Seminars in Orthodontics 29 (2023) 278−288

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Myth and evidence in palatal expansion

Birte Melsen a,b,c,*, Joseph G. Ghafari d,e
a
Department of Orthodontics, Aarhus University, Denmark
b
Department of Orthodontics NYU, New York, United States
c
Department of Orthodontics, University of West Australia, Perth, Australia
d
Department of Dentofacial Medicine, Faculty of Medicine, American University of Beirut
e
Department of Orthodontics, University of Pennsylvania

A R T I C L E I N F O A B S T R A C T

Keywords: Untruths and distortion of scientific findings inhabit the medical and dental fields, not intentionally but often
Maxillary expansion because of the lack of firm evidence. The aim in this paper is to visit a common orthodontic treatment modality,
Suture, palate palatal expansion, and explore whether the accumulated biologic and mechanical findings are sufficient or misin-
Closure
terpreted for proper intervention. Specifically, questions are raised regarding the sutural response to maxillary
Development
Adverse effects
widening in relation to the age-related changes in the morphology of the suture. The fractures occurring when
expansion of a heavily interdigitated suture is performed and the healing that leads to its closure may impede the
sutural pubertal growth spurt. Later widening of the arch width, even when surgically assisted, may lead to a
bony relapse and severe bony dehiscence of the lateral teeth. Extensive research is needed to help generate appro-
priate guidelines for palatal expansion especially the age of the patient, timing and amount of expansion, duration
of retention, and factors related to maintenance of the treatment results.

Introduction into variations in cephalometric analyses. Tweed’s focus on the position

A myth is a widely held but likely false idea or belief that is coun-
tered by the provision of evidence, the available body of information or
facts that indicate the validity or misconception of the belief. In a scien-
tific concept, we consider the myth in this paper to include a body of
workable hypotheses awaiting the confirmation of reliable evidence. A
myth may originate from an observation (a credible report of treatment
success or failure in one or more individuals), but its generalization is a
risk, requiring the rigor of focused investigation.
In this perspective, myths have inhabited the world of orthodontics
not the least because esthetics has misplaced function as the main indi-
cation for orthodontic treatment, undoubtedly because a nice smile is
closely related to an improved life quality and as such not life threaten-
ing. The differentiation between myth and evidence is illustrated in
facial esthetics. The perception of beauty has varied over time, likely
influenced by the prevailing culture, social norms and fashion, as well as
the popularity of persons at the special time. Such concepts are readily
recognized through the images of the Virgin Mary whose representa-
tions over 20 centuries have varied in vertical and sagittal proportions,
and the consideration at one time that a flat profile (e.g. Monaco prin-
cess Grace Kelly’s) was ideal and an inspiring goal for orthodontic treat-
ment, and at another time that a more protruded profile (e.g. Sofia
Loren’s) was desirable. The different assessments of beauty translated
of the mandibular incisors through their inclination to the mandibular
and Frankfort planes as essential to facial balance1 was strongly criti-
cized by Wylie2 as unfounded.
Orthodontists have also been subjected to differing and at times con-
flicting treatment modalities related to appliances such as a special
“technique” being superior to other approaches, or a distinctive bracket
foregoing the need to bend wires,3 and more recently aligners possibly
correcting all malocclusions.4 Melsen5 stated that orthodontics cannot
claim to be scientific without focusing on biology, and that although
orthodontists manage the same tissues as bone biologists, they do not
share a common perception: orthodontists regard tissue reaction as
related to forces whereas bone biologists focus on bone deformation.
The gap in perception, if not knowledge, propagates in the approach to
treatment, which may rely on interpretation of evidence rather than
solid scientific confirmation of theory.6
In this context, the focus of this paper is to explore the gaps between
facts and practice in the treatment of arch width that has been related to
both esthetics and mechanics. Evidence is assembled from published
and some supportive unpublished material to examine maxillary sutural
anatomy and its impact on the time of palatal expansion, and recognize
the problems that could emerge if treatment does not account for biolog-
ical limitations and suture adaptation. The presented information does
not provide solutions to the long-term problems resulting from palatal

* Corresponding author.
E-mail address: birte@melsen.com (B. Melsen).

https://doi.org/10.1053/j.sodo.2023.04.003

1073-8746/© 2023 Published by Elsevier Inc.

B. Melsen and J.G. Ghafari Seminars in Orthodontics 29 (2023) 278−288

widening, but rather demonstrates reasons for unexpected long-term

results. Findings from studies of skulls, human autopsy and biopsy mate-
rial are presented to support, contradict, or clarify references that pur-
port to define the “state of the art” of transverse widening.

The “wider” maxillary arch

Past the original objective to correct posterior crossbites, the indica-

tions of palatal widening have expanded to the correction of crowding
and eliminating “black corridors.” An anecdote reveals the association
of the wider arch with the development of dentures. Full dentures would
be renewed regularly with an increased width that contributed to less
wrinkles, thus a rejuvenating effect on the face. The first author remem-
bers from her childhood experience the neighbour’s wife who sought a
new denture almost every year, the newer always broader than the older
one. The neighbourhood children would laugh and shout: “There is the
denture coming with Mrs H.” The orthodontist’s equivalent tool to the
prosthodontist’s denture widening is palatal expansion. To understand
overcorrection of a posterior crossbite or widening “on demand” for
smile esthetics, normal dentofacial transverse development is reviewed
first.

Normal transverse development

Growth of palatal suture

ork and Skieller7 used tantalum indicators as references to quantify
Bj€
the displacement of bones consequent to sutural or condylar growth, and
to differentiate displacement from modelling and intramaxillary tooth
movement. They demonstrated that the sutural growth between ages 4
and 18 was on the average 6.9 mm and that after the eruption of the pre-
molars around 10 to 11 years of age, 4 mm of growth were left in the
midpalatal suture (Fig. 1).7,8 When the authors compared the growth in
height with the sutural growth, they found a close correlation between
the respective growth intensities.
In the same period Melsen9 described the development of the midpa-
latal suture on autopsy material excised from the cranial base (Fig. 2).
The histological analysis of the sutures from individuals at different ages
demonstrated the change in shape of the midpalatal suture from a Y
shaped suture in the children with deciduous dentition to a wavy shape
in children with mixed dentitions, ending in a suture characterized by
heavy interdigitation in individuals with permanent dentitions (Fig 3).
Changes in the transverse dimension of the maxillary arch during dentofacial
growth
In their description of the development of the maxillary arch, Bj€ ork
and Skieller8 reported a medial eruption direction of the premolars; the
width of the dental arch was maintained unchanged after the age of 5
(Fig. 4). This conclusion was recently supported by a CBCT study of
transverse maxillomandibular relations in untreated children.10 Greater
dentoalveolar increases were found in the maxilla, attributed by the
authors to sutural growth, while the first molars maintained their
“coordination with each other despite the differential increase in the
maxillary and mandibular dentoalveolar processes.” Moorrees and co-
workers,11 reported that, on average, the width of the maxillary arch cor-
responding to the second deciduous molars at the age of 5 years ends up
nearly unchanged by the end of growth at the age of 18 (Fig. 4). The
available space within the arch also does not change significantly
between 5 and 18 years, the increase in maxillary arch length following
the labial eruption of the permanent incisors relative to the primary inci-
sors being eventually offset by the nearly equal loss of the leeway
space.11 A wide range of variation reflects the possibility of crowding as
well as spacing in the individual child.
The inference from these observations is that the growth of the
midpalatal suture is balanced by the medial eruption direction of
Fig. 1. Graphs illustrating the correlation between the growth in height (A) and
the increase in distance between tantalum indicators placed on the right and the
left sides of the midpalatal suture (B). The small peaks shown before the pubertal
growth spurt were likely artefacts. The measurements were taken every year, but
sometimes the study participants did not show up exactly every 12 months. If the
interval was for example 15 months, the growth data were divided by 15 then
multiplied by 12 to calculate the annual growth rate. If the interval included 2
summers, the growth rate was higher than when the 15-month interval included
2 winters, because children grow significantly more during light periods than
during dark periods.8 (graphs adapted from Bj€ ork).7
the buccal teeth (as described by Bjo €rk and Skieller7) to maintain
proper transverse occlusion with the mandibular arch. The first
author witnessed first-hand routine maxillary arch expansion by
Isaacson et al12 of patients in the late mixed dentition to prevent
foreseen crowding, and later the abandonment of this routine as the
patients revealed almost 100% relapse. Although of great signifi-
cance, this communicated information was not published. Appropri-
ate explanation may be provided from autopsy and biopsy material
and implant studies presented in the next section on the effects of
maxillary expansion on the palatal suture.
Changes in pharynx
Based on measurements performed on skulls and later 3D images,
the width of the pharynx increases by an average of 10 mm between
4 and 18 years of age.13 The pharynx is delineated by the pterygoid
plates of the sphenoidal bone, which is part of the cranial base and
does not have a growth zone in the mid sagittal plane. The widening
of the pharynx is a result of a modelling expressed through resorp-
tion of the medial surfaces and apposition on the lateral surfaces
(Fig. 5). The palatal bone adapts with differing growth patterns, the
separation of the two parts of the maxilla by sutural growth and the
widening of the pharynx by modelling of the pterygoid plates. In
pathologic or morphologic conditions impacting sutural growth, the
pharyngeal space may be affected. However, in cleft palate patients
in whom the maxillary arch is collapsed and nasal breathing is
impaired, the absence of suture apparently does not affect pharyn-
geal airway dimensions compared to control individuals with normal
occlusion.14

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B. Melsen and J.G. Ghafari Seminars in Orthodontics 29 (2023) 278−288

Fig. 2. Graphic (A) and anatomical (B,C) representation of images showing how the midpalatal suture was excised after the brain had been removed at autopsy.

Fig. 3. Drawings (A-C) and corresponding histological images (D-E) of the midpalatal suture from individuals in the deciduous dentition (A,D), mixed (B,E) and perma-
nent (C,F) dentitions.

Closure of palatal suture
Does the palatal suture close, and if so, when? Two panels are consid-
ered: natural closure and post-expansion closure.
Natural closure: In most skulls of adults, the intermaxillary suture is
heavily interdigitated, but still open. A study of the skull collection at
the Dental college in Aarhus revealed that most skulls from individuals
with fully erupted third molars still demonstrated an open midpalatal
suture, whereas some exhibited no visible suture. Therefore, too many
intermaxillary sutures in adults will be estimated closed on CBCT
images, which remain the optimal mean for in vivo appraisal.15 The
interdigitation complicates the detection of absent transmaxillary bridg-
ing.
To find out if sutural status was associated with function in stud-
ies conducted before the development of the CBCT, alginate impres-
sions were taken and cut in thin slices to analyse the occlusal
surfaces (Fig. 6). The results indicated that in the presence of both
latero- and medio-trusion facets, whereby the right and left maxilla
would be moved in both contraction and expansion during occlusion
movements, the suture was open. In the presence of only laterotru-
sion facets, reflecting merely lateral movement, the suture was
closed.

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B. Melsen and J.G. Ghafari
Fig. 4. Available space in maxillary and mandibular dental arches at ages 5 and 18 (after Moorrees11).
An early finite element analysis indicated that the strain on both
sides of the suture was identical when only laterotrusion facets were
simulated during occlusion (Fig. 7).16 However, the strain was different
between the two sides of the suture when both latero- and medio-trusion
facets were simulated. These observations provide a qualified estimate
of the open or closed status of the suture in relation to function yet to be
further researched for conclusive evidence. Variations with malocclu-
sion and related function can be achieved on autopsy material if allowed
by institutional review boards.
Post-expansion closure: The histological images from the biopsies fol-
lowing palatal expansion demonstrated that fractures had occurred and
that the suture was in the state of repair following the fracture six weeks
after expansion.17 The question was therefore whether the healing
Fig. 5. Image of a dry skull from an individual in the early mixed dentition illus-
trating that the width of the palate (blue arrow) is nearly unchanged between
the ages of 5 and 18. The increase in the width of the pharynx results from bone
modelling, apposition on the lateral aspect and resorption on the medial side of
the adjacent bones. This process widens the pharynx the same amount as the
growth of the midpalatal suture widens the upper airways.
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Seminars in Orthodontics 29 (2023) 278−288
would lead to a closure of the suture. In a female patient age 14 at the
time of expansion, the surgeon who took out the biopsies declared that
he could not verify an open suture 1 year after expansion. The signifi-
cance of this observation is the verification that suture closure can result
from expansion, a finding difficult to ascertain in individual patients
undergoing maxillary distraction, possibly impacting the opportunity of
a repeated maxillary expansion if needed. Considering natural facial
growth, it is reasonable to hypothesize that growth of the mid-palatal
suture, which reaches about 7mm in an average course of
development,7,8 would not escort and might impede pharyngeal opening
if the suture closes following palatal expansion.
Effects of maxillary expansion on the palatal suture
A limiting factor in the assessment of biological palatal sutural
response to maxillary expansion is that any intervention for in situ obser-
vation in humans is invasive. A historic landmark in this field that
impacted current knowledge by providing unique qualitative assessment
of the sutural response was the analysis by Melsen17 of 5 children (ages
8-14) who volunteered for biopsies, a study that could not be repeated
in larger samples with current limitations by institutional review boards
(Fig. 8). The histological image of a midpalatal suture from an 8 year-
old boy in the early mixed dentition who had undergone palatal expan-
sion with a hyrax expander revealed apposition of woven bone on both
sides of the suture. What appeared as an island (indicated with an arrow
in Fig. 8C) on the histological image was a section of the bony exten-
sion.
Krebs18 analysed the result of palatal expansion in a 10-year-old boy
in whom they had inserted the Bj€ ork implants (Fig. 9). Following the
expansion of 8 mm at the dental level and approximately 6 mm between
the implants, a minor relapse occurred when the appliance was
removed. However, of significant importance was the finding that
approximately 1 year after the expansion, an increased distance between
the implants reflected growth in the midpalatal suture in relation to the
B. Melsen and J.G. Ghafari
Fig. 6. Two skulls of adult individuals. A-C. Skull with a narrow maxilla and an open suture. The sliced alginate impressions (C) reveal both laterotrusion (yellow
arrows) and mediotrusion (white arrows) facets. D-F Skull with a wide maxilla and a closed suture. The sliced alginate impressions revealed only laterotrusion facets.
pubertal growth spurt, underscoring the potential for maintenance of the
pubertal growth after the early hyrax expansion.
These observations indicate that in the early growing (likely prepu-
bertal) years, an open suture with less interdigitation facilitates maxil-
lary expansion, resulting in apposition on both sides of the suture
(Fig. 8). In contrast, opening the suture following expansion in older
individuals could not be conceived without fractures across the interdig-
itation, because of the pronounced interdigitation between the sutural
sides (Fig 10).17 Delineating the individual variation in the topology of
interdigitation is not possible with present diagnostic tools. In this con-
text, the earlier the intervention, the less risk of closure from the ensuing
fractures.
Effects of expansion on craniofacial structures
Maxillary expansion has been reported to result in distant compensa-
tions. Animal research has shown the distant histological effect of pala-
tal expansion in the nasal cavity and structures of the neurocranium
including the floor and lateral and medial walls of the orbits,19 as well
as opening of the spheno-occipital synchondrosis and “severe disori-
entation” of the lambdoid, parietal, and midsagittal sutures.20 This
potential is informative in the “orthopaedic” frame of bone modelling.
Research is warranted to determine whether such effects are common,
under which circumstances, and at which age.
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Seminars in Orthodontics 29 (2023) 278−288
Three-dimensional radiographic records do not provide information
that mirrors the histologic revelations but may provide additional infor-
mation on the response in the total maxilla, such as suture opening
depicted on a frontal tomogram (Fig. 11). CBCT imaging revealed a
small increment of the volume of the spheno-occipital synchondrosis
and a posterosuperior pattern of displacement of basion.21 However,
CBCT remains limited as radiation is not allowed in short-term intervals.
Non-invasive finite element modelling has not yet simulated the expan-
sion effect beyond the immediate surrounding maxillary structures.
Future development of these technologies, combined with vast longitu-
dinal data aided by artificial intelligence will hopefully bring present
questions to a higher threshold of knowledge.
Recognizing gaps of knowledge for improved clinical outcome
In current practice, proper diagnosis not only focusing on the hard
tissue, but also soft tissue (and potentially genetics) should help deter-
mine the planned changes in the position of teeth, the dental width, and
the skeletal width, before performing the bony expansion. These and
other questions have yet to be addressed to generate appropriate guide-
lines for palatal expansion including age of patient, timing and amount
of expansion, and duration of retention. In this section, we cover salient
issues related to palatal expansion and the corresponding gaps of knowl-
edge heretofore not answered and requiring focused research.
B. Melsen and J.G. Ghafari Seminars in Orthodontics 29 (2023) 278−288

Fig. 7. Results of a finite element model in a study of the palatal suture. A. Changes occurring when the person occludes with only laterotrusion facets; the arch widens
slightly (arrow). B. Higher density is concentrated at the sutural area. C,D. Strain in the sutural area when the teeth occlude: in a person with a closed suture (C), and
when a person has both latero- and medio- trusion facets (D)- note the difference on the two sides of the suture.

Biological knowledge
This review indicates that the main biological underpinnings of
palatal development and palatal expansion have been determined
by the qualitative works of Melsen,9,17 who contributed knowledge
about histological sutural anatomy and response to expansion, and
Bj€ork et al,7,8 who documented sutural separation relative to
implants. Most of the later publications have focused on mechani-
cal issues, because of the invasive nature of biological explorations
in humans.
Gaps: These relate to biological diagnosis and clinical indications.
Biological markers to routinely gauge the status of the suture (open,
closed, interdigitated at higher or lower levels) and time its expansion
are not available for palatal distraction and other orthodontic proce-
dures (e.g. state of tooth movement or root resorption). Much work is
invested in the non-invasive finite element modelling to help predict
clinical intervention, but shortcomings have yet to be overcome, not
least of which the individual variation.22 Clinically, this question still
needs an appropriate answer: what is the biological background for any
expansion protocol beyond the basic indications to correct a posterior
crossbite, such as the reduction of the “black corridors” between the
buccal teeth and commissures?
Time of expansion
The observations reported in this paper would indicate that earlier
expansion is recommended, when the suture is less interdigitated, not-
withstanding the fact that less resistance from the buttressing zygomatic
bones would also be expected.23 However, adequate knowledge is miss-
ing of the impact of the expansion on post-expansion growth of the den-
tofacial complex.
Such limitation was exemplified in the use by Isaacson et al12 of a
hyrax expander in the late mixed dentition when crowding and/or
impaction of permanent canines could be predicted. Years later, the
authors abandoned this approach as they experienced transverse prob-
lems reoccurring during puberty, probably because closure of the

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B. Melsen and J.G. Ghafari
Fig. 8. Biopsy made from a girl of early mixed dentition (A). The palatal mucosa was flapped back and a 5mm cylinder biopsy (B) was removed before the appliance
was recemented. C,D. Histological images of two adjacent sections . What can be perceived as an island on image C shows on the next section (D) as a cutting of an
extension.
sutures impeded sutural growth that would take place at puberty. Also,
the trend towards a later initiation of the orthodontic treatment, in one
rather than two stages of treatment, reinforced the same tendency.
Fig. 9. Graph redrawn from Krebs18 illustrating the development of various
transverse dimensions after rapid palatal expansion in an 11-year-old boy. An
immediate small relapse of all the variables occurs except for the interdental
(molar and canine) distances that were maintained with a retention plate, until
the plate was removed. A significant finding is the increase in the distance
between the implants at the age of 12 years reflecting the pubertal growth spurt.
This finding is possible when the expansion is performed when the sutural mor-
phology allows for a separation of the two maxillary halves.
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Seminars in Orthodontics 29 (2023) 278−288
Gaps: Whether the suture can be fractured again in a subsequent
expansion with tooth borne or bone borne expanders may not be pre-
dicted, particularly in the individual patient. Such outcome is con-
founded by the fact that with growth, the resistance to expansion from
the buttressing lateral bones may increase, blurring the status of the
suture.
Potential dentoalveolar hazards of overexpansion
To reduce dental tipping and favor skeletal expansion, the surgically
or mini-screw assisted rapid palatal expansion (SARPE or MARPE) was
recommended to overcome the resistance to expansion. SARPE is illus-
trated in the records of a 15-year-old patient shown in Fig. 12A. An
expansion corresponding to the width of one incisor was performed
without any damage to the periodontium of the central incisors
(Fig. 12B). To maintain the arch widening, a 0.019″ × 0.021″ stainless
steel wire was inserted in the brackets and a 0.036” transpalatal arch
was placed anchored on the first molars. A gradual closure of the suture
was observed. However, a CBCT reconstruction demonstrated that the
maxillae moved medially in relation to the teeth and the teeth did not
move with the bone or in relation to the bone (Fig. 12 D,E). The roots of
the teeth were maintained by the transpalatal arch and were clearly out-
side the buccal bone.
The same effects were demonstrated in another patient with failing
bone coverage shown on CBCT imaging and verified by a flap surgery
(Fig 13). This finding counters the claim by pro-widening advocates that
the threshold of the radiograph could be changed to demonstrate bony
coverage of the expanded teeth that was too thin to be seen on the
image.
Gaps: While overexpansion is accepted with tooth-bone expansion
devices, guidelines based on high-level evidence are absent, leading to
B. Melsen and J.G. Ghafari Seminars in Orthodontics 29 (2023) 278−288

Fig. 10. A. Graphic illustration of the split of a heavily interdigitated suture when subjected to expansion. A fracture occurs across the interdigitations. B. A histological
image of a suture biopsy 3 weeks after expansion demonstrating not only formation but also resorption (yellow arrow) taking place. Red arrows point to true island
(fractured extensions) C. Biopsy at 9 weeks showing healing of the fracture. D. The suture (red arrows) has closed, but the sutural tissue can still be distinguished below
the consolidated bone. White arrow: Bony island in the middle of the suture. Note the lamellar bone (blue arrows) and adjacent woven bone formed during the closure
(orange arrow).

a wide margin of variation among clinicians with irreversible effects,
probably related to suture closure and longer duration of retention of
the appliance, at times requiring the reverse treatment strategy (e.g.
crossbite elastics). In addition, overexpansion with bone-borne expan-
sion is subject to different also yet to be established evidence-based
guidelines.
Potential breathing hazards of early sutural closure
What is the impact on breathing of early closure of the palatal
suture that may affect the width of the nasal airways? Claims have
been raised regarding the effect of maxillary premolar extractions
and associated constriction of the maxillary arch, or the aggressive
use of headgear and maxillary distalization on normal breathing.
The generation of obstructive sleep apnea through premolar
extraction has not been supported in an electronic health records
review.24
Gaps: Further exploration is needed by assessing the volumetric
changes in the oral cavity when the adaptive sutural contribution in the
pubertal period is prevented.
Maintenance of results: role of soft tissues
The observations underscore the role of the soft tissues in maintain-
ing the expansion-induced changes in skeletal pattern, including the
tongue and cheek at rest and in function. The long-term outcome is asso-
ciated with the orofacial function. Sarn€as et al25 reported that maxillary
expansion leads to traumatic sutural damages and the healing process
along with the restoration of a soft tissue balance can cause a relapse of
the expansion. They also put in question the rationale for rapid maxillary

Fig. 11. Frontal radiographs constructed from CBCT images before (A), after (B) and 3 months following expansion (C) in a child with full deciduous dentition. Note
the open suture (yellow arrow) and apposition on the buccal side (blue arrow) after expansion (B) and additional apposition (blue arrow) 3 months later (C). (The
CBCT was taken as part of a treatment for a patient suffering from a syndrome).

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B. Melsen and J.G. Ghafari Seminars in Orthodontics 29 (2023) 278−288

Fig. 12. A. Clinical photograph of a 15-year-old girl showing the significant diastema developed following a surgical assisted rapid palatal expansion. B. Intraoral
radiograph demonstrating that the expansion occurred without periodontal damage. C. An artificial tooth was connected to the archwire in the diastema. Subsequently,
the tooth was gradually slenderized to allow for the closure of the space. D. CBCT image before expansion, demonstrating the presence of bilateral cross bites. Note the
apices of the molars penetrating the buccal bone (yellow arrows). E. Six weeks following the expansion, the molars were held with a transpalatal bar and the maxillary
halves approximated, indicating the medial movement of the bone with respect to the teeth. Accordingly, the roots of the teeth held by the palatal bar are completely
outside of the bone (grey arrow).

expansion unless normal growth and a change in function during treat-
ment generate a new balance. Thereby they confirmed the observation
of Isaacson,11 although either group of researchers did not refer to the
biopsy material17 demonstrating the fractures occurring when the suture
is interdigitated.
Gaps: While the displacements of hard tissues (teeth and bone) are
measurable, the influence of the neuromuscular envelope is not predict-
able. The adaptive potential of soft tissues varies individually, confound-
ing the issue of maintainability of the arch width expansion, let alone
the occurrence of side effects such as those illustrated in Figs. 12 and 13.
Missing is the answer to this question: what is the effect of a long-stand-
ing retention protocol of an over-corrected maxillary expansion on the
periodontium and on the transverse dimension if a closed suture main-
tains an overexpanded maxillary basal bone and the tongue does not
support it?
Conclusion
The combination of research and clinical observations on arch wid-
ening addressed in this paper indicate the following principles under-
scoring the presence of numerous gaps of knowledge:
1 Orthodontic widening should be performed before the suture
becomes highly interdigitated to avoid fracture and fusion. Clini-
cal or radiographic diagnostic tools to determine the amount of
interdigitations within the suture or suture closure are not yet
available.
2 Early intervention in the mixed dentition and prepubertal years is
more dependable for palatal suture opening but may not yet antici-
pate the feasibility or success of additional future expansion if
needed. Sutural opening is unpredictable individually in pubertal or
postpubertal years and becomes limited or questionable, requiring
MARPE or SARPE as indicated for the specific malocclusion and
patient age, notwithstanding the fact that skeletal expansion also
presents various limitations.
3 Maxillary arch expansion in the period when the suture is highly
interdigitated results in a sutural reaction comparable to a fracture
healing, possibly leading to fusion of the suture that may prevent fur-
ther growth of the suture and its adaptive escort of the growth of sur-
rounding structures. Consequently, the transversal development of
the upper airways may be reduced, and normal breathing affected.
High level evidence is warranted in this area.
4 Maintenance of the widened arch depends on removing the etiol-
ogy (e.g., mouth breathing) and preserving the soft tissue bal-
ance, particularly tongue posture. A low tongue posture may
prevent the maintainability of a maxillary expansion. This bal-
ance is a determining factor of successful and maintainable
results, irrespective of the rationale for the expansion, including
the correction of a crossbite and the reduction of “black
corridors” to achieve a wider smile.
5 The indications and extent of palatal expansion should be revisited,
and appropriate guidelines developed taking into consideration the
biological limits of the health and function of the oral tissues and
long-term maintainability of results.

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B. Melsen and J.G. Ghafari Seminars in Orthodontics 29 (2023) 278−288

Fig. 13. A. Intraoral x-rays constructed from CBCT show the lack of buccal bone after palatal expansion, unlikely related to the threshold used. B. Clinical photograph
demonstrates the perforated bone as an iatrogenic effect of the expansion.

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