Observation of orthopedic Jome distribution

produced by maxillary orthodontic DI Chaconas

appliances
Spiro J. Chaconas, D.D.S., KS.,* and Angelo A. Caputo, Ph.D.**
Los Angrles, Cal$,

A three-dimensional anatomic model was duplicated from a human skull, using different birefringent materials
to simulate the various craniofacial structures. Individual bones of the midface were fabricated separately and
then articulated in their correct sutural relation. One removable and four fixed maxillary appliances were used.
The fixed appliances included the Haas, Minne-expander, Hyrax, and quad helix devices. The removable
appliance incorporated an expansion screw in a full acrylic palate with appropriate retentive clasps. After
the insertion of each appliance, intraoral forces were produced by incremental activation. The model was
examined and photographed in the field of a transmission polariscope. Each appliance used produced a different
range of load-activation characteristics. This was reflected by the differences in the stresses transmitted through
the bones of the craniofacial complex and the effect on the various sutures. Stresses produced by the fixed
appliances were concentrated in the anterior region of the palate, progressing posteriorly toward the palatine
bone. The Haas, Minne-expander, and Hyrax appliances produced stresses that radiated superiorly along the
perpendicular plates of the palatine bone to deeper anatomic structures, such as the lacrimal, nasal, and malar
bones, as well as the pterygoid plates of the sphenoid. Similar stress characteristics were seen with the
removable appliance. However, increased activation decreased retention of the appiiance, thereby lessening the
stress. The quad helix appliance proved to be the least effective orthopedic device. Although the effects of palate
separation were seen with increased activation, this appliance primarily affected the posterior teeth.

Key words: Maxillary expansion, load-activation characteristics, photoelastic evaluation, craniofacial

complex, stress characteristics

M any cases of posterior cross-bite are often

complicated by the skeletal problem of a constricted
maxillary arch. These cross-bites can be unilateral or
bilateral, and they may be associated with a functional
deviation of the mandible. In these cases, tooth move-
ment alone cannot adequately accomplish the treatment
objectives. The arch width itself must be increased.
Numerous appliances have been used in the treat-
ment of interarch width discrepancies due to a narrow
maxillary arch. The effects of these appliances have not
been completely understood, and the treatment has
often led to failure.
The purpose of this investigation was to observe the
effects of the orthopedic forces produced within the
craniofacial complex by various maxillary orthodontic
appliances. This would facilitate clinical selection
and use of various maxillary removable and fixed ap-
pliances by determining the magnitude and distribu-
From the School of Dentistry. University of California. Los Angeles
*Professor and Chainnan, Orthodontic Section.
**Pmfessor and Chairman, Biomaterials Science Section.
492
tion of the stresses produced at various areas of the
craniofacial complex after the activation of each ap-
pliance .
The rapid palatal expansion appliance has been in
the orthodontic literature since 1860 when E. C. An-
gell’ described its use in treating maxillary deficiency.
Since then, such researchers as G. V. Black* and J. H.
Babcock3 have described its use. It has also been stud-
ied by rhinologically oriented researchers Pfaff,4
Ketchurn,” and N. M. Black.fi From these studies, it is
obvious that this is one of the orthodontist’s most useful
appliances.
Within the last 10 to 15 years, several significant
studies have been performed on the rapid palatal expan-
sion appliances. In 1964, Isaacson and associates,‘. H
measured forces created by a rapid palatal expansion
appliance. Their appliance was cemented on the maxil-
lary first molars and first premolars via bands. Activa-
tions of 0.2 mm. were induced with each quarter-
revolution of a midline expansion screw. The force in
0002-9416/82/120492+ 10$01.00/0 0 1982 The C. V. Mosby Co.
Volume a2
Number 6
Fig. 1.Minne-expander. A fixed appliance used to increase
maxillary width by activating the palatal compressed-coil spring.
Fig. 2. Hyrax appliance. A fixed appliance used to increase
maxillary width by activating the palatal jackscrew.
pounds was measured by a deformation gauge on a
metal piece of the expander. The forces measured were
horizontal, vertical, and a combination of the two, re-
sulting in a buccal rotational force on the alveolar
shelves of the maxilla. A single activation created be-
tween 3 and 10 pounds of force that decayed rapidly at
first and continued to decrease slowly. Isaacson sur-
mised that the major resistance to the expansion was
apparently not in the midpalatal suture but in the re-
mainder of the maxillary articulations, since no sig-
nificant changes in the force values were recorded dur-
ing the time the sutures opened. This research describes
a “force” which is really the resistance of the bony
skeleton as a whole to the appliance. There is no men-
tion of the magnitude or the nature of changes which
occur as activation continues.
In 1965, Zimring and Isaacsong further studied the
forces produced by an appliance similar to that used in
the 1964 study. Each activation was one fourth of a turn
equivalent to 0.2 mm. The appliance was inserted in
four patients, and forces were measured during expan-
Orthopedic force distribution by maxillary orthodontic appliances 493
Fig. 3. Haas appliance. A fixed appliance used to increase
maxillary width by activating the palatal jackscrew. Acrylic im-
proves stability of appliance and uses palate as anchorage.
Fig. 4. Removable appliance. A removable expansion appli-
ance to increase maxillary width by activating palatal jackscrew.
sion and retention. This study also indicated that the
“facial” skeleton was the main resistance to expan-
sion. Maximum loads on the patients ranged from 16.6
pounds to 34.8 pounds during treatment. These forces
were gradually dissipated during the retention period of
6 weeks. Various pressure sensations were reported,
such as under the eyes and at the nasal area (bridge of
the nose). Again, as in the prior study, there was a
“total” quantitative force measurement but the forces
in other areas are not known. The reports of pressure
sensations in other areas do indicate that forces are
probably there, but their magnitude and type (tension or
pressure) remain unknown.
Histologic studies have been carried out by several
researchers. In 196 1, Haas’O used an expander on pigs
and then killed the pigs to see some of the changes due
to expansion forces that had been present. He noted a
bending of the alveolar process and a lowering of the
palatal vault. He then put an expander on human pa-
tients. It was cemented by bands to the first permanent
molars and the first premolars or first deciduous molars.

Fig. 5. Quad helix. A fixed appliance used to widen
Activation is attained by expanding the appliance
cementation.
Fig. 6. Removable expansion appliance on a split stone
lary cast mounted on a straining frame.
The activation was 0.2 mm. per quarter-turn. The pa-
tients reported pressure at the alveolar process, in the
vault area, and at the articulations of the maxilla (fron-
tal and nasal, zygomaticomaxillary) and some pressure
at the zygomaticotemporal suture. It was further noted
that the maxilla moved forward in all cases and down-
ward in several cases.
In 1966, Stambach, Bayne, Cleall, and Subtelny”
placed expansion appliances on four rhesus monkeys.
The animals were killed at various times during the
treatment and retention phases. Histologic examination
showed that lateral “bodily” movement seemed to
predominate over rotational movement. They also dem-
onstrated sutural bony activity at the nasal, zygomati-
comaxillary, and zygomaticotemporal suture areas,
with activity being greatest at the nasal suture and least
at the zygomaticotemporal suture. In relation to
Wolff’s law of bone formation and stresses, this seems
to point to force concentrations in these areas.
Fig. 7. Quad helix appliance being tested on a straining frame.
maxilla.
prior to In 197 I, Gardner and Kronman” emphasized the
seriousness with which palatal expansion should be
undertaken. In their experiments on MUCUCN rhesus
monkeys, they showed evidence of distortions in the
lambdoid and parietal sutures as well as the spheno-
occipital synchondrosis after expansion with fixed
jackscrew acrylic appliances. In 1973 StoreyLZi illus-
trated that palatal expansion is greater at the alveolar
crest and less at the palatal vault and that the maxillary
bones swing laterally with the center of rotation near
the frontonasal suture. In 1977 Wertz and Dreskin14
showed, in their clinical study, that the maxilla always
moves downward and usually forward during suture
opening. This confirms Gardner and Kronman’s con-
tention that the opening of the spheno-occipital syn-
chondrosis may be the reason for the anterior move-
maxil- ment of the maxilla. Wertz and Dreskin also stated that
the maxillary skeletal expansion in younger patients
showed no relapse, whereas the older patients in their
study lost much of the width increase that was achieved
through palatal expansion. Also in 1977, Chaconas and
de Alba’” reported that the relatively light forces pro-
duced by the quad helix appliance are sufficient to pro-
duce skeletal changes in young patients but that the
forces are not sufficient to produce the same results in
adults. In his clinical study using the Minne-expander
appliance, HicksI produced measurable separation of
the maxillary segments. Using a 2 pound continuous
load, he achieved 3.8 to 8.7 mm. of expansion during a
13-week period.
In 1980 Timms17 showed that, after activation of a
fixed jackscrew appliance, not only the maxilla but also
the palatine bones moved apart, with the pterygoid pro-
cesses of the sphenoid bone splaying outward. In 1981
Bell and L,e ComptelR obtained as much as 7 mm. of
maxillary expansion in the deciduous dentition and 9
mm. of expansion in the mixed dentition after use of
the quad helix appliance. Each of the ten subjects ex-
Volume 82 Orthopedic
Number 6
Fig. 9. A three-dimensional photoelastic model duplicated from
a human skull was used to visualize forces produced by the
activated appliances.
hibited radiographic evidence of midpalatal suture
opening after the second week of active treatment. In
his 1981 review of maxillary expansion, Belllg em-
phasized the age significance of palatal expansion pro-
cedures. He stated that, although the literature15* 2ohas
revealed that fixed palatal arch wire expansion
appliances may effectively increase maxillary width
during the deciduous and mixed dentitions, older pa-
tients may require the higher force systems of rapid
expansion procedures or surgical intervention.21, 22
Although a review of the literature points to the
far-reaching effects of the forces produced during rapid
expansion of the palate, little is known about the exact
nature of these forces and how they are transmitted
through the craniofacial complex.
MATERIALS AND METHODS
This study was carried out in two phases. It in-
cluded a determination of the force-activation charac-
teristics of various maxillary expansion appliances and
the mechanisms by which they transmit forces to the
supporting teeth and the craniofacial complex. The fol-
lowing maxillary expansion appliances were consid-
ered in this study:
force distribution by maxillary orthodontic appliances 495
Fig. 9. Schematic representation of a circular polariscope ar-
rangement. LS, Light source; D, diffuser; P, polarizer; Q, quar-
ter wave plates; M, model.
1. Minne-expander (Fig. 1). This is a fixed appli-
ance cemented to the first permanent molars and first
premolars. It is activated by turning the adjustment
screw, thereby compressing the coil spring.
2. Hyrax appliance (Fig. 2). This is also a fixed
wire appliance which is similarly cemented to the first
permanent molars and first premolars. It is activated by
means of a centrally located jackscrew.
3. Haas appliance (Fig. 3). This fixed appliance is
similar in construction and activation to the Hyrax, ex-
cept for the inclusion of the palatal acrylic.
4. Removable appliance (Fig. 4). This acrylic
palatal appliance also has a centrally located jackscrew
for activation. The retention of the appliance is ob-
tained by means of the Adams clasps on the molars and
circumferential clasps on the premolars.
5. Quad helix (Fig. 5). This is a fixed appliance
which is cemented to the maxillary deciduous second
molars or first permanent molars. The initial activation
is derived by expanding the appliance prior to cemen-
tation.
Force-activation characteristics
The force-activation characteristics of the various
appliances were measured on a straining frame which
had a load-sensing cell in line with the appliance. The
appliances were mounted on a split-stone maxillary cast
(Fig. 6). One portion of the cast was fixed to the load
cell and the other was clamped to the fixed crosshead of
the straining frame. The force corresponding to each
increment of activation was recorded with an X-Y re-
corder. The amount of expansion per activation incre-
ment for each appliance was determined with dial
calipers. Five determinations of these properties were
made for each appliance under consideration. The force
activation characteristics of the quad helix appliance
were also measured on a straining frame (Fig. 7). The
appliance was expanded 8 mm. initially and incremen-
tally constricted to determine the force produced for
each millimeter of a simulated activation.
Photoelastic visualization of forces
A three-dimensional anatomic model was dupli-
cated from a human skull; birefringent materials were
used to simulate the various craniofacial structures
496

