75
21 F 13.4 4 7.5 53
22 M 13.5 6 8.0 75
23 M 13.5 8.0 62
24 F 13.6 7.5 53
25 F 14.2 4 7.5 53
26 F 15.6 3 8.0 31
27 F 15.8 9.0 55
28 F 16.6 8.0 62
29 M 19.8 8.5 35
30 F 22.3 8.5 59
31 M 23.8 7.5 53
32 M 24.1 7.0 43

The screw was turned 180 degrees per day. This gives an expansion of 0.35 mm.,
which is usually done with a 90 degree turn in the morning and another in the evening. In
the older patients, a 90 degree turn can produce a force build-up with painful symptoms,
but the rate of expansion may be maintained without untoward effects if four turns of 45
degrees are made throughout the day.

Material and subjects

All the subjects used in this investigation were selected from patients who had been
referred through the usual channels for orthodontic treatment, and the course of R.M.E.
was dictated solely by the diagnosed conditions. The specific malocclusions are immate-
rial to this particular study, but suffice it to say that in nearly every case there was a buccal
cross-bite of some description.
For reasons of comparative validity, the group was kept as homogeneous and normal
504 7‘;rrim.\

Fig. 3. Normal distribution curve of the percentage increase in interhamular width to increase intermolar

arch width $ percent. Mean (IL) = 58 percent; standard deviation (CT) = 12

as possible. Without entering into any arguments over what constitutes normality, it
should be stated that cases of cleft palate or dysostosis and those in which the R.M.E. was
assisted by surgical intervention were not selected. It was also found necessary to reject a
couple of cases because difficulties in measuring the interhamular widths rendered the
recordings unreliable.
Since R.M.E. imposed a short time scale of up to only 1 month, the effects of growth
could be disregarded and a control group was therefore unnecessary.
The data were obtained from a total of thirty-two subjects, comprising twenty females
and twelve males. The age range (at the commencement of R.M.E.) was 8.2 years to 24.1
years, but the distribution was far from even and 59 percent fell within the narrow band of
11 to 14 years.

Results and analysis

As a result of R.M.E., the increases in intermolar arch width ranged from 6.5 to 9.5
mm., according to the individual therapeutic requirements and, coincident with those
dental expansions, were increases in interhamular width of 3.0 to 7.0 mm.
As might be expected, the more the dental arch was expanded, the greater the increase
in interhamular width, but this proved to be only a generalization. When the increases in
interhamular width were compared with the increases in dental arch width, the ratio was
found to be very far from constant. When analyzed statistically, using the coefficient of
correlation (r), the relationship was no higher than r = +0.55.
In order to make a comparative examination of the results, the increases in interhamu-
lar width were expressed as a percentage of the increases in intermolar arch width in each
case (Table I). This gave a wide variation from 35 to 89, with a mean value of 58 percent,
and a standard deviation of 12. This extensive distribution is shown by the curve in Fig. 3.
Some thought was given to the possible causes for this wide individual variation in the
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m-
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l l ee
70.
I.H. .l
l
I.M.
w- l le l
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l me l l
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5.3. l l l

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40. l
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30-

Fig. 4. Scattergram showing ratio of increases in interhamular widths to increases in intermolar arch
widths to age, suggesting an age factor.

ratio of the interhamular width increases to the increases in intermolar arch width, and it
would be rational to expect an age factor, whereby the increasing skeletal rigidity with
advancing age would reduce the movement of the pterygoid hamulus.
Again using the coefficient of correlation, the result was somewhat disappointing,
with r = -0.33, which is a weak relationship. However, the scattergram shown in Fig. 4
does demonstrate a bias in favor of the hypothesis, but there was a very uneven distribu-
tion of cases and no attempt was made to draw a regression line. The particularly wide
variation in the 12- to 1Cyear group might be attributable to pubertal effects.

