ORIGINAL ARTICLE

Three-dimensional evaluation of
dentopalatal changes after rapid
maxillary expansion in growing children
Woowon Jang,a Yoon Jeong Choi,b Jung-Yul Cha,b Yoon Goo Kang,c Euiseong Kim,d and Kyung-Ho Kime
Seoul, South Korea

Introduction: In growing children with transverse malocclusion problems, various types of rapid maxillary ex-
panders (RMEs) have been effectively used in skeletal and dental expansions. We evaluated 3-dimensional
dentopalatal changes in growing children who underwent maxillary expansion using RMEs and bonded
RMEs. Methods: We investigated dentopalatal changes in 20 patients treated with bonded RMEs, 19 with
RMEs, and 38 control patients. Dental plaster models before and after expansion were scanned 3-
dimensionally and superimposed to evaluate transverse expansion, expansion ratio, angular expansion, and
palatal expansion height ratio. Results: Using bonded RMEs, similar anterior and posterior dental expansions
were achieved with an efficiency of 69%-76% (expansion ratio), and palatal soft-tissue expansion occurred more
apically in the posterior area (palatal expansion height ratio, 1.00) than in the anterior area (palatal expansion
height ratio, 0.64). Using RMEs, a larger posterior dental expansion was achieved, with an efficiency of
106%-117% (expansion ratio), than anterior dental expansion (55%-60%), and palatal soft-tissue expansion
occurred more apically in the posterior area (palatal expansion height ratio, 0.99) than anterior area (palatal
expansion height ratio, 0.23). Conclusions: Dental expansions in the anterior and posterior areas were similar
using bonded RMEs, whereas the posterior dental expansions were larger than those of the anterior area using
RMEs. The entire palatal soft-tissue slope expanded in the posterior area, whereas the occlusal part expanded
in the anterior area using RMEs and bonded RMEs. (Am J Orthod Dentofacial Orthop 2024;165:103-13)

A
fter the report on maxillary expansion by An- dentition, palatal soft tissue, and temporary skeletal
gell,1 the expansion appliance manufactured anchorage devices, to effectively treat transverse
by Haas2 has been used in orthodontics. Maxil- discrepancy and minimize side effects, such as buccal
lary expansion appliances alleviate dental crowding, cor- crown tipping of posterior teeth or buccal alveolar
rect posterior crossbite, and expand maxilla width when bone loss.4,5
narrower than the mandible.3 Since the initial use of In growing children with transverse malocclusion,
maxillary expansion, orthodontists have been investi- various rapid maxillary expanders (RMEs) have been
gating the use of various anchorages, including widely studied and effectively used in both skeletal and
dental expansions. Tooth-borne (Hyrax-type) and
a tissue-borne (Haas-type) appliances have been commonly
Yonsei Twins Orthodontic Dental Clinic, Seoul, South Korea.
b
Department of Orthodontics, Institute of Craniofacial Deformity, College of used to induce maxillary skeletal and dental expansions.
Dentistry, Yonsei University, Seoul, South Korea. Garib et al6 and Weissheimer et al7 reported that Haas-
c
Department of Orthodontics, Kyung Hee University, Seoul, South Korea.
d type expanders induced larger buccal molar inclination,
Department of Conservative Dentistry and Oral Research Center, College of
Dentistry, Yonsei University, Seoul, South Korea. whereas Oliveira et al8 suggested that Haas-type ex-
e
Department of Orthodontics, Gangnam Severance Dental Hospital, College of panders achieved larger orthopedic expansion of the
Dentistry, Institute of Craniofacial Deformity, Yonsei University, Seoul, South
maxilla. Furthermore, different effects of band type and
Korea.
All authors have completed and submitted the ICMJE Form for Disclosure of bonded RMEs have been reported. Kiliç et al9 and Olmez
Potential Conflicts of Interest, and none were reported. et al10 demonstrated larger dentoalveolar tipping after us-
Address correspondence to: Kyung-Ho Kim, Department of Orthodontics, Gang-
ing band-type RMEs than that observed after using
nam Severance Hospital, Institute of Craniofacial Deformity, College of Dentistry,
Yonsei University, 211 Eonjuro, Gangnam-gu, Seoul 135-720, South Korea; bonded RMEs. Sarver and Johnston11 showed that the
e-mail, khkim@yuhs.ac. bonded RME reduced the extrusion of posterior teeth.
Submitted, September 2022; revised and accepted, July 2023.
However, Asanza et al12 reported no significant difference
0889-5406/$36.00
Ó 2023 by the American Association of Orthodontists. All rights reserved. in dental tipping between the 2 RMEs.
https://doi.org/10.1016/j.ajodo.2023.07.016

103
104
Changes in the teeth and periodontal tissue during
maxