Volume 34 Issue 3 Article 3

August 2022

Mandibular Expansion Appliances and Their Activation Protocols

Tivanani Venkata Durga Mahendra
Department of Orthodontics and Dentofacial Orthopedics, Vishnu Dental College, Vishnupur, Bhimavaram,
India

Vyshnavi Mulakala
Andhra Pradesh, India

Manda Anoosha
Department of Orthodontics and Dentofacial Orthopedics, Vishnu Dental College, Vishnupur, Bhimavaram,
India

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Recommended Citation
Mahendra, Tivanani Venkata Durga; Mulakala, Vyshnavi; and Anoosha, Manda (2022) "Mandibular
Expansion Appliances and Their Activation Protocols," Taiwanese Journal of Orthodontics: Vol. 34: Iss. 3,
Article 3.
DOI: 10.38209/2708-2636.1135
Available at: https://www.tjo.org.tw/tjo/vol34/iss3/3

This Review Article is brought to you for free and open access by Taiwanese Journal of Orthodontics. It has been
accepted for inclusion in Taiwanese Journal of Orthodontics by an authorized editor of Taiwanese Journal of
Orthodontics.
Mandibular Expansion Appliances and Their Activation Protocols

Abstract
A tooth size-arch length discrepancy (TSALD) occurs when there is an imbalance between the size of the
teeth and the space available in the dental arches to accommodate them. Relief of crowding through
expanding the arch is the most employed non-extraction method in orthodontics. Because of the absence
of a midline suture and the resistance of the mandibular body, resolving crowding in the lower arch is
more complex than in the upper arch. However, numerous researchers have devised innovative
techniques and methods to successfully bring about the desired and stable changes through mandibular
expansion. The advantage of this procedure was not only reduction of anterior crowding and decrease of
the buccal corridors but also the avoiding of tooth extraction. The current review aims to recapitulate the
numerous approaches of mandibular expansion in orthodontics and their activation protocols.

Keywords
Mandibular expansion; Orthodontic appliances; Dental crowding

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REVIEW ARTICLE

Mandibular Expansion Appliances and Their

Activation Protocols

Tivanani Venkata Durga Mahendra a,*, Vyshnavi Mulakala b, Manda Anoosha a

a
Department of Orthodontics and Dentofacial Orthopedics, Vishnu Dental College, Vishnupur, Bhimavaram, India
b
Private Practioner, Andhra Pradesh, India

ABSTRACT

A tooth size-arch length discrepancy (TSALD) occurs when there is an imbalance between the size of the teeth and the
space available in the dental arches to accommodate them. Relief of crowding through expanding the arch is the most
employed non-extraction method in orthodontics. Because of the absence of a midline suture and the resistance of the
mandibular body, resolving crowding in the lower arch is more complex than in the upper arch. However, numerous
researchers have devised innovative techniques and methods to successfully bring about the desired and stable changes
through mandibular expansion. The advantage of this procedure was not only reduction of anterior crowding and
decrease of the buccal corridors but also the avoiding of tooth extraction. The current review aims to recapitulate the
numerous approaches of mandibular expansion in orthodontics and their activation protocols. Taiwanese Journal of
Orthodontics 2022;34(3):138e144

Keywords: Mandibular expansion; Orthodontic appliances; Dental crowding

INTRODUCTION limited to the alveolar bone and predominantly

A tooth size-arch length
(TSALD) is the most common type of
discrepancy
malocclusion in most orthodontic patients. This
disparity, particularly in the mandibular arch, is a
critical factor in the extraction decision. Given the
recent shift in treatment techniques toward more
conservative approaches, methods like inter-
proximal reduction, distalization, and arch
expansion space gaining are more preferred.1
Edward Angle opposed extractions as part of or-
thodontic treatment and the question persists till
this day, with no universal solution in sight. The lack
of sutures in the mandible evoked a heated debate
about extraction versus non-extraction.2 Unlike the
Rapid maxillary expansion of the maxillary arch that
separates the sutures, for increase in transverse
dimension, mandibular expansion effects are often
causing tooth inclinations.
Although some researchers claim that mandibular
expansion is not conceptually stable and that
appliance therapy cannot change the mandibular
arch form. Some investigations have demonstrated
that the width of the mandibular arch can be
permanently increased.3,4 The contemporaneous
rule of expansion for the mandibular arch was
applied when the inter-premolar and inter-molar
widths were smaller than 25 and 34 mm, as reported
by Hadelman.5
According to Walter,6 the width of the mandibular
arch can be permanently altered. In the last several
years, mandibular expansion has become more
prevalent. A significant expansion in dental arch
widths, as well as a significant reduction in crowd-
ing and even long-term stability, were seen
following mandibular expansion treatment.7
Although there is limited evidence of the use of
orthodontic appliances to achieve mandibular

Received 22 April 2022; revised 12 July 2022; accepted 15 July 2022.

Available online 8 September 2022.

* Address correspondence to Dr. Tivanani Venkata Durga Mahendra, Assistant Professor: Department of Orthodontics and Dentofacial Orthopedics,
Vishnu Dental College, Vishnupur, Bhimavaram, India.
E-mail address: dr.mahendramds@gmail.com (T.V. Durga Mahendra).

https://doi.org/10.38209/2708-2636.1135
2708-2636/© 2022 Taiwan Association of Orthodontist. This is an open access article under the CC-BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
Taiwanese Journal of Orthodontics T.V. DURGA MAHENDRA ET AL
2022;34(3):138e144 MANDIBULAR EXPANSION APPLAIANCES

expansion in the current orthodontic literature, not

all orthodontists are aware of these appliances. The
aim of this review is to compile these appliances and
their activation protocols.

SEARCH STRATEGY
The literature on mandibular expansion appli-
ances was searched for using PubMed/Medline,
EBSCO, and Google Scholar between 1990 and 2020.
The search results included crowding cases with
TSALD of more than 5 mm and constricted arches
with reduced inter canine width ranging from 20 to
24 mm. All were treated by arch expansion. The
databases search included keywords such as Figure 2. Schwartz appliance.
“mandibular expansion” and “expansion appliance,
apparatus,” and “device”. A sample search may be Activation protocol
“mandibular expansion” and “device,” allowing for
the sorting of the most relevant documents from the The appliance is activated at a rate of 1/4 turn per
archives. The following are the few mandibular week till the screw reached its expansion limit
expansion devices or appliances employed to bring before the end of the treatment. The device should
about changes in the transverse discrepancy of the be worn for at least 14 hours per day.
mandibular arch (Figure 1).
2) Lip bumper10,11
8,9
1) Schwartz appliance
The lip bumper enables for both anterior-poste-
This device is a removable mandibular expander rior and transverse extension of the mandibular
(Figure 2). It consists of acrylic resin, stainless steel dental arch. It's usually made of 0.04500 stainless steel
ball hooks and Adams clasps with thicknesses of wire and runs from molar to molar across the
0.8 mm and 0.7 mm respectively, and an expansion mandibular dentition. The wire is kept away from
screw were used to construct the devices. The the labial surfaces of the teeth, usually near the
appliance is activated by turning the screw. gingival margin, and may or may not be covered

Figure 1. Search strategy.

139
T.V. DURGA MAHENDRA ET AL
MANDIBULAR EXPANSION APPLAIANCES
with plastic or acrylic anteriorly. The appliance is
designed to fit into tubes on the lower molars and
includes adjustment loops just above them
(Figure 3).
Activation protocol
The lip bumper displaces the facial musculature,
keeping it from coming into contact with the lower
teeth, and causes the tongue's pressures on lingual
surface of teeth to stay imbalanced, causing
mandibular dental arch forward and lateral expan-
sion. The lip bumper is based on the fundamental
principle of disrupting the equilibrium surrounding
the dentition.
3) Williams' expander1,12
This fixed appliance was designed by Williams to
correct crowding in the early mixed dentition
(Figure 4). The appliance consists of two long
stainless-steel tubes soldered to each of the lower
primary second molar bands, with extensions back
to join the lingual of the first permanent molars. An
Figure 3. Lip bumper.
Figure 4. Williams expander.
140
Taiwanese Journal of Orthodontics
2022;34(3):138e144
expansion screw is attached to the molar bands by
stretching the wire over the anterior region of the
jaw. An arc of 0.016 NiTi arch wire is placed into the
forward ends of the stainless tubes when the
expansion screw is activated, and the NiTi wire is
automatically dragged forward to relieve crowding
of the incisors.
Modifications:
3.a Modified williams expander1
The modified Williams expander is similar to the
original design, but it lacks the arc of 0.016 NiTi
archwire. On the cervical third of the premolars, the
expansion appliance's arms are aligned with the
occlusal line.
3.b 2-arm mandibular fixed lateral expansion
appliance (FLEA).1
The expansion screw has two 0.060-inch extension
arms and two first molar bands (Leone, Italy). A
0.035-inch wire was soldered to these arms to add
the required length, allowing the wire to extend
2.0 mm away from the alveolus. The wire continues
below the mid-crown level of the second and first
premolars to minimize the tissue injury.
Activation protocol
The screw should be activated once every two
weeks for a quarter turn, which amounted to
approximately 0.25 mm and resulted in 0.5 mm
expansion per week.
4) Trombone appliance13
The trombone appliance is used to aid the maxilla
and mandible to develop in the anterior-posterior
region (Figure 5). The device does not obstruct
speech and can be used in conjunction with other
Figure 5. Trombone appliance.
Taiwanese Journal of Orthodontics
2022;34(3):138e144
fixed equipment. An inner tube slides freely within
an outer tube to extend or contract the length of the
device, comparable to the slide trombone from
which it derives its name. The molar component of
the appliance, which also has a vertical tube
attachment for insertion of the trombone part, is
secured by double lingual posts.
Activation protocol
To achieve the desired expansion, the appliance
should be preactivated. The mechanism should be
reactivated every 4 to 6 weeks by substituting the
silicone tubing with a new tube of the right length
till the arch form is corrected. Because there are no
frictional forces, moderate, controlled lingual forces
allow rapid tooth movement.
5) TORKO Appliance14
It is a specialized micro expansion screw for or-
thodontic therapy (Figure 6). LEONE's first mono
guide, hygienic expansion was the “TORKO” appli-
ances. TORKO screws have a specific torque, and no
weld marks to prevent food, debris, and plaque from
accumulating in mandibular hygiene appliances.
Activation protocol
The appliance delivered the appropriate trans-
lingual force to promote transverse and sagittal
dentoalveolar expansion. The appliance is activated
one-quarter turn in the morning and in the evening.
It results in 0.4 mm of daily expansion. This tech-
nique is repeated daily for another 28 days, to ach-
ieve 11 mm of expansion.
6) Mandibular Arnold Expander15
Berkowitz popularised the Arnold appliance
(Figure 7). It is a fixed coil-spring device, in the 1970s
Figure 6. TORKO appliance.
141
T.V. DURGA MAHENDRA ET AL
MANDIBULAR EXPANSION APPLAIANCES
Figure 7. Mandibular Arnold expander.
as a means to achieve slow, orthopaedic maxillary
expansion in cleft-palate patients. The Arnold
appliance can open 4e5 mm of space in the
mandibular arch by tipping the buccal teeth and
distalizing the first molars.
The device comprises a split lingual frame with an
0.04000 tube on one side and a wire insert on the
other, both joined by an open-coil spring made of
0.01000 Elgiloy or 0.040” nickel titanium.
Modified designs
Dr. James Thacker's variation on traditional
mandibular Arnold expander, with deciduous molar
occlusal rest and mesial stop for open-coil spring.
6.a For distalization
The lingual frame of the expander is lifted over
the occlusal table, causing molar distalization rather
than transverse expansion.
Activation protocol
The spring is compressed and activated for
expansion when the appliance is seated. There is no
need to turn an expansion key or make any more
adjustments.
7) Transforce Arch Developer16,17
Transforce is a set of prefabricated invisible
lingual appliances for the development of the
sagittal and transverse arches (Figure 8). The light,
biological forces generated by encapsulated nickel-
titanium springs achieve good results in patients of
all ages, from selective intervention in mixed
dentition to adult therapy. This device can be uti-
lized in conjunction with any traditional fixed ap-
pliances at any time throughout treatment. This
method is both cost-effective and efficient,
T.V. DURGA MAHENDRA ET AL
MANDIBULAR EXPANSION APPLAIANCES
Figure 8. Transforce arch developer.
decreasing the time spent in a fixed appliance,
particularly in adult therapy.
Activation protocol
After the appliance is placed, there is no need to
activate it, and this approach is used to several appli-
ances for sagittal and transverse arch development.
8) Beta-titanium auxiliary expansion archwire
(TMA-EA)18
An auxiliary overlay arch for dentoalveolar
extension in the maxillary and mandibular arches
was designed using the mechanical features of beta-
titanium wires, such as low stiffness and resilience.
The TMA-EA (Figure 9) was created using a straight
0.03200 beta-titanium wire with tear-form hooks on
both ends, which was designed to fit into the
0.016  0.022” NiTi thermo archwire. The TMA-EA
was preserved as a straight segment, not curled in
an arch form, to induce buccal traction of the NiTi
Figure 9. Beta-titanium auxiliary expansion archwire (TMA-EA).
142
Taiwanese Journal of Orthodontics
2022;34(3):138e144
thermo archwire and, as a result, the dentoalveolar
process. The length of the TMA-EA was determined
by measuring the circumference between each
mesial entry of the molar tubes. The TMA-EA hooks
were engaged with the main archwire at the inter-
proximal area between the second premolars and
the first molars.
Activation protocol
Three stainless steel ligatures were placed at the
central incisor and premolar regions to increase the
stability of the TMA-EA. The device was removed
and straightened during each appointment. For 60
days, the TMA-EA was employed until the trans-
verse relationship had been overcorrected.
9) Bi-helix expander19
The Bi-Helix Expander (Figure 10) in the lower
arch is effective for gaining development of the arch
while simultaneously achieving an upright position
of the molars. It is an effective and efficient appli-
ance that creates room in the lower jaw. This is
accomplished through the position and use of the
helix coils lingual to the molars and it is cemented to
the most prominent posterior teeth. The absence of
the anterior helixes also provides patient comfort.
Modification
9.a A cobalt chromium wire measuring 0.9 mm in
diameter, was used to enhance rigidity to the
anterior arm. The Bi-helix appliance was used to
apply force to the mandibular arch, resulting in a
movement of 2.0 mm for every three months.
Activation protocol
Bi helix can be pre-activated by stretching the 2-M
band apart prior to cementation or by using three
Figure 10. Bi-helix expander.
Taiwanese Journal of Orthodontics T.V. DURGA MAHENDRA ET AL
2022;34(3):138e144 MANDIBULAR EXPANSION APPLAIANCES

Table 1. Instructions to the patients for wearing the appliances.

I. Visit the orthodontist for reactivation of appliance at regular intervals
II. You may find it difficult to speak at first, but with practice (maybe reading aloud), it will become easier and easier.
III. Do not be worried if you notice an impression on your tongue; this is natural.
IV. The appliance must be activated accordingly as advised by the clinician
V. When the appliance is adjusted, you may experience some soreness.
VI. If sores develop, rinse with warm, diluted salt water at least four times a day.
VII. After each meal and before bedtime, clean your appliance with your toothbrush.
VIII. To avoid loosening or ruining the equipment, remember to follow the diet list's restrictions.
IX. Playing with your fingers or pulling on it with your tongue can cause the appliance to loosen or shatter.

prong pliers after cementation at lingual bridge of
the expander.
The instructions to be given to the patient after the
appliance is delivered is summarized in Table 1.
RETENTION PROTOCOL20
 The same appliance used for mandibular
expansion, or a fixed lingual arch appliance can
be utilised as a retention device.
 After achieving the optimum expansion, the
required retention period is approximately 3 to 6
months.
 In many adult patients with transverse
mandibular deficiency, this nonsurgical expan-
sion approach can effectively achieve mandib-
ular expansion.
DISCUSSION
The mandibular expansion is often performed
whenever there is TSALD or mandibular constric-
tion in the growing individuals. Nevertheless, it is
limited due to the early fusion of mid-symphyseal
region. This paper attempted to highlight the
various expansion devices available for mandibular
dental arch.
Dental crowding in permanent dentition is cor-
rected by Schawrz appliance. It is commonly spec-
ified in severe deficit arch length. The outcome
mainly depends on patient cooperation as it re-
quires frequent activation.9 Lip bumper is better
indicated for expansion in late mixed dentition with
hyperactive mentalis activity. It also helps correct lip
trap as well.10 While William's expander largely
corrects crowding in the early mixed dentition even
before the eruption of first permanent molars. It
shall bring about 0.5 mm expansion per week.1,12
Whenever, expansion is needed in 3 spatial di-
rections to correct maxillary and mandibular arches
as in Class II division 2, Trombone appliance is
more useful.13 The mandibular dental arch perim-
eter increases by 7.4 mm. Any collapse in the inter-
canine width for patients of growing age and
adolescence TORKO appliance is more suited. It
primarily acts by bringing about dentoalveolar
expansion.14 Arnold expander is generally used in
patients with moderate TSALD during early inter-
ceptive to late adolescence.15 Of all, Arch develop-
ment with trans-force lingual appliances are
generally patient friendly as no activation is
required after the appliance is fitted.17 However, the
selection of appliance for mandibular expansion
depends on the severity of malocclusion, patient
compliance and age.
CONCLUSION
Expansion in the mandibular arch may be per-
formed with several appliances. However, each has
its own advantages and indications. Selection of
appliance is critical for a successful treatment
outcome, and it varies for every patient. The amount
of expansion achieved mainly depended on the type
of appliance chosen and stage of development of
dentition.
FUNDING
None.
ETHICAL APPROVAL
Not required.
PATIENT CONSENT
Not required.
CONFLICT OF INTEREST STATEMENT
The authors declare no conflicts of interest.
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