Discussion
These results are especially interesting, even before any analysis of the measurements
is made, since, as mentioned earlier, it was not generally accepted that the pterygoid
processes could be moved by expanding the dental arch.
The picture becomes intriguing when compared with the anatomy; the force is applied
to the maxillae which separate, their juxtaposition with the palatine bones through the
palatomaxillary sutures moves these bones apart also, and there is still sufficient force to
affect the pterygoid processes through the pterygopalatine sutures. The pterygoid pro-
cesses are not bilaterally paired bones, but parts of one and the same-the sphenoid,
which is a cranial bone.
In view of the extent of the hamular movements, it is extremely unlikely that much
slippage exists at either of the sutures. In any case, this would entail some disarticulation
of the bones, because of their lengthy, contorted junction. It is also known from holo-
graphic studies that certain facial sutures act as hinges when under stress, but again the
intricacies of the interface between these bones must curtail this type of movement.
The only realistic interpretation of these results is to accept that the maxillae, the
palatines, and the pterygoid processes act as single bones in the context of R.M.E., the
first two separating but the pterygoid processes, which cannot separate, splaying outward,
at least as far as their lower portions are concerned. The effect of expansion is greatest in
the dentoalveolar region and diminishes with increasing remoteness from this region as the
stress is attenuated.
The weak correlations between dental and basal movements and the wide individual
variations may be a reflection on the geometric morphology and the degrees of buttressing
within the circummaxillary structures. However, these results compare well with the work
of Hershey and colleagues:’ in the vertical dimension, where it was found that expansion of
the nasal cavity was not closely related to the expansion of the dental arch.
This inquiry may have satisfactorily answered the original problem, but, like many
research projects, it has produced more questions, and further investigations may be
fruitful along the following suggested lines: (1) Long-term follow-up of cases for stability
of the pterygoid hamulus. (2) Longitudinal study for correlation of pterygoid hamular
movement under R.M.E. with normal growth. (3) As the pterygoid hamulus has a role in
the origins of some of the perioral musculature, does its movement affect the pressures
upon the teeth, and could it account for the better results of R.M.E. over slow-expansion
techniques?

Conclusion
The evidence from this modest research project throws new light on the effects of
R.M.E. on the basal bone posterior to the application of the force, if the pterygoid hamuli
are used as datum points, and shows that movements are greater than one had been led to
believe hitherto. Not only the maxillae but also the palatine bones move apart, with the
pterygoid processes of the sphenoid bone splaying outward, at least as far as their inferior
portions are concerned.
The relationship of the basal movement to the dental expansion was not close, and
increasing age may be a factor in progressively reducing basal movement.

Summary
1. Thirty-two patients (twenty female and twelve male) underwent rapid maxillary
expansion.
2. The increases in intermolar arch widths and interhamular widths were recorded.
3. A weak correlation existed between the increases in intermolar arch width and
interhamular width (r = +0.55).
4. The mean percentage increase in interhamular width to increase in intermolar width
was 58 percent (range, 35 percent to 89 percent).
5. A remote correlation existed between age and the percentage increases in in-
terhamular width to increases in dental arch width (r = -0.33).

REFERENCES
1. Krebs, A.: Expansion of the mid-palatal suture studied by means of metallic Implants, Trans. Eur. Orthod.
Sot., pp. 163-171, 1958.
2. Ktebs, A.: Mid-palatal suture expansion studied by the implant method over a seven year period, Trans.
Eur. Otthod. Sot., pp. 131-142, 1964.
3. Hershey, H. G., Stewart, B. L., and Warren, D. W.: Changes in nasal airway resistance associated with
rapid maxillary expansion, AM. J. ORTHOD. 69~274.284. 1976.
4. Wertz, R. A.: Changes in nasal airflow incident to rapid maxillary expansion, Angle Orthod. 38: 1-l I.
1968.
5. Wertz, R. A.: Skeletal and dental changes accompanying rapid midpalatal suture opening, AM. J. ORTHOD.
58: 41-66, 1970.
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Bascrl movement Mith rapid mclxillur~ expansion 507
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6. Lines, P. A.: Adult rapid maxillary expansion with corticotomy, AM. J. ORTHOD. 67: 44-56, 1975.
7. West, I. M.: Histologic study of sutural tissue changes accompanying palate splitting in the monkey,
Master’s Thesis, University of Illinois, 1964.
8. Federspiel, M. N.: Discussion on paper by Dewey, M.: Development of the maxillae with reference to
opening the median suture, Items of Interest 35: 271, 1913.
9. Price, W. A.: Some contributions to dental and medical science, Dent. Summary 34: 253-290, 1914.
10. Timms, D. i.: Some medical aspects of rapid maxillary expansion, BR. J. ORTHOD. 1: 127-132, 1974.

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