ONLINE ONLY

Skeletal effects to the maxilla after rapid

maxillary expansion assessed with cone-beam
computed tomography
Brett J. Garrett,a Joseph M. Caruso,b Kitichai Rungcharassaeng,c James R. Farrage,c Jay S. Kim,d and
Guy D. Taylore
Loma Linda, Calif

Introduction: The purpose of this study was to use cone-beam computed tomography to quantitatively
evaluate skeletal expansion and alveolar tipping of the maxilla at the maxillary canine (C1), first premolar (P1),
second premolar (P2), and first molar (M1) after rapid maxillary expansion (RME). The transverse effects to
the maxillary suture, nasal width, and maxillary sinus were also assessed. Methods: Thirty consecutive
patients (17 boys, 13 girls; mean age, 13.8 ⫾ 1.7 years) who required RME with Hyrax appliances as part of
their comprehensive orthodontic treatment were studied. Measurements before and after RME of palatal and
buccal maxillary widths, palatal alveolar angle, nasal width, nasal floor width, and maxillary sinus width at C1,
P1, P2, and M1 were compared by using Wilcoxon signed rank, Kruskal-Wallis, and Wilcoxon rank sum tests.
Pearson correlation analyses were also performed (␣ ⫽ .05). Results and Conclusions: Skeletal expansion
of the maxilla had a triangular pattern with a wider base in the anterior region, accounting for 55% of total
expansion at P1, 45% at P2, and 38% at M1. Alveolar bending or tipping accounted for 6% of total expansion
at P1, 9% at P2, and 13% at M1. The remaining orthodontic (dental tipping) portions of total expansion were
39% at P1, 46% at P2, and 49% at M1. RME produces a statistically significant increase in nasal width and
a decrease in maxillary sinus width (P ⬍0.0001). Retention time showed a significant negative correlation to
the change in palatal maxillary width at C1, P2, and M1 (P ⬍0.05), the rate of appliance expansion had a
significant correlation with palatal maxillary expansion at P1 and P2 (P ⬍0.05), and age had no statistically
significant association with any parameter (P ⬎0.05). (Am J Orthod Dentofacial Orthop 2008;134:8.e1-8.e11)

R
apid maxillary expansion (RME) is frequently
used to correct maxillary width deficiency or
posterior crossbite, or to expand arch perime-
ters to alleviate dental crowding. Many orthodontists
routinely use RME in patients with already adequate
arch forms to relieve arch length discrepancy because
of the trend toward more conservative, nonextraction
treatment and broader, more esthetic smiles.1-10
a
Private practice, Loma Linda, Calif.
b
Associate professor, chair, and program director, Advanced Education Pro-
gram in Orthodontics and Dentofacial Orthopedics, School of Dentistry, Loma
Linda University, Loma Linda, Calif.
c
Associate professor, Advanced Education Program in Orthodontics and
Dentofacial Orthopedics, School of Dentistry, Loma Linda University, Loma
Linda, Calif.
d
Professor, statistics, School of Dentistry, Loma Linda University, Loma
Linda, Calif.
e
Assistant professor, Advanced Education Program in Orthodontics and Dento-
facial Orthopedics, School of Dentistry, Loma Linda University, Loma Linda,
Calif.
Reprint requests to: Brett Garrett, Department of Orthodontics, Loma Linda
University, Loma Linda, CA 92350; e-mail, silo113@excite.com.
Submitted, October 2007; revised and accepted, December 2007.
0889-5406/$34.00
Copyright © 2008 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2007.11.024
Rigid, fixed RME appliances produce heavy forces
that separate the maxillary suture, resulting in maxi-
mum skeletal or orthopedic expansion with minimum
orthodontic tooth movement.1-8 Orthopedic expansion
via RME is gained not only by bodily separation of the
midpalatal suture, but also by additional buccal rota-
tional force on the maxillary alveolar shelves.7-9 The
maxillary bones swing transversely with the frontonasal
suture as the approximate center of rotation.1,5,11 Al-
though RME force is concentrated on splitting the
maxillary suture, there are concomitant changes to the
surrounding frontomaxillary, zygomaticomaxillary, zy-
gomaticotemporal, and pterygopalatine sutures.12 An
increase in width of the nasal cavity is sometimes
observed, possibly leading to decreased nasal resistance
and improved airflow.1-3,13-15
Studies on RME to date have measured the pretreat-
ment to posttreatment skeletal changes with dental
casts, 2-dimensional (2D) cephalometric or occlusal
radiographs, a human skull model made of birefringent
materials, and holographic interferometry on a macer-
ated human skull.14,16-21 With cone-beam computed
tomography (CBCT) technology, it is now possible to
acquire accurate radiographic images that allow clini-
8.e1
8.e2 Garrett et al
Fig 1. Occlusal view of 4-banded Hyrax appliance.
Fig 2. Occlusal view of 2-banded Hyrax appliance with
expansion arms and mesial rests bonded to first
premolars.
cians and researchers to quantitatively evaluate bone
changes in 3 dimensions with minimal distortion and
lower radiation dosages.22
The purpose of this study was to use CBCT to
quantitatively evaluate and compare skeletal expansion
and alveolar tipping of the maxilla at the maxillary
canine (C1), first premolar (P1), second premolar (P2)
and first molar (M1) after RME. Transverse effects to
the maxillary suture, nasal width, and maxillary sinus
were also assessed.
MATERIAL AND METHODS
This study was approved by the Institutional Re-
view Board of Loma Linda University, Loma Linda,
Calif. Included in the study were 30 consecutive pa-
tients treated since January 2005 at the Graduate
Orthodontic Clinic, Loma Linda University School of
Dentistry, and requiring RME with Hyrax appliances
during comprehensive orthodontic treatment. The New-
tom 3G (AFP Imaging, Elmsford, NY) was used to
American Journal of Orthodontics and Dentofacial Orthopedics
July 2008
Fig 3. Diagram showing M1 furca and respective C1,
P1, and P2 apex reference points with measurement
lines connecting contralateral sides.
Fig 4. Axial slice depicting measurements with refer-
ence points erased for visualization (white, PMW; red,
BMW).
obtain pre-RME (T1) CBCT images before orthodontic
treatment and post-RME (T2) images within 3 months
after the end of appliance activation. This was the same
patient population used in a previous study to assess
buccal bone changes of maxillary posterior teeth after
RME.23 The Hyrax appliances were either 4-banded
(first premolars and first molars all banded) (Fig 1) or
2-banded (first molars banded with expansion arms and
mesial rests bonded to first premolars) (Fig 2).
During the first study of this sample, general infor-
mation was collected from each patient’s record; it was
still valid for this study. This included sex, age at the
start of treatment, type of appliance, activation time (in
weeks), retention time (in weeks, from the tie-off to the
3-dimensional [3D] radiographic scan). It is standard
procedure at Loma Linda University to obtain 12-in
field-of-view CBCT scans of patients before orthodon-
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 134, Number 1
Fig 5. Three orthogonal views showing triangulation of M1 furca location and respective C1, P1,
and P2 apex reference points with measurement lines connecting contralateral sides.
Fig 6. T1 coronal image derived from the opened-
polygon cut (white, NW1; green, NFW1; red, MSW1).
tic treatment; this allows for the most radiographic
information for patients of varying sizes. The 12-bit
grayscale CBCT scans were performed at 110 kV and
a scan time of 36 seconds. Smart-Beam technology,
exclusive to the Newtom 3G, automatically sets the
radiation level based on the patient’s anatomic density
so that milliampere values fluctuate with a maximum of
15 mA. The patients were scanned in supine position,
with chin and shoulder rests, as well as a vertical
sighting beam to ensure their accurate and repeatable
positioning. The data of each patient were recon-
structed with 0.5-mm slice thickness, and the DICOM
Garrett et al 8.e3
Fig 7. Coronal image derived from the opened-polygon
cut (Fig 6). PAA is formed by the intersection of best-fit
lines drawn through the palatal alveolar plates.
(digital imaging and communications in medicine)
images were assessed by using the OsiriX Medical
Imaging software program (Open-Source, OsiriX Med-
ical Imaging Software, www.osirix-viewer.com).24 All
measurements were made by 1 examiner (B.J.G.).
Linear and angular measurements were made to the
nearest 0.1 mm and 0.1°, respectively. The following
parameters were evaluated at the central incisor (Inc1),
C1, P1, P2, and M1 and recorded.
8.e4 Garrett et al American Journal of Orthodontics and Dentofacial Orthopedics
July 2008

Table I.Summary of measured parameters and associ-

ated landmarks
Parameter Measured landmarks

PMW (palatal maxillary width) Distance between palatal cortical

BMW (buccal maxillary width)
NW (nasal width)
NFW (nasal floor width)
MSW (maxillary sinus width)
Fig 8. Thick slice axial image showing maxillary SE
(white). PAA (palatal alveolar angle)
SE (sutural expansion)
AE (appliance expansion)
plates
Distance between buccal cortical
plates
Width at widest portion of nasal
aperture
Width at widest portion of floor
of the nose
Combined width of right and left
maxillary sinuses along
extended NW measurement
line
Angle formed from best-fit lines
through right and left palatal
cortical plates (coronal view)
Width of maxillary suture
separation
Total Hyrax expansion obtained

Table II. Means, standard deviations, and ranges of age,

appliance expansion, activation time, rate of appliance
expansion, and retention time
Mean ⫾ SD Range

Ages (y) of subjects (n ⫽ 30) 13.8 ⫾ 1.7 10.3-16.8

Boys (n ⫽ 17) 14.1 ⫾ 1.8 10.3-16.8
Girls (n ⫽ 13) 13.3 ⫾ 1.5 10.3-15.8
AE (mm) 5.08 ⫾ 1.89 1.8-10.5
Activation time (wk) 7.8 ⫾ 4.4 2-18
Fig 9. Coronal image derived from the opened-polygon
Rate of appliance expansion (mm/wk) 0.86 ⫾ 0.57 0.2-2.4
cut (Fig 10). The appliance expansion is the difference Retention time (wk) 3.6 ⫾ 4.1 0-12
between the separation distance of the appliance and
the thickness of the middle portion of the appliance.