r/ifa .__
?ooo-
8ooo-
7oao-

MOO-

SOOO-

4000-

3mo-

SOW-

1ooo-

Fig. 10. Force-activation curves for the jackscrew and Mime-expander appliances.

800
1

Fig. 11. Force-activation curve for the quad helix appliance.

(Fig. 8). Bones of the midface were fabricated sepa-
rately and then articulated in their correct sutural rela-
tion. Also, different birefringent materials were used to
fabricate teeth and the surrounding periodontal lig-
aments .
Each intermaxillary device was inserted onto the
photoelastic model and incrementally activated. Vari-
ous anatomic areas of the skull were examined in the
field of a circular polariscope (Fig. 9). The stress pat-
terns that resulted were recorded photographically.
RESULTS
Forceectivatican dmraeteristics
Fig. 10 shows the force-activation curves for the
appliances tested. For each activation, the Minne-
expander increased in width slightly more than % mm.
For a corresponding activation the Haas, Hyrax, and
removable apphances increased 0.25 mm. The Haas
and Hyrax appliances delivered very high orthopedic
forces that were similar. The removable appliance,
when fully and firmly seated, delivered the highest
force of all appliances tested. When unstable, however,
the removable appliance was only capable of much
lower forces, similar to those of the Minne-expander.
Fig. 11 represents the force-activation curve for the
quad helix appliance. When compared to the Minne-
expander and jackscrew appliances, the quad helix
exerted considerably less force for comparable amounts
of activations. For successive increments of expansion,
the quad helix similarly revealed less over-all maxi-
mum force when compared to similar activations for
the other appliances tested.
Fig. 12 illustrates the typical intraoral adjustments
that are made to the anterior bridge and inner arms
of the quad helix appliance. As shown in the graph,
there was an incremental decrease from the original
force placed in the appliance with each successive acti-
vation.
Volume 82 Orthopedic
Number 6
Quad Helix Intraoral Adjustments
Fig. 12. Effect of the intraoral adjustments on the forces gen-
erated by the quad helix appliance.
Fig. 13. Stresses produced by the fixed appliances were con-
centrated in the anterior and posterior regions of the palate.
Darker shading represents areas of higher stress.
Photoelastic analysis
To facilitate presentation and interpretation of the
photoelastic data, schematic representations of stress
intensity have been prepared. It is to be emphasized
that these diagrams do not contain actual isochromatic
fringe lines.
Stresses produced by the fixed appliances were
concentrated in the anterior region of the palate (Fig.
13). The initial effect of the appliance activations were
observed in the alveolus between the central incisors
and radiated toward the area of the incisive foramen.
With successive activations, the stresses radiated
posteriorly along the intermaxillary suture toward the
junction of the palatine bones (Fig. 13).
With increased activation, the Haas, Minne-ex-
force distribution by maxillav orthodontic appliances 497
Fig. 14. Stresses radiated from the junction of the palatine
bones to deeper structures via the perpendicular plates of the
palatine bone. Darker shading represents areas of higher
stress.
Fig. 15. Stresses radiated from the maxillary tuberosity to the
base of the medial pterygoid plate. Darker shading represents
areas of higher stress.
pander, and Hyrax appliances produced stresses that
radiated from the midpalatine area superiorly along the
perpendicular plates of the palatine bone to deeper
anatomic structures (Fig. 14). The buttressing of the
maxillary tuberosity with the pterygoid plates of the
sphenoid bone allowed the forces to then radiate to the
base of the medial pterygoid plate (Fig. 15).
From this region, the forces then branched su-
periorly toward the malar and zygomatic bones. Spe-
cifically, the areas of the zygomaticomaxillary and
zygomaticotemporal sutures were affected (Fig. 16).
The forces then radiated superomedially toward the
medial wall of the orbit and concentrated at the junction
of the nasal and lacrymal bones (Fig. 17).
Stress characteristics seen with the removable

Fig. 16. Concentration of stress at the zygomaticotemporal
ture. Darker shading represents areas of higher stress.
Fig. 17. Concentration of stress at the junction of the nasal and
lacrymal bones. Darker shading represents areas of higher
stress.
appliances were similar to those illustrated with the
fixed devices. However, increased activation decreased
retention of the appliance, thereby lessening the ob-
served stress. The quad helix appliance proved to be the
least effective orthopedic device. Although the effects
of palate separation were seen with increased activa-
tion, this appliance primarily affected the alveolus sur-
rounding the posterior teeth (Fig. 18).
Force-activation characteristics
Of the fixed appliances, the Haas and Hyrax de-
vices produced similar load-activation characteristics in
the orthopedic force range. Clinically, these appliances
would therefore be the most efficient in terms of or-
thopedically affecting the sutures necessary to widen
Fig. 18. Activation of the quad helix appliance primarily affected
the alveolar bone. Darker shading represents areas of higher
stress.
su-
the maxillary complex. Both of these appliances incor-
porate a jackscrew device for activation, and it was
observed that each quarter-turn of the activating ele-
ment produced a 0.25 mm. width increase of the
appliance. Consequently, if the sutures of the maxillary
complex are patent at the time of appliance adjustment,
then a similar amount of intermaxillary width would be
expected to occur with each incremental activation of
these orthopedic devices.
It was also determined that the stabilized removable
jackscrew appliance produced force-activation charac-
teristics similar to those of the previously mentioned
Haas and Hyrax appliances. The amount of force pro-
duced in the orthopedic range was similar, as was the
width increase of the appliance with each activation of
the jackscrew device. The orthodontist would therefore
expect to achieve the same clinical results with a stable
removable expansion appliance as he would with the
fixed appliances that have the jackscrew activating
element. However, as noted by most clinicians who use
the removable jackscrew appliance, incremental acti-
vations of this device produce an inherent instability of
the appliance and lessen the effective force necessary to
produce maxillary expansion. The force-activation
curve of the removable jackscrew appliance, when not
stabilized to the teeth, reflects this decrease in force
production. Theoretically, therefore, a stabilized re-
movable appliance can be as effective as a fixed ex-
pansion appliance. However, this phenomenon is more
of an academic than a practical fact, since it is seldom,
if ever, that a clinician would anchor the removable
appliance to the teeth sufficiently to give it the stability
that is needed to create efficient orthopedic results. It is
apparent from this study, however, that good retention
on the anchor teeth by means of the clasps of the re-
movable appliance will produce relatively efficient or-
thopedic results upon activation.
Volume 82 Orthopedic
Number 6
The Minne-expander appliance revealed a load-
activation curve in a lower orthopedic force range, and
each activation of the expansion device produced less
of a force increase than the previously mentioned
appliances. This was probably due to the fact that each
incremental activation of the expansion element of the
Minne-expander produced one half the amount of ex-
pansion produced by the jackscrew appliances (l/s mm.
as compared to 0.25 mm.). Therefore, even though the
Minne-expander is not as efficient as the “rapid maxil-
lary expansion appliances” that utilize the jackscrew
devices, it may be more physiologic because of the
lessened effect to the maxillary sutures and the conse-
quent healing and repair of the latter during the expan-
sion procedure. The slower intermaxillary expansion
produced by the Minne-expander may also produce in-
creased stability or retention of the orthopedic result.
The load-activation curve produced by incremental
expansion of the quad helix appliance revealed forces
that are considered to be well below those necessary for
orthopedic movement of the two halves of the maxilla.
In fact, these forces are considered to be in the tooth-
movement range. However, the question arises as to
why the quad helix appliance can produce clinical or-
thopedic effects to the maxilla, especially in children
during the mixed dentition. On the other hand, only
expansion of the dentition is usually observed by clini-
cians when this appliance is used in adults. The answer
to this question is probably that the effects of the quad
helix appliance are “age dependent. ” In other words,
when the midfacial sutures are patent, as seen in chil-
dren in the 7- to 9-year-old range, activation of the
quad helix meets with little resistance, and hence
widening of the maxilla occurs. Conversely, during
adult treatment, the intermaxillary and surrounding su-
tures are less patent or even fused, and therefore or-
thopedic results are much more difficult to obtain. In
most cases, an interdental width increase is observed in
adults with expansion of the quad helix appliance,
along with often severe tipping of the posterior teeth.
An interesting thing happened to the force-acti-
vation curve when the usual intraoral adjustments were
placed in the quad helix appliance. Contrary to the
belief of most clinicians, there was an actual decrease
in the expansion force of the appliance after each of the
three intraoral activations. If the objective of the in-
traoral activations is to rotate the anchor teeth, there is
clinical evidence to substantiate the fact that these ad-
justments will produce the necessary result. Therefore,
on the basis of the results of this study, it is recom-
mended that if additional widening of the maxilla is
necessary the quad helix appliance should be removed,
expanded, and then recemented to the anchor teeth.
force distribution by muxillary orthodontic appliances 499
Photoelastic analysis
The fixed orthopedic appliances tested in this in-
vestigation (the Haas, Hyrax, and Minne-expander de-
vices) revealed similar photoelastic results. The same
was true with the removable jackscrew appliance when
it was stabilized to the teeth. As revealed previously,
the stresses produced were initially concentrated in the
anterior region of the palate in the area of the incisive
foramen. This is also observed clinically by the orth-
odontist, since initial activation of these appliances
usually produces a separation in the anterior region of
the maxilla as indicated by the development of a space
or diastema between the upper central incisors. As each
appliance was activated, the forces were observed to
proceed posteriorly toward the interpalatine suture.
Clinically, this type of force would initiate the inter-
premolar and intermolar expansion that is necessary in
cases of maxillary constriction. Also, this is usually
seen clinically after the interdental space increase in the
area of the upper incisors, which follows the pho-
toelastic observation.
The force was then seen to radiate superiorly along
the perpendicular plates of the palatine bones to deeper
anatomic structures that were mentioned previously.
The clinical effectiveness of these maxillary orthopedic
appliances may very well depend on the intricacy of the
suture formation within these deeper structures. For
instance, a limiting factor for maxillary expansion may
depend on the fusion or lack of fusion between the
maxilla and the pterygoid plates of the sphenoid bone.
As illustrated photoelastically, there was stress ob-
served in the area of the base of the medial pterygoid
plates. If the maxilla is fused to these structures, as is
the probable case in adult patients, intermaxillary ex-
pansion will be difficult to obtain, regardless of how
much the suture between the two halves of the maxilla
is affected by the orthopedic forces. Further indications
of the deep anatomic effect of these orthopedic
appliances were observed by the stress in the areas of
the zygomatic process, namely, the zygomaticomaxil-
lary and zygomaticotemporal sutures. This should indi-
cate to the clinician that these orthopedic devices
should be used sparingly and judiciously, and with an
understanding of what deep anatomic structures are ac-
tually being affected by incremental activation of these
appliances. In other words, the clinician should realize
that, with each activation of these appliances, he or she
is producing not only an expansion force at the inter-
maxillary suture but also forces on other structures
within the craniofacial complex which may or may not
be beneficial for the patient.
An interesting effect of these appliances was ob-
served in the area of the medial wall of the orbit in the
