European Journal of Orthodontics, 2021, 265–273

doi:10.1093/ejo/cjaa050
Advance Access publication 25 August 2020

Randomized Controlled Trial (RCT)

Dental arch changes comparison between

expander with differential opening and fan-type
expander: a randomized controlled trial

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Camila Massaro1,*, , Guilherme Janson1, Felicia Miranda1, ,
Aron Aliaga-Del Castillo1, , Fernando Pugliese2,
José Roberto Pereira Lauris3 and Daniela Garib1,4
1
Department of Orthodontics, Bauru Dental School, University of São Paulo, Brazil, 2Department of Orthodontics, School
of Dental Medicine, Case Western Reserve University, Cleveland, OH, USA, 3Department of Public Health, Bauru Dental
School, University of São Paulo, Brazil, 4Department of Orthodontics, Hospital of Rehabilitation of Craniofacial Anomalies,
University of São Paulo, Bauru, Brazil

Correspondence to: Daniela Garib, Department of Orthodontics, Bauru Dental School, University of São Paulo, Alameda
Octávio Pinheiro Brisolla 9–75, Bauru, São Paulo 17012–901, Brazil. E-mail: dgarib@usp.br

*This article is based on research submitted by Dr. Camila Massaro in partial fulfilment of the requirements for the degree
of PhD in Orthodontics at Bauru Dental School, University of São Paulo.

Summary
Objectives:  To compare posterior crossbite correction frequency and dentoalveolar changes of the
expander with differential opening (EDO) and the fan-type expander (FE).
Trial design:  Two-arm parallel randomized controlled trial.
Methods:  Forty-eight patients from 7 to 11 years of age were allocated into two groups.Twenty-four
patients were treated with the EDO and 24 patients were treated with the FE. Block randomization
was performed. The study was single blind. Digital dental models were acquired before treatment
and 6  months after rapid maxillary expansion. The primary outcomes were crossbite correction
rate and maxillary arch width changes. Secondary outcomes were interincisal diastema, arch
perimeter, length, size and shape, and mandibular dental arch changes.
Results:  The final sample comprised 24 patients (13 female and 11 male; mean initial age of
7.62 years) in the EDO group and 24 patients (14 female and 10 male; mean initial age of 7.83 years)
in the FE group. The crossbites were corrected in 100 per cent of subjects from EDO group and in
75 per cent of patients in FE group. EDO showed greater increases in maxillary intermolar region
(P < 0.001), while the FE demonstrated greater increases in the intercanine distance (P = 0.008).
Increase in mandibular inter-first permanent molar distance was slightly greater in the EDO group
(mean difference of 0.8 mm). Changes in arch length and perimeter were similar in both groups.
Both expanders changed the maxillary arch shape. The post-treatment arch shape was larger in the
anterior region for FE and in the posterior region in the EDO group.
Harms:  Discomfort during activation was reported by 54 per cent of the participants. A temporary
change in the nasal bridge was reported by one patient from FE group.
Conclusions:  Maxillary arch width and shape changes were distinct between the EDO and the FE.
Greater transversal increases of the anterior and posterior regions were observed for the FE and