Table III.
Comparison of T1 and T2 measurements with
1. Palatal maxillary width (PMW) and buccal maxil- Wilcoxon signed rank test (␣ ⫽ 0.05)
lary width (BMW). From an axial section of the T1
T1 (mean ⫾ SD) T2 (mean ⫾ SD) P value
CBCT image, at the level of the furcation of the
M1, a line was drawn between the right and left NW (mm) 29.06 ⫾ 3.59 30.95 ⫾ 3.53 ⬍0.0001
furca. The palatal maxillary width (PMW M1) was NFW (mm) 27.64 ⫾ 3.73 29.23 ⫾ 3.85 ⬍0.0001
MSW (mm) 43.20 ⫾ 7.65 41.75 ⫾ 8.42 ⬍0.0001
the interalveolar distance between the palatal plates
PAA (°) 34.11 ⫾ 11.27 38.86 ⫾ 11.00 ⬍0.0001
along this line (Figs 3 and 4). For C1, P1, and P2, PMW C1 (mm) 21.33 ⫾ 3.49 23.68 ⫾ 4.06 ⬍0.0001
the root apices were found on 3 orthogonal slices PMW P1 (mm) 23.15 ⫾ 2.78 26.19 ⫾ 3.82 ⬍0.0001
(coronal, sagittal, and axial), and a corresponding PMW P2 (mm) 26.23 ⫾ 2.76 29.04 ⫾ 3.32 ⬍0.0001
point was triangulated onto the M1 furcation axial PMW M1 (mm) 27.98 ⫾ 2.58 30.65 ⫾ 2.95 ⬍0.0001
BMW C1 (mm) 45.09 ⫾ 4.46 48.65 ⫾ 4.44 ⬍0.0001
cut (Fig 5). A line was drawn between these points
BMW P1 (mm) 47.63 ⫾ 3.49 51.29 ⫾ 3.79 ⬍0.0001
that corresponded to the position of C1, P1, or P2 BMW P2 (mm) 52.10 ⫾ 3.47 55.31 ⫾ 3.83 ⬍0.0001
and the contralateral tooth. The respective PMW BMW M1 (mm) 57.28 ⫾ 3.30 60.67 ⫾ 3.63 ⬍0.0001
measurements were taken as the interalveolar dis-
NW, Nasal width; NFW, nasal floor width; MSW, maxillary sinus
tance between the palatal alveolar plates along this width; PAA, palatal alveolar angle; PMW, palatal maxillary width;
line (Figs 3 and 4). The lines connecting the C1, P1, BMW, buccal maxillary width; C1, canine; P1, first premolar; P2,
and P2 root apices and the M1 furca were then second premolar; M1, first molar.
American Journal of Orthodontics and Dentofacial Orthopedics Garrett et al 8.e5
Volume 134, Number 1

Table IV. Comparison of appliance expansion with Wilcoxon rank sum test (␣ ⫽ .05)
Inc1 (mean⫾SD) C1 (mean⫾SD) P1 (mean⫾SD) P2 (mean⫾SD) M1 (mean⫾SD)

AE (mm) 5.08 ⫾ 1.89

SE (mm) 3.87 ⫾ 1.77 3.33 ⫾ 1.49 3.32 ⫾ 1.37 2.68 ⫾ 1.31 2.55 ⫾ 1.10
P ⫽ 0.009* P ⫽ 0.012* P ⫽ 0.001* P ⫽ 0.0001* P ⬍0.0001*
⌬PMW (mm) – 2.35 ⫾ 2.58 3.04 ⫾ 2.62 2.81 ⫾ 2.07 2.67 ⫾ 1.6
P ⬍0.0001* P ⬍0.0001* P ⬍0.0001* P ⬍0.0001*
⌬BMW (mm) – 3.56 ⫾ 2.64 3.66 ⫾ 2.35 3.21 ⫾ 2.05 3.39 ⫾ 1.57
P ⫽ 0.002* P ⫽ 0.001* P ⬍0.0001* P ⬍0.0001*

Inc1, Central incisor; C1, canine; P1, first premolar; P2, second premolar; M1, first molar.
*Statistically significant.

Table V. Comparison of RME effect with Kruskal-Wallis test (␣ ⫽ .05)

Inc1 (mean⫾SD) C1 (mean⫾SD) P1 (mean⫾SD) P2 (mean⫾SD) M1 (mean⫾SD) P value

SE (mm) 3.87 ⫾ 1.77 3.33 ⫾ 1.49 3.32 ⫾ 1.37 2.68 ⫾ 1.31 2.55 ⫾ 1.10 0.089
⌬PMW (mm) – 2.35 ⫾ 2.58 3.04 ⫾ 2.62 2.81 ⫾ 2.07 2.67 ⫾ 1.6 0.774
⌬BMW (mm) – 3.56 ⫾ 2.64 3.66 ⫾ 2.35 3.21 ⫾ 2.05 3.39 ⫾ 1.57 0.781
⌬ID (mm)* – – 6.02 ⫾ 2.27 5.97 ⫾ 2.31 6.66 ⫾ 2.69 0.485

Inc1, Central incisor; C1, canine; P1, first premolar; P2, second premolar; M1, first molar.
*Data from Rungcharassaeng et al.23

Table VI. Comparison of RME effect on nasal, sinus
and palatal factors at M1 level with Wilcoxon rank sum
test (␣ ⫽ .05)
Mean ⫾ SD
AE (mm) 5.08 ⫾ 1.89
⌬NW (mm) 1.89 ⫾ 1.18
⌬NFW (mm) 1.59 ⫾ 1.81
⌬MSW (mm) –1.45 ⫾ 1.77
⌬PAA (°) 4.75 ⫾ 6.54
*Statistically significant.
extended to the outer buccal cortical plates. The
BMW was the interalveolar distance between the
buccal alveolar plates along each line (C1, P1, P2,
or M1) (Figs 3 and 4). The procedure was repeated
for the T2 measurements. The amount of palatal
maxillary expansion (⌬PMW) was the difference
between T1 and T2 widths (PMW2 – PMW1). The
amount of buccal maxillary expansion (⌬BMW)
was the difference between T1 and T2 widths
(BMW2 –BMW1). Positive ⌬PMW and ⌬BMW
values indicated expansion.
2. Nasal width (NW), nasal floor width (NFW), and
maxillary sinus width (MSW). From the axial
section of the T1 images, at the level of furcation of
M1, an opened-polygon cut (tool used in OsiriX to
create dissection lines through points of interest to
obtain orthogonal image slices) was made bucco-
lingually so that it bisected the furcation bilaterally.
On the coronal image derived from the opened-
polygon cut, NW was obtained by measuring the
P value
distance between the widest transverse portion of
the nasal aperture (Fig 6). MSW was then obtained
by first extending through the NW line to the lateral
⬍0.0001*
maxillary sinus borders and measuring the total
⬍0.0001*
⬍0.0001* distance. The NW dimension was then subtracted
0.673 from this total distance to get combined bilateral
MSW (Fig 6). NFW was obtained on the same
coronal slice by measuring the distance between the
widest transverse portion of the nasal floor at the
most inferior border of the nasal aperture (Fig 6).
The procedure was repeated for the T2 measure-
ments. The change in NW (⌬NW) was the differ-
ence between T1 NW and T2 NW (NW2 –NW1);
the change in NFW (⌬NFW) was the difference
between T1 NFW and T2 NFW (NFW2 –NFW1).
MSW change (⌬MSW) was the difference between
T1 MSW and T2 MSW (MSW2 –MSW1). Positive
⌬NW and ⌬NFW values indicated expansion, and
negative ⌬MSW values indicated narrowing of the
maxillary sinus.
3. Palatal alveolar angle (PAA). From an axial section
of the T1 and T2 images, at the level of the
furcation of M1, an opened-polygon cut was made
buccolingually to bisect the furcation bilaterally.
From this coronal image, best-fit lines were con-
structed through the right and left palatal alveolar
bones, and the PAA was obtained by measuring the
8.e6 Garrett et al American Journal of Orthodontics and Dentofacial Orthopedics
July 2008

Table VII. Comparison of 2-banded vs 4-banded Hyrax on all parameters with the Wilcoxon rank sum test (␣ ⫽ .05)
Inc1 C1 P1 P2 M1

⌬NW – – – – P ⫽ 0.680
⌬NFW – – – – P ⫽ 0.592
⌬MSW – – – – P ⫽ 0.509
⌬PAA – – – – P ⫽ 0.536
SE P ⫽ 0.252 P ⫽ 0.335 P ⫽ 0.055 P ⫽ 0.650 P ⫽ 0.167
⌬PMW – P ⫽ 0.614 P ⫽ 0.737 P ⫽ 0.869 P ⫽ 0.650
⌬BMW – P ⫽ 0.042* P ⫽ 0.856 P ⫽ 0.300 P ⫽ 0.094

Inc1, Central incisor; C1, canine; P1, first premolar; P2, second premolar; M1, first molar.
*Statistically significant.

Table VIII. Pearson correlation coefficients (r) for changes at Inc1 and C1
Rate of ⌬PMW ⌬BMW SE
Age AE Retention AE ⌬NW ⌬NFW ⌬MSW ⌬PAA C1 C1 SE C1 Inc1

Age
Rate of AE 0.12
Retention –0.14 0.05
AE 0.07 0.35 –0.49†
⌬NW –0.06 0.31 –0.30 0.70†
⌬NFW –0.16 0.30 –0.29 0.49† 0.67†
⌬MSW 0.02 0.11 0.12 0.15 –0.03 –0.03
⌬PAA –0.06 0.22 0.12 –0.08 –0.35 –0.22 0.02
⌬PMW C1 0.15 0.33 –0.42* 0.54† 0.53† 0.44* –0.16 –0.25
⌬BMW C1 0.22 0.31 –0.17 0.53† 0.50† 0.40* –0.13 –0.14 0.60†
SE C1 0.09 –0.06 –0.18 0.53* 0.89† 0.62† 0.05 –0.47* 0.58* 0.44
SE Inc1 0.11 0.03 –0.52* 0.62* 0.87† 0.71† 0.14 –0.38 0.46 0.37 0.99†

*P ⬍0.05; †P ⬍0.01.

Table IX. Pearson correlation coefficients (r) for changes at P1

Rate of ⌬PMW ⌬BMW
Age AE Retention AE ⌬NW ⌬NFW ⌬MSW ⌬PAA P1 P1 SE P1

Age
Rate of AE 0.12
Retention –0.14 0.05
AE 0.07 0.35 –0.49†
⌬NW –0.06 0.31 –0.30 0.70†
⌬NFW –0.16 0.30 –0.29 0.49† 0.67†
⌬MSW 0.02 0.11 0.12 0.15 –0.03 –0.03
⌬PAA –0.06 0.22 0.12 –0.08 –0.35 –0.22 0.02
⌬PMW P1 –0.21 0.41* –0.22 0.54† 0.55† 0.47* –0.14 –0.07
⌬BMW P1 0.07 0.37 –0.27 0.60† 0.39* 0.40* –0.06 –0.03 0.73†
SE P1 –0.06 –0.03 –0.18 0.62* 0.91† 0.63* 0.10 –0.17 0.51 0.22

*P ⬍0.05; P ⬍0.01.
†

angle formed by intersecting the lines (Fig 7). The
amount of palatal alveolar tipping (⌬PAA) was the
difference between the T1 PAA and T2 PAA
(PAA2 –PAA1). A positive ⌬PAA indicated alve-
olar tipping or bending in the buccal direction.
4. Maxillary sutural expansion (SE). On a thick slice
axial cut of the T2 image that showed the expanded
maxillary suture, the root apex points used for
PMW and BMW were reproduced. Reference lines
connecting M1 furca, Inc1, C1, P1, and P2 root
apices were drawn. The amount of SE was mea-
sured along these reference lines (Fig 8).
5. Appliance expansion (AE). From the axial sec-
tion of the T2 images, at the level of the Hyrax
American Journal of Orthodontics and Dentofacial Orthopedics Garrett et al 8.e7
Volume 134, Number 1

Table X. Pearson correlation coefficients (r) for changes at P2

Rate of ⌬PMW ⌬BMW
Age AE Retention AE ⌬NW ⌬NFW ⌬MSW ⌬PAA P2 P2 SE P2

Age
Rate of AE 0.12
Retention –0.14 0.05
AE 0.07 0.35 –0.49†
⌬NW –0.06 0.31 –0.30 0.70†
⌬NFW –0.16 0.30 –0.29 0.49† 0.67†
⌬MSW 0.02 0.11 0.12 0.15 –0.03 –0.03
⌬PAA –0.06 0.22 0.12 –0.08 –0.35 –0.22 0.02
⌬PMW P2 –0.12 0.37* –0.53† 0.71† 0.59† 0.51† 0.05 –0.05
⌬BMW P2 0.12 0.32 –0.19 0.72† 0.61† 0.44* –0.14 –0.04 0.65†
SE P2 –0.04 0.01 –0.45 0.64† 0.91† 0.62† 0.12 –0.38 0.65† 0.46*

*P ⬍0.05; P ⬍0.01.
†

Table XI. Pearson correlation coefficients (r) for changes at M1

Rate of ⌬PMW ⌬BMW SE
Age AE Retention AE ⌬NW ⌬NFW ⌬MSW ⌬PAA M1 M1 M1

Age
Rate of AE 0.12
Retention –0.14 0.05
AE 0.07 0.35 –0.49†
⌬NW –0.06 0.31 –0.30 0.70†
⌬NFW –0.16 0.30 –0.29 0.49† 0.67†
⌬MSW 0.02 0.11 0.12 0.15 –0.03 –0.03
⌬PAA –0.06 0.22 0.12 –0.08 –0.35 –0.22 0.02
⌬PMW M1 –0.12 0.22 –0.41* 0.72† 0.77† 0.51† –0.17 –0.22
⌬BMW M1 0.18 0.16 –0.33 0.63† 0.64† 0.33 0.03 –0.15 0.62†
SE M1 0.22 0.21 –0.35 0.64† 0.87† 0.62† 0.03 –0.23 0.50† 0.58†

*P ⬍0.05; †P ⬍0.01.

appliance, an opened-polygon cut was made
bisecting the appliance transversely. On the coro-
nal image derived from the opened-polygon cut,
the separation distances of the appliance and the
thickness of the middle portion of the appliance
were measured (Fig 9). Their difference repre-
sented the amount of AE.
The rate of appliance expansion was defined as the
amount of AE divided by the activation time (millime-
ters per week) per patient. The mean value of the 30
patients is the recorded rate of appliance expansion.
Table I summarizes all parameters and associated
landmarks used to obtain the measurements.
Statistical analysis
Intraexaminer reliability of the measurements was
determined by comparing triple assessments of each
parameter at M1 taken at least 2 weeks apart and
expressed as the intraclass correlation coefficient.
Means and standard deviations were calculated for each
parameter. T1 and T2 data were compared by using the
Wilcoxon signed rank test, the Kruskal-Wallis test, and
Wilcoxon rank sum test at the significance level of ␣ ⫽
.05. To evaluate the level of association, a Pearson
correlation analysis was performed. Percentages of
orthopedic expansion vs that of orthodontic expansion
as calculated in a previous study were compared.23
RESULTS
This study included 30 subjects used to evaluate
dental and buccal marginal bone changes associated
with RME, so the following initial information re-
mained valid.23 They included 17 boys and 13 girls
with a mean age of 13.8 years (range, 10.3-16.8).
Hyrax-type expanders were used, consisting of
4-banded (n ⫽ 17) and 2-banded (n ⫽ 13) appliances.
8.e8 Garrett et al
Fig 10. Diagram of T1 and T2 coronal views at M1
depicting the 3 components of total expansion.
Mean values for appliance expansion, activation time,
rate of appliance expansion, and retention time were
5.08 mm, 7.8 weeks, 0.86 mm per week, and 3.6 weeks,
respectively (Table II). Bilateral first premolars were
extracted before T2 imaging in 4 patients. The canines
were horizontally impacted unilaterally in 3 patients,
making these landmarks unmeasurable.
Intraclass correlation coefficients for variables of
interest (NW, NFW, MSW, PAA, PMW, BMW, and
SE) were greater than 0.91 for all measured variables,
indicating a high level of repeatability with these CBCT
measurement methods. Tables III through VI show the
means and standard deviations of all T1 and T2
parameters, their differences, and the results of the
statistical analyses.
When comparing the T1 and T2 NW, NFW, MSW,
and PAA values at the M1 furcation level, and PMW
and BMW at C1, P1, P2, and M1 with the Wilcoxon
signed-rank test, statistically significant differences
were found in all parameters (P ⬍0.05) (Table III).
When comparing the effect of appliance expansion
at Inc1, C1, P1, P2, and M1 with the Wilcoxon
rank-sum test, statistically significant differences were
found in the amounts of SE and palatal and buccal
maxillary expansion (Table IV). Pairwise comparisons
of the RME effect at Inc1, C1, P1, P2, and M1 with the
Kruskal-Wallis test showed no statistically significant
differences between SE or palatal or buccal maxillary
expansion (P ⫽ 0.089, 0.774, and 0.781, respectively)
(Table V). In addition, RME effects at the M1 furcation
show statistically significant differences in the changes
American Journal of Orthodontics and Dentofacial Orthopedics
July 2008
Table XII. Summary of orthopedic, alveolar bending,
and orthodontic contributions to total expansion
Orthopedic Alveolar bending Orthodontic Total
P1 55% 6% 39% 100%
P2 45% 9% 46% 100%
M1 38% 13% 49% 100%
to NW, NFW, and MSW (P ⬍ 0.0001), but no
statistically significant differences were found in the
changes in PAA (P ⫽ 0.673) (Table VI).
Comparing the effects of 2-banded vs 4-banded
Hyrax appliances on all parameters using the Wilcoxon
rank-sum test, we found the only statistically significant
difference in buccal maxillary expansion at C1 (P ⫽
0.042). Here the 4-banded Hyrax produced greater
expansion (Table VII).
Tables VIII through XI show the matrices of
Pearson correlation coefficients (r) for changes in Inc1,
C1, P1, P2, and M1. Appliance expansion had a
significant correlation with changes in NW and NFW (r
⫽ 0.70 and 0.49; P ⱕ0.006). For all locations (C1-M1),
changes in PMW correlated well with the respective
BMW (r ⫽ 0.60, 0.73, 0.65 and 0.62; P ⱕ0.001). For
all locations, changes in palatal and buccal maxillary
expansion had significant correlations with appliance
expansion and change in NW (range, r ⫽ 0.39 to r ⫽
0.77; P ⱕ0.044). The rate of appliance expansion
showed a significant correlation only with palatal max-
illary expansion at P1 and P2 (r ⫽ 0.41, 0.37; P ⬍0.05).
Appliance retention time had a significant negative
linear correlation with PMW changes at C1, P2, and
M1 (r ⫽ – 0.42, – 0.53, and – 0.41; P ⫽ 0.029, 0.003,
and 0.024, respectively).
DISCUSSION
The objective of this study was to evaluate the
skeletal responses in the transverse plane immediately
after RME treatment by using high-resolution CBCT.
Similar measurements have been attempted in previous
studies,14,16-21 but research was limited to using 2D
x-rays for data acquisition or model analysis with
overlying soft-tissue interferences; this allowed only
dental measurements. The increased accuracy of mea-
surements from CBCT comes from the submillimeter
isotropic voxel resolution, which ranges from 0.4 mm
down to 0.125 mm with some systems.22,25 Computed
tomography analysis of RME effects gives better quan-
tity and exactness of the diagnostic parameters mea-
sured, and might soon become the routine analysis for
patients undergoing such treatment.13,26
The total expansion achieved with an RME appli-
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 134, Number 1
ance can be divided into 3 parts: skeletal expansion,
alveolar expansion or bending, and dental tipping (Fig
10).18 The latter 2 are often combined for analysis as
the dentoalveolar (orthodontic) contribution to total
expansion. The skeletal (orthopedic) expansion is the
direct separation of the maxillary halves evident by
separation of the suture, the alveolar bending or tipping
is any additional expansion at the buccal alveolar plates
beyond that of the maxillary suture, and the dental
tipping is the further buccal tipping of the dentition.
The total expansion was analyzed in a previous study
with the same patient population as this study, so those
data will be used to assess contributions of orthopedic
vs orthodontic expansion.23 There, the total amounts of
expansion (skeletal and dental) at the P1, P2, and M1
levels were 6.02, 5.97, and 6.66 mm, respectively
(Table V).
Skeletal expansion
The transverse expansion at the suture in this study
gradually decreased from 3.87 (Inc1), 3.33 (C1), 3.32
(P1), 2.68 (P2), to 2.55 mm (M1) (Table IV, P