region of the lacrimal and nasal bones. Clinically, any 4. Stresses produced by the fixed appliances were
clinician who has “split” a palate with these appliances concentrated in the anterior region of the pal-
has heard the complaint from the patient that the in- ate. progressing posteriorly toward the palatine
creased activation of the aforementioned devices has bones.
caused a sensation on either side of the base of the nasal 5. The Haas, Hyrax, and Minne-expander appli-
bones. This feeling has been described by patients as ances produced stresses that radiated superiorly
the same sensation that is experienced upon drinking a along the perpendicular plate of the palatine
glass of very cold beverage. It is now clear that this bone to deeper anatomic structures, such as the
phenomenon is due to the forces in the nasal area that pterygoid plates of the sphenoid, the zygomatic
are produced by activation of the expansion appliances. process, and the medial wall of the orbit.
The stable removable expansion appliance pro- 6. Similar stress characteristics were seen with the
duced photoelastic force observations similar to the removable appliance. However, increased acti-
above except that more of the alveolus surrounding the vation decreased retention of the appliance and
teeth was involved. Perhaps this is an indication that thereby lessened the stress.
this appliance may well be a more effective device 7. The quad helix appliance proved to be the least
because of its increased anchorage. This, of course, effective orthopedic device. Although the ef-
may be more theoretical than practical, since it is sel- fects of palate separation were minimal, in-
dom that the clinician “ties in” this appliance. As creased activation of the appliance affected
mentioned previously, a stable appliance with good tis- primarily the posterior teeth.
sue- and tooth-bearing retention will increase the or-
thopedic effectiveness with incremental activations of
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3. Babcock. J. H.: The screw expansion plate, Dent. Record 31:
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this area after each succeeding intraoral activation of expansion of the maxilla, Dent. Cosmos 47: 570-573, 1905.
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8. Isaacson, R. J., and Ingram, A. H.: Forces produced by rapid
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SUMMARY AND CONCLUSIONS
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expansion, Angle Orthod. 36: 152-164, 1966.
mental activation of the devices.
12. Gardner, G. E., and Kronman, J. H.: Cranioskeletal displace-
2. The Minne-expander appliance showed less ments caused by rapid palatal expansion in the rhesus monkey.
force with each activation, but that which was AM. J. ORTHOD. 5% 146-155, 1971.
produced was within the orthopedic range. 13 Storey. E.: Tissue response to the movement of bones, AM. J.
3. The quad helix appliance produced forces less ORTHOD. 6rl: 229-247, 1973.
14 Wertz, R., and Dreskin, M.: Midpalatal suture opening: A nor-
than the orthopedic range and was therefore
mative study, AM. J. ORTHOD. 71: 367-381, 1977.
considered to be an orthodontic appliance except 15 Chaconas, S. J., and de Alba y Levy, J. A.: Orthopedic and
when used in younger patients in whom the su- orthodontic application of the quad helix appliance, AM J.
tures are patent. ORTHOD. 72: 422-428. 1977.
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16. Hicks, E. P.: Slow maxillary expansion, AM. J. ORTHOD. 73: 20. Harberson, V. A., and Myers, D. R.: Midpalatal suture opening
121-141, 1978. during functional posterior cross-bite correction, AM. J. OR-
17. Timms, D. J.: A study of basal movement with rapid maxillary THOD. 74: 310-313, 1978.
expansion, AM. J. ORTHOD. 77: 500-507, 1980. 21. Bell, W. H., and Turvey, T. A.: Surgical correction of posterior
18. Bell, R. A., and Le Compte, E. J.: The effects of maxillary cross-bite, J. Oral Surg. 32: 81 l-816, 1974.
expansion using the quad helix appliance during the deciduous 22. Kennedy, J. W., Bell, W. H., Kimbrough, 0. L., and James,
and mixed dentitions, AM. J. ORTHOD. 79: 152-161, 1981. W. B.: Osteotomy as an adjunct to rapid maxillary expansion,
19. Bell, R. A.: A review of maxillary expansion in relation to rate AM. J. ORTHOD. 70: 123-137, 1976.
of expansion to a patient’s age, AM. J. ORTHOD. 81: 32-37,
1982.