© The Author(s) 2020. Published by Oxford University Press on behalf of the European Orthodontic Society.
265
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266
the EDO, respectively. A slightly greater mandibular spontaneous expansion was observed for the
EDO only at the molar region.
Trial registration:  NCT03705871.
Introduction
Maxillary constriction and posterior crossbites are common con-
ditions in paediatric orthodontic patients. Interceptive treatment
starting in the mixed dentition is highly recommended since most
of posterior crossbites do not self-correct (1, 2). Rapid maxillary
expansion (RME) is a viable option to treat maxillary constriction
and posterior crossbites (3–6). A wide variety of appliance designs
can be used to split the midpalatal suture, with successful correction
of maxillary constriction (3, 7–10).
Conventional expanders promote transverse increase in the
maxillary arch by means of parallel opening of the expander screw
positioned in the centre of the palate (3, 10, 11). Similar increases
in intercanine and intermolar distances were found after RME with
the Haas-type and Hyrax expanders (12, 13). The fan-type ex-
pander (FE) can be indicated when an increase in the anterior arch
width with minimal effects in the molar region is desired (12, 14,
15). More recently, the expander with differential opening (EDO)
was proposed to treat maxillary constriction individualizing the
expansion in the anterior and posterior regions of the dental arch
(5, 7, 13).
Previous studies compared the Hyrax and FE outcomes dem-
onstrating that intercanine distance increase was similar in both
groups, while greater increase in intermolar distance was found for
the Hyrax expander (12, 14). A previous comparison between Hyrax
and the EDO showed similar intermolar expansion in both groups
and greater intercanine expansion for the EDO (13).
Patients with cleft lip and palate and non-cleft individuals can
demonstrate greater constriction in the anterior region of the dental
arch (5, 16–18). In this scenario, greater expansion in the anterior
region of the maxillary dental arch should be indicated to avoid an
over and undesired expansion in the molar region. However, no pre-
vious study compared the FE with the EDO guiding the clinician in
the expander selection.
Spontaneous dentoalveolar expansion might be expected in the
mandibular arch after RME procedure (3, 10, 19, 20). A recent sys-
tematic review concluded that negligible short and long-term spon-
taneous dentoalveolar changes occur in the mandibular dental arch
after RME in the mixed and early permanent dentitions (21). No
previous study assessed the spontaneous mandibular dental arch
changes with the EDO and the FE.
Considering the above-mentioned concerns, some questions
remain: is there a difference between the EDO and the FE for the
posterior crossbite correction rate and maxillary arch dimension
changes? Is the arch shape influenced by the different appliance de-
signs? Does the EDO and the FE induce similar spontaneous changes
in the mandibular arch dimensions and shape? No clinical study
compared the EDO and the FE.
Specific objectives or hypotheses
The aim of this study was to compare the frequency of posterior
crossbite correction and the maxillary and mandibular dental arch
changes of the EDO and the FE in the mixed dentition using digital
dental models. The null hypothesis was that there is no difference
between the EDO and the FE.
European Journal of Orthodontics, 2021, Vol. 43, No. 3
Methods
Trial design and any changes after trial
commencement
This two-arm parallel study was a single-centre randomized con-
trolled trial (RCT) with a 1:1 allocation ratio. Consolidated
Standards of Reporting Trials (CONSORT) statement and guide-
lines were followed (22).
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Ethical considerations
Ethical approval was obtained from the Research Institutional Board
of Bauru Dental School, University of São Paulo, Brazil (Process
number: 71648917.6.0000.5417) before trial commencement.
Participants who met the eligibility criteria were invited to partici-
pate and informed consent was obtained from all patients and their
parents or legal guardians. In addition, the protocol of this study was
registered at Clinicaltrials.gov with the identifier NCT03705871.
Participants, eligibility criteria, and settings
From November 2017 to June 2018, patients were recruited at the
Orthodontic Clinic of Bauru Dental School, University of São Paulo,
Brazil. Eligibility criteria included Class I and Class II patients from
7 to 11 years of age with maxillary constriction and posterior cross-
bites. Individuals with a Class  III malocclusion, craniofacial syn-
dromes, clinical absence of maxillary deciduous canines, and history
of previous orthodontic treatment were excluded.
Interventions
Twenty-four patients were treated with the EDO (EDO group). The
EDO was composed by two 10-mm screws, one posteriorly and
the other anteriorly positioned on the palate (Peclab Ltda., Belo
Horizonte, MG, Brazil). During the first 6 days of activation, both
expander screws were activated two-quarter turns in the morning
and two-quarter turns in the evening. For extra 4 days, only the an-
terior screw was activated following the same activation protocol.
The total expansion was 4.8 mm in the posterior screw and 8 mm in
the anterior screw (Figure 1).
Twenty-four patients were treated with the FE (FE group). The
FE was composed by one 11-mm screw anteriorly positioned on the
palate (Morelli Ortodontia, Sorocaba, SP, Brazil). For 10 consecu-
tive days, the expander screw was activated two-quarter turns in
the morning and two-quarter turns in the evening, resulting in an
expansion of 8 mm in the screw (Figure 2).
In both groups, orthodontic bands were adapted on the right
and left maxillary second deciduous molars. Clasps were bonded on
the right and left maxillary deciduous canines and a bilateral palatal
extension from the maxillary second deciduous molars to the first
permanent molars was added (Figures 1 and 2). After a 10-day active
phase, the expander was kept as a retainer for 6 months. At the end
of the retention phase, the expander was removed, and a removable
retention plate was delivered. The orthodontic treatment of all pa-
tients was conducted by the same orthodontist (CM).
Digital dental models of the maxillary and mandibular dental
arches were obtained for each patient before (T1) and 6 months after
C. Massaro et al.
Figure 1.  Maxillary expander with differential opening. (A) Pre-expansion phase. (B) Post-expansion phase.
Figure 2.  Fan-type expander. (A) Pre-expansion phase. (B) Post-expansion phase.
RME (T2) using TRIOS 3 intraoral scanner (3-Shape, Copenhagen,
Denmark). Digital dental models were saved in .stl file format.
Outcomes (primary and secondary) and any
changes after trial commencement
The primary outcomes were the frequency of crossbite correction
and the maxillary arch width changes. Interincisal diastema, arch
perimeter, arch length, arch size, arch shape, and mandibular dental
arch changes were considered secondary outcomes. The amount of
differential expansion between the anterior and posterior region of
the maxillary dental arch was also considered a secondary outcome.
Other secondary outcomes stated in the trial registration will be re-
ported in further studies.
All variables except the midline diastema were measured
on the pre- and post-expansion digital dental models using the
OrthoAnalyzer 3D software (3-Shape A/S, Copenhagen, Denmark)
as shown in Figure  3. The width of the maxillary interincisal dia-
stema (Figure 4) was clinically measured before treatment and imme-
diately after the active phase of the expansion using an odontometric
calliper (Precision equipment co., Boston, Massachusetts, USA).
For dental arch size and shape analyses, 14 landmarks were
placed on the occlusal surface of the T1 and T2 digital dental
models of each patient using the Stratovan Checkpoint software
(Stratovan Corporation, Davis, California, USA) as shown in
Figure  3D (23). The x and z coordinates for each landmark were
extracted and imported into the MorphoJ software (Klingenberg
Lab, Manchester, UK). The dental arch size was calculated auto-
matically in the MorphoJ software considering the square root of
the sum of the squared distances between the dental arch centroid
point to each of the 14 landmarks (23–25). Using the same coord-
inates, a Generalized Procrustes Analysis (23, 26) was performed
in the MorphoJ software to assess the maxillary and mandibular
arch shapes. A mean shape of the dental arch was obtained for each
group at the two time points and a Procrustes mean shape superim-
position was performed.
267
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Sample size calculation
The intercanine distance was selected for sample size calculation be-
cause both expanders are indicated to treat maxillary constrictions
that are more severe in the canine region (7, 8, 12–14). Additionally,
a minimal difference of 2 mm was considered clinically relevant. In
order to detect a difference of 2 mm in intercanine width change, with
a standard deviation of 2.18 mm (13), power of 80 per cent, and alpha
of 5 per cent, a sample size of 20 patients per group was required.
Considering possible losses, 24 patients were selected in each group.
Randomization
After recruitment, patients were randomly allocated into two study
groups. A  block randomization was performed before trial com-
mencement using the Web site Randomization.com (http://www.
randomization.com) to ensure that the trial arms have equal num-
bers of participants (27). Opaque, sealed, and sequentially numbered
envelopes containing the treatment allocation cards were prepared
before trial commencement. The envelopes were sequentially opened
for each participant during recruitment. The initials of the name of
the participant were written on the envelope before opening it. The
generation of randomization list, allocation concealment, and im-
plementation were performed independently by different researches.
Blinding
Double blinding was not possible since the patient and the operator
were aware of the type of expander delivered. However, blinding
was accomplished during outcome assessment since all data were
unidentified before analysis and all the digital dental models were
taken without the expander in the oral cavity.
Statistical analyses
All assessments were performed by the same observer and 50 per
cent of the sample was evaluated twice after a 30-day interval. The
intrarater error was assessed using intraclass correlation coefficients
(ICC) and Bland–Altman method (28).
268 European Journal of Orthodontics, 2021, Vol. 43, No. 3

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Figure 3.  Maxillary and mandibular arch dimensions assessment: (A) arch widths were measured at the level of the cusp tips of the deciduous canines, first
deciduous molars, second deciduous molars, and first permanent molars; (B) arch perimeter was the sum of the four segments from mesial aspect of the right
first permanent molar to the mesial aspect of the contralateral tooth; (C) arch length was measured on the horizontal plane from the mesial aspect of the first
permanent molars to the mesial edge of the right permanent incisor; (D) 14 landmarks at the level of cusp tips and incisal edges of the maxillary and mandibular
teeth were selected on the digital dental model surface to provide raw coordinates representing dental arch shape and size. The dental arch size (centroid size
method) was automatically calculated in the MorphoJ software considering the square root of the sum of the squared distances between the arch centroid (AC)
to each 14 landmarks.

Figure 4. Maxillary interincisal diastema (A) before and (B) immediately after the active phase of the expansion. (C) The interincisal diastema width was
measured between the mesial incisal edge of right and left maxillary incisors before and after the active phase of the expansion using an odontometric calliper.
T1–T2 differences were considered interincisal diastema width changes.

Kolmogorov–Smirnov test was used to verify normal distri-
bution. All variables showed normal distribution. Intergroup ini-
tial age and sex ratio at baseline were assessed with t-test and
chi-square test, respectively. Crossbite data at baseline and inter-
group comparison of the correction rate was performed using
chi-square tests. T-tests with Holm–Bonferroni correction were
used for other intergroup comparisons. The significance level con-
sidered was 5 per cent. All statistical analyses were performed
using Statistica software (Statistica for Windows version 11.0;
StatSoft, Tulsa, Oklahoma, USA).
Results
Participant flow
Figure 5 shows the CONSORT flow diagram of the study. A total
of 48 patients were enrolled and were followed during the entire
observation period.
Baseline data
Both groups showed similar baseline characteristics (Table 1). All
unilateral crossbites showed CO–CR shift at pre-treatment. No sig-
nificant intergroup differences were found for the initial dental arch
dimensions showing adequate intergroup comparability (Table  2
and Figures 6 and 7).
Numbers analysed for each outcome, estimation,
and precision
The EDO group comprised 24 patients (13 female and 11 male) with
a mean age of 7.62 years (SD = 0.92) treated with the EDO. The FE
group comprised 24 patients (14 female and 10 male) with a mean
age of 7.83 years (SD = 0.96) who underwent RME using the FE.
All patients were properly analysed in their original assigned groups.
The complete sample demonstrated midpalatal suture split. No pa-
tients were lost during the follow-up period.
The error study showed an excellent intraexaminer reproduci-
bility, with ICC varying from 0.947 to 1.00 (29). The variable with
the greatest Bland–Altman limits of agreement was the mandibular
arch perimeter (−0.56 and 0.63) and the variable with smallest was
the maxillary intercanine distance (−0.33 to 0.27).
The frequency of posterior crossbite correction was greater in the
EDO group (Table 3). The crossbites were corrected in 100 per cent
of the patients from EDO group and in 75 per cent of patients from
FE group (P = 0.008).
Both groups demonstrated similar changes in the maxillary inter-
incisal diastema width (Table  3). The interincisal diastema width
opened 3.6 and 3.4  mm in groups EDO and FE, respectively. The
EDO group showed greater increases in the maxillary inter-second de-
ciduous (mean difference of 1.4 mm) and inter-first permanent (mean
difference of 2.7 mm) molars distances (P < 0.001). Conversely, the FE
C. Massaro et al. 269

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Figure 5.  Consolidated standards of reporting trial flow diagram showing the study design.

Table 1.  Intergroup comparisons for age, sex ratio, and frequency The mandibular dental arch showed mild spontaneous changes
of posterior crossbite at baseline (t-test and chi-square tests). after RME in both groups (Table 3). No intergroup differences were
observed except for the slightly greater increase in mandibular inter-
EDO FE
first permanent molars distance observed in the EDO group (mean
N = 24 N = 24
change of 0.9  mm ± 0.9 and 0.1  mm ± 0.8 for the EDO and FE
Variable Mean SD Mean SD P groups, respectively).
Changes in the maxillary and mandibular arch length and per-
Initial Age (y) 7.62 0.92 7.83 0.96 0.448
imeter after RME were similar in both groups (Table 3). The EDO
Sex Female 13 (54%) 14 (58%) 0.771
Male 11 (46%) 10 (42%) group showed greater increase in arch size (centroid size method)
Posterior Unilateral 18 (75%) 19 (80%) 0.731 than the FE group for maxillary (P  <  0.001) and mandibular
crossbite Bilateral 6 (25%) 5 (20%) (P = 0.008) arches.
The maxillary arch shape demonstrated significant changes in
EDO, expander with differential opening; FE, fan-type expander; SD, stand- both groups (Figure 6). Mandibular arch shape changed very slightly
ard deviation. only in the EDO group (Figure  7). The post-expansion maxillary
arch shape was different in the EDO and FE groups (P  <  0.001).
A  larger anterior width was observed for the FE group, while a
larger posterior width was found for the EDO group (Figure 6D).
group showed greater increase in intercanine distance (mean change of Post-expansion mandibular arch shape was similar in both groups
7.7 mm ± 1.2 for the EDO group and 8.8 mm ± 1.3 for the FE group). (Figure  7D). The differential expansion between anterior and
270 European Journal of Orthodontics, 2021, Vol. 43, No. 3

Table 2.  Baseline comparisons (t-tests).

EDO FE
N = 24 N = 24

Variables Mean SD Mean SD P

Interincisal diastema (mm) 1.45 1.10 1.14 1.10 0.341

Arch dimensions Maxilla c–c 29.70 3.01 29.24 2.25 0.557
(mm) d–d 36.29 2.22 34.78 2.21 0.051
e–e 42.47 2.38 41.26 2.64 0.103
6–6 49.23 2.71 47.91 2.65 0.096
Arch length 29.27 2.64 29.39 2.27 0.865
Arch perimeter 76.30 4.65 75.34 4.38 0.465
Arch size 83.00 3.99 81.71 4.20 0.286
Mandible c–c 27.74 2.46 26.50 2.21 0.115
d–d 33.13 2.47 31.64 1.47 0.041

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e–e 40.15 2.97 39.06 2.06 0.167
6–6 46.03 2.68 45.36 2.42 0.373
Arch length 25.26 1.91 24.86 1.80 0.461
Arch perimeter 70.57 3.38 69.23 3.76 0.234
Arch size 76.96 3.29 75.53 3.69 0.168

P < 0.05; Holm–Bonferroni correction method was applied. EDO, expander with differential opening; FE, fan-type expander; SD, standard deviation; c, decidu-
ous canines; d, first deciduous molars; e, second deciduous molars; 6, first permanent molars.

Figure 6.  Superimpositions of maxillary dental arch shape. (A) Pre-expansion maxillary dental arch in the fan-type expander (FE) group (grey line) and in the
expander with differential opening (EDO) group (black line). (B) Maxillary dental arch before (grey line) and after expansion (black line) in the EDO group. (C)
Maxillary dental arch before (grey line) and after expansion (black line) in the FE group. (D) Post-expansion maxillary dental arch in the FE group (grey line) and
in the EDO group (black line). The P-value is observed for each comparison (variance analysis).

posterior regions of the maxillary dental arch was significantly
greater in the FE group (Table 4).
Harms
No important harm was caused to the participants of this study.
Fifteen patients from the EDO group (62 per cent) and 11 from the
FE group (45 per cent) reported a slight pain or discomfort during
the activation of the expander screw. Additionally, one patient from
the FE group showed a clinical change in the nasal bridge after ex-
pansion probably caused by the opening of the nasomaxillary suture.
The nasal alteration was reported by parents and spontaneously re-
covered during the follow-up period.
Discussion
Sample and methodology
No previous study compared the outcomes of the EDO and the
FE. Comparisons between RME treatment outcomes are difficult
since the clinical studies vary regarding sample size, age of the pa-
tients, and amount of expansion achieved (4, 30). A  controlled
prospective study with sufficient power and standardized method-
ology is important for answering clinical questions. An expansion
of 8 mm was performed in the anterior screw of the EDO and the
FE to allow intergroup comparisons. Additionally, only Class I and
Class II patients were included in this study. Class III patients were
not included once maxillary protraction could influence the out-
comes. The baseline comparisons showed no intergroup differences
confirming the homogeneity of the sample (Tables 1 and 2). These
results ensure the effectiveness of randomization and allocation of
patients, decreasing the risk of bias in the intergroup comparisons
of treatment changes (31).
In the present study, digital dental models were obtained using
an intraoral scanner. Previous studies showed adequate accuracy
and reliability of interarch and intra-arch measurements performed
on digital dental models derived from intraoral scans (32–34). Our
results are in accordance with previous studies demonstrating ad-
equate intraexaminer reproducibility. The dental arch size and shape
analyses were based on the centroid size and location (23–26) pro-
viding a visual representation of intergroup comparisons.
Main findings
In this study, 48 patients in the mixed dentition with posterior cross-
bites were treated with RME procedure. The crossbites were cor-
rected in all 24 subjects from the EDO group (100 per cent) and in
18 out of 24 patients from the FE group (75 per cent). The FE did
not completely correct the posterior crossbite in six patients because
C. Massaro et al. 271

Table 3.  Intergroup comparisons of the interphase changes (t-tests and chi-square test).

EDO FE
N = 24 N = 24

Mean SD Mean SD
Variables (T2–T1) (T2–T1) P

Interincisal diastema (mm) 3.65 0.74 3.43 1.13 0.449

Arch dimensions Maxilla c–c 7.76 1.23 8.80 1.33 0.008*
(mm) d–d 7.85 1.31 7.42 1.66 0.398
e–e 6.36 0.84 4.90 0.91 <0.001*
6–6 5.10 1.17 2.33 0.75 <0.001*
Arch length −0.54 0.86 −0.36 0.76 0.449
Arch perimeter 5.14 1.56 5.33 1.40 0.662
Arch size 9.28 1.28 7.01 1.05 <0.001*
Mandible c–c −0.35 1.11 −0.05 0.67 0.324

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d–d 0.27 0.83 0.35 0.88 0.803
e–e 0.59 0.66 0.31 0.79 0.225
6–6 0.93 0.91 0.12 0.89 0.003*
Arch length −0.55 0.60 −0.52 0.60 0.844
Arch perimeter −0.64 0.86 −0.66 1.27 0.955
Arch size 1.02 0.83 0.23 1.09 0.008*
Posterior crossbite correction
Yes 24 18 0.008**
No 0 6

P < 0.05; Holm–Bonferroni correction method was applied.

*Statistically significant (t test).
**Statistically significant (chi-square test).
EDO, expander with differential opening; FE, fan-type expander; SD, standard deviation.

Figure 7.  Superimpositions of mandibular dental arch shape. (A) Pre-expansion mandibular dental arch in the fan-type expander (FE) group (grey line) and in the
expander with differential opening (EDO) group (black line). (B) Mandibular dental arch before (grey line) and after expansion (black line) in the EDO group. (C)
Mandibular dental arch before (grey line) and after expansion (black line) in the FE group. (D) Post-expansion mandibular dental arch in the FE group (grey line)
and in the EDO group (black line). The P-value is observed for each comparison (variance analysis).

the appliance posterior hinge restricted the expansion in the pos- Table 4.  Intergroup comparison of the differential expansion in the
terior region (second deciduous and fist permanent molars). The re- deciduous canines and first permanent molars (t-test).
sults from the present study demonstrated that the FE should be
c–c 6–6 Difference
selected to treat posterior crossbites restricted to the canine and first
deciduous molar regions. When the posterior crossbite extends to Mean SD Mean SD Mean SD
the second deciduous and/or permanent molars, the EDO should be Group change change P
preferred over the FE.
EDO 7.76 1.23 5.10 1.17 2.65 1.47 <0.001*
Similar opening of the interincisal diastema was observed in both
FE 8.80 1.33 2.31 0.76 6.09 1.47
groups (Table 3). An opening of 3.6 mm for the EDO and 3.4 mm
for the FE (45 and 42 per cent of the screw activation, respect-
P < 0.05; *Statistically significant. EDO, expander with differential open-
ively) were observed. These outcomes were expected since the same
ing; FE, fan-type expander; SD, standard deviation; c, deciduous canines; 6,
amount of expansion was performed in the anterior screw of the first permanent molars.
EDO and in the FE (8 mm). A previous study reported an opening of
4.1 mm in the interincisal diastema width with the EDO and 2.4 mm
with Hyrax expanders (13). A meta-analysis showed a mean increase Increase in intercanine distance was slightly greater in the FE
in the midline diastema of 2.9  mm after RME with conventional group (Table 3). Since the anterior expansion amount was the same
expanders (30). The slightly greater mean values found for the EDO in both groups, it is possible to suggest that this small transverse
and the FE compared to conventional expanders might be explained difference (approximately 1 mm) was probably caused by a greater
by the greater anterior activation. canine buccal inclination after a fan expansion. Greater tendency for
272
labial inclination of the anterior supporting teeth with the FE was
previously reported in cleft patients (16). The assumption is that the
FE concentrates the activation force in the canine region. On the
other hand, the EDO might distribute the expansion stress by all an-
chored teeth, mainly in the first days of the active phase.
Conversely to intercanine increase, intermolar expansion was
greater in the EDO group (Table  3). The possible explanation is
the presence of the posterior screw in the EDO. A  previous RCT
showed that the EDO caused an intermolar expansion similar to the
Hyrax expander (13). Using a fan-shape expander, the intermolar
increase was not clinically important (2.3  mm). These results cor-
roborate with a previous study showing an intermolar width in-
crease of 2.6 mm after RME with an FE (12). Despite the intergroup
differences in maxillary arch width expansion, the arch perimeter
increased similarly in both EDO and FE groups (Table 3). In this per-
spective, both appliances can be indicated to solve maxillary incisor
crowding (4, 35, 36). A slight decrease in maxillary arch length was
observed in both groups and might be explained by the slight palatal
inclination of the maxillary central incisors after RME related to
interincisal diastema closure (6, 37, 38).
The mandibular dental arch changes were very mild in the
EDO and FE groups (Table 3). Additionally, the mandibular out-
comes were similar in both groups, except for the greater increase
in inter-first permanent molar distance in the EDO group (mean
difference of 0.8 mm; Table 3). The greater transverse change in the
posterior region of the mandibular arch in the EDO group might
be explained by the greater maxillary molar expansion caused by
the EDO (Table 3). Previous studies assessing the mandibular arch
changes after a conventional RME also showed spontaneous in-
crease in the mandibular intermolar width (3, 10, 19). The small
widening in the mandibular dental arch after RME might be ex-
plained by changes in balance between the tongue and buccinator
muscles. The cusp-fossa occlusal contact between the palatal cusp
tip of the maxillary molar and the occlusal aspect of the mandibular
molars also might have contributed to the slight uprighting of the
mandibular posterior teeth (3, 20). Both the EDO and the FE in-
duced very small widening of the mandibular dental arch, however,
without causing a perimeter arch increase (Table  3). Mandibular
arch length decreased equally in both groups, probably as a result
of dental development in the mixed dentition leading to Leeway
Space loss (39).
Interestingly, both expanders were capable of changing the max-
illary arch shape (Figures 6B and 6C). In this study, the post-expan-
sion maxillary arch shape differed between the groups (Figure 6D).
The mean final arch shape was wider in the molar region for the
EDO group and wider in the canine region for the FE group.
Mandibular arch shape after RME was similar in both groups. The
literature is scarce for arch shape analysis after RME. A  previous
study showed that the arch shape changed in 98 per cent of the
patients after conventional expansion (40). In cleft patients, using
similar methodology, arch shape changes were observed after ex-
pansion with Quad-helix and EDO (23). In addition, the arch size
calculated thought the centroid size method increased more in the
EDO group both in the maxilla and mandible (Table 3). These dif-
ferences might be explained by a greater expansion in the posterior
region of both dental arches in the EDO group. No previous study
evaluated the arch size after RME using the centroid size method in
a non-cleft population. In patients with cleft lip and palate, the arch
size increased similarly after slow maxillary expansion and RME
with the Hyrax, Quad-helix, and EDO (23).
European Journal of Orthodontics, 2021, Vol. 43, No. 3
Differential expansion between molar and canine regions was
observed in both groups with more intensity for the FE group. The
ratio between intercanine and intermolar expansions were approxi-
mately 1.5:1 in the EDO group and 3.5:1 in the FE group. Our re-
sults are in accordance with previous studies that found a ratio of
1.7:1 for the EDO (13) and 3.5:1 for the FE (14). The EDO and the
FE are two viable options to treat maxillary arch constriction with
very similar impact on the canine region. The decision between both
expander designs should consider the required amount of expansion
in the intermolar distance and the presence of posterior crossbite,
including molars.
Limitations
This was a single-centre study and the treatment was conducted by
Downloaded from https://academic.oup.com/ejo/article/43/3/265/5896800 by guest on 29 January 2023
one operator. Moreover, the participants and the operator were not
blinded as a consequence of the differences in the appliance designs.
However, data were de-identified before analysis. Other limitation
of this study was the lack of a tension distribution analyses. Further
studies should assess the EDO and the FE force concentration using
finite element analysis.
Generalizability
The results of the present study may be generalized to non-cleft pa-
tients in the mixed dentition. Additionally, the generalizability of the
results should be limited to similar expanders using the same acti-
vation protocol.
Conclusions
The null hypothesis was rejected.
1. A greater frequency of posterior crossbite correction was ob-
served in the EDO group.
2. The EDO showed greater expansion at the level of the maxillary
second deciduous and first permanent molars.
3. The FE produced greater maxillary intercanine distance increase.
4. A greater mandibular dental arch change was observed after
RME with the EDO compared to the FE.
5. The EDO and the FE induced distinct post-expansion arch
shapes.
Funding
This study was financed in part by the Coordenação de
Aperfeiçoamento de Pessoal de Nível Superior - Brasil (CAPES) -
Finance Code 001, and by the São Paulo Research Foundation
(FAPESP) - Grant numbers 2017/12911-9 and 2017/24115-2.
Conflict of interest
Licensed patent of the expander with differential opening (PI
1101050-9) registered by the last author, FAPESP and University
of São Paulo at the National Institute of Industrial Property
(INPI-Brazil).
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