ⱕ0.012). This sutural orthopedic separation accounted
for 55%, 45%, and 38% of total expansion at P1, P2,
and M1, respectively (Fig 10). This agrees with reports
that sutural expansion is approximately less than or
equal to 50% of total dentoalveolar expansion.9,18 This
geometry of sutural opening confirms previous reports,
where the separation occurred in a triangular pattern
with the wider base at the anterior portion of the
maxilla.2,3,5,9,27 Although a midline suture runs the full
length, anterior to posterior, of the maxilla and the
palatine bones, which should allow for equal or parallel
opening, the proposed lack of opening in the posterior
region is due to the interlocking pyramidal processes of
the palatine bone with the immovable medial and
lateral pterygoid plates of the sphenoid bone.5,28
Dentoalveolar expansion or tipping
The expansion of palatal and buccal alveolar plates
gives us information about the alveolar process of
bending or tipping. Any additional expansion beyond
that of sutural separation would be derived from tipping
of the alveolar ridges. The expansion of the buccal
cortical plates (⌬BMW) was greater than that of the
suture at all measured regions (C1, P1, P2, M1). The
amounts of additional buccal plate expansion beyond
that of the suture (ie, alveolar tipping) were 0.23 (C1),
0.36 (P1), 0.53 (P2), and 0.84 mm (M1) (Table IV:
⌬BMW-SE). These additional alveolar bending contri-
butions to total expansion were 6%, 9%, and 13% at P1,
P2, and M1, respectively (Fig 10). This shows a trend
toward increased buccal alveolar bending from the
Garrett et al 8.e9
anterior to the posterior maxilla and agrees with previ-
ous studies.5,27,29
The palatal cortical plate expansion (⌬PMW) pro-
duced mixed results. In the posterior region (P2, M1),
the expansion trend followed that of the buccal alveo-
lus: outward lateral tipping. As before, the ⌬PMW
value was larger than the suture separation. However,
the palatal alveolar expansion did not have the same
magnitude as that of the buccal plate. The PMW
increased only by 2.81 (P2) and 2.67 mm (M1),
whereas the corresponding ⌬BMW values were 3.21
(P2) and 3.39 mm (M1) (Table IV). In opposition,
PMW expansion in the anterior region (C1, P1) was
less than that of the suture, although the same trend of
alveolar widening was seen. The PMW increased only
by 2.35 (C1) and 3.04 mm (P1), whereas the corre-
sponding ⌬BMW values were 3.56 (C1) and 3.66 mm
(P1) (Table IV). This indicates either additional expan-
sion in the right and left alveolar ridges themselves or
relapse of the orthopedic expansion on the palatal side.
For the suture to expand more than the palatal width in
the anterior region, there must be either inward relapse
or bone formation on the palatal alveolar plate. This
finding might be explained by the functional matrix
theory of Moss and Young.30 Since the suture expan-
sion follows the triangular pattern previously discussed,
the greater separation in the anterior region might cause
greater elastic force on the palatal soft tissues in this
area. The higher inward soft-tissue force in the anterior
region might stimulate bone growth as the theory
proposes. Haas31 proposed a more likely cause, sug-
gesting that the tooth-borne Hyrax could maintain only
dental expansion. He thought that lack of the acrylic
pad against the palate would allow bone to move
through teeth, so skeletal relapse would be seen during
the retention period. This is supported by the significant
negative correlation found between retention time and
amount of palatal alveolar expansion at C1, P2, and
M1. It is possible that RME with the Haas-type appli-
ance, which incorporates acrylic expansion blocks that
rest against the palatal alveolus, could provide more
uniform expansion of the palatal and buccal cortical
plates, and stop orthopedic relapse, eliminating this
discrepancy and alveolar tipping.1-4,17 Further studies
with CBCT analysis are needed to support or refute this
claim.
Direct measurement of angular palatal alveolar
tipping was attempted by measuring along the palatal
alveolar shelf, but the results were not statistically
significant (Table VI, P ⫽ 0.673). These inconclusive
data might again be caused by skeletal relapse with the
Hyrax appliance or the lack of defined, accurate land-
8.e10 Garrett et al
marks. Improved, more repeatable landmarks might
yield valid measurements in future studies.
The remaining fractions of total expansion derived
from dental tipping (orthodontic contribution) were
39% at P1 (2.34 mm), 46% at P2 (2.76 mm), and 49%
at M1 (3.27 mm) (Fig 10). The combined data show a
trend associated with RME of decreasing orthopedic
skeletal effect and increasing alveolar bending and
orthodontic tipping from anterior to posterior; this
agrees with previous reports (Table XII).19,27
The rate of appliance expansion showed a strong
correlation only with palatal maxillary expansion lim-
ited to P1 and P2 but did not correlate well with sutural
expansion, buccal expansion, or palatal expansion at
the M1 or canine. This showed a rate independent of
appliance expansion relative to most measured param-
eters. In this study, we found that the 3 components of
total expansion associated with Hyrax expansion (or-
thopedic expansion, alveolar bending, and orthodontic
tipping) do not correlate well with the rate of appliance
activation, but correlate strongly with the amount that
the appliance is expanded.
Nasal changes
The effects of RME are not limited to the maxilla
but extend to the surrounding nasal and craniofacial
structures. Haas1 showed that the nasal aperture could
be significantly widened, thereby increasing nasal res-
piration. In this study, the NW and MSW were evalu-
ated at a coronal plane that bisected the M1 furcation.
Comparison of appliance expansion with change in NW
was statistically significant at ␣ ⫽ .05 (P ⬍0.0001).
The NW increase of 1.89 mm was 37.2% of the mean
Hyrax appliance expansion (5.08 mm). Another study
with 2D cephalometric analysis reported increases of
23.1% of appliance expansion.14 The ability to look at
NW on a 0.5-mm coronal slice with CBCT allows for
a more accurate analysis and might explain the different
values. Expansion across the nasal floor was 1.59 mm,
which represented 31% of appliance expansion. This
compares with similar findings with computed tomog-
raphy by Garib et al,13 who found nasal floor separation
to be one-third of appliance expansion. These findings
back other reports that RME increases nasal volume,
possibly leading to decreased nasal resistance and
improved airflow.1-3,13-15,32 The increase in NW led to
a decrease in MSW (–1.45 mm; P ⬍0.0001). We are
not aware of other research reporting on this maxillary
sinus reduction. The linear reduction in MSW might
indicate decreased sinus volume, but the degree to
which it affects the patient is beyond the scope of this
study. Further rhinometric studies and volumetric mea-
American Journal of Orthodontics and Dentofacial Orthopedics
July 2008
surements at additional points along the anteroposterior
plane with CBCT are needed to confirm this.
Our use of CBCT allowed for new, more reliable
measurements as shown by high intraclass correlation
coefficient values. The ability to obtain MSW measure-
ments and to quantify finite changes in alveolar bending
at various points on the sagittal plane were unavailable
before 3D imaging. The new information from CBCT
will improve 3D modeling and finite element analysis
algorithms, benefiting orthodontists by enhancing our
tools and knowledge for diagnosing patients and im-
plementing treatment modalities.
CONCLUSIONS
The following conclusions can be made from this
study.
1. CBCT is an accurate and reliable method for
assessing changes associated with RME on naso-
maxillary structures.
2. Sutural expansion with RME showed a wedge
shape, with the wide base at the anterior maxilla.
3. Orthopedic and skeletal expansion accounted for
55% of the total expansion at P1, 45% at P2, and
38% at M1 (decreased from anterior to posterior).
4. An alveolar bending or tipping contribution to
overall expansion accounted for an additional 6% at
P1, 9% at P2, and 13% at M1 (increased from
anterior to posterior).
5. The remaining orthodontic (dental tipping) portions
were 39% of total expansion at P1, 46% at P2, and
49% at M1 (increased from anterior to posterior).
6. RME produced a statistically significant increase in
NW and a decrease in MSW.
7. Orthopedic expansion, alveolar bending, and orth-
odontic tipping lack significant correlations with
the rate of appliance expansion, but correlate well
with the amount of appliance expansion.
REFERENCES
1. Haas AJ. Rapid expansion of the maxillary dental arch and nasal
cavity by opening the mid palatal suture. Angle Orthod 1961;31:
73-89.
2. Haas AJ. The treatment of maxillary deficiency by opening the
mid-palatal suture. Angle Orthod 1965;65:200-17.
3. Haas AJ. Palatal expansion: just the beginning of dentofacial
orthopedics. Am J Orthod 1970;57:219-55.
4. Haas AJ. Long-term posttreatment evaluation of rapid palatal
expansion. Angle Orthod 1980;50:189-217.
5. Wertz RA. Skeletal and dental changes accompanying rapid
midpalatal suture opening. Am J Orthod 1970;58:41-66.
6. Timms DJ. An occlusal analysis of lateral maxillary expansion
with mid-palatal suture opening. Dent Pract 1968;18:435-41.
7. Isaacson RJ, Wood JL, Ingram AH. Forces produced by rapid
maxillary expansion. Part I. Design of the force measuring
system. Angle Orthod 1964;34:256-60.
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 134, Number 1
8. Isaacson RJ, Ingram AH. Forces produced by rapid maxillary
expansion. Part II. Forces present during treatment. Angle
Orthod 1964;34:261-9.
9. Krebs A. Expansion of the midpalatal suture studied by means of
metallic implants. Eur Orthod Soc Rep 1958;34:163-72.
10. Adkins MD, Nanda RS, Currier GF. Arch perimeter changes on rapid
palatal expansion. Am J Orthod Dentofacial Orthop 1990;97:194-9.
11. Storey E. Tissue response to the movement of bones. Am J
Orthod 1973;64:229-47.
12. Starnbach H, Bayne D, Cleall J, Subtelny JD. Facioskeletal and
dental changes resulting from rapid maxillary expansion. Angle
Orthod 1966;36:152-64.
13. Garib DG, Henriques JFC, Janson G, Freitas MR, Coelho RA. Rapid
maxillary expansion—tooth tissue-borne versus tooth-borne expanders:
a computed tomography evaluation of dentoskeletal effects. Angle
Orthod 2005;75:548-57.
14. Chung CH, Font B. Skeletal and dental changes in the sagittal,
vertical, and transverse dimensions after rapid palatal expansion.
Am J Orthod Dentofacial Orthop 2004;126:569-75.
15. Babacan H, Sokucu O, Doruk C, Ay S. Rapid maxillary
expansion and surgically assisted rapid maxillary expansion
effects on nasal volume. Angle Orthod 2006;76:66-71.
16. Ladner PT, Muhl ZF. Changes with orthodontic treatment when
maxillary expansion is a primary goal. Am J Orthod Dentofacial
Orthop 1995;108:184-93.
17. Oliveria NL, Da Silveira AC, Kusnoto B, Viana G. Three-
dimensional assessment of morphologic changes in the maxilla:
a comparison of 2 kinds of palatal expanders. Am J Orthod
Dentofacial Orthop 2004;126:354-62.
18. Handelman CS, Wang L, BeGole EA, Haas AJ. Non-surgical
rapid maxillary expansion in adults: report of 47 cases using the
Haas expander. Angle Orthod 2000;70:129-44.
19. Lamparski DG, Rinchuse DJ, Close JM, Sciote JJ. Comparison of
skeletal and dental changes between 2-point and 4-point rapid palatal
expanders. Am J Orthod Dentofacial Orthop 2003;123:321-8.
20. Chaconas SJ, Caputo AA. Observation of orthopedic force
distribution produced by maxillary orthodontic appliances. Am J
Orthod 1982;82:492-501.
Garrett et al 8.e11
21. Pavlin D, Vukicevic D. Mechanical reactions of facial skeleton
to maxillary expansion determined by laser holography. Am J
Orthod 1984;85:498-507.
22. Scarfe WC, Farman AG, Sukovic P. Clinical applications of
cone-beam computed tomography in dental practice. J Can Dent
Assoc 2006;72:75-80.
23. Rungcharassaeng K, Caruso JM, Kan JYK, Kim J, Taylor G.
Factors affecting buccal bone changes of maxillary posterior
teeth after rapid maxillary expansion. Am J Orthod Dentofacial
Orthop 2007;132:428.e1-8.
24. Rosset A, Spadola L, Ratib O. OsiriX: an open-source software
for navigating in multidimensional DICOM images. J Digit
Imaging 2004;17:205-16.
25. Kau CH, Richmond S, Palomo JM, Hans MG. Three-dimen-
sional cone beam computerized tomography in orthodontics.
J Orthod 2005;32:282-93.
26. Habersack K, Karoglan A, Sommer B, Benner KU. High-
resolution multislice computerized tomography with multiplanar
and 3-dimensional reformation imaging in rapid palatal expan-
sion. Am J Orthod Dentofacial Orthop 2007;131:776-81.
27. Davidovitch M, Efstathiou S, Sarne O, Vardimon AD. Skeletal
and dental response to rapid maxillary expansion with 2- versus
4-band appliances. Am J Orthod Dentofacial Orthop 2005;127:
483-92.
28. Iseri H, Ozsoy S. Semirapid maxillary expansion—a study of
long-term transverse effects in older adolescents and adults.
Angle Orthod 2004;74:71-8.
29. da Silva Filho OG, Montes LA, Torelly LF. Rapid maxillary
expansion in the deciduous and mixed dentition evaluated
through posteroanterior cephalometric analysis. Am J Orthod
Dentofacial Orthop 1995;107:268-75.
30. Moss ML, Young RW. A functional approach to craniology.
Am J Phys Anthropol 1960;18:281-92.
31. Haas AJ. Interviews. J Clin Orthod 1973;7:227-45.
32. Ehrler T, Caruso J, Lessard G, Leggitt L. The effect of rapid
maxillary expansion on nasal cavity volume and nasal airway
resistance [thesis]. Loma Linda, Calif: Loma Linda University;
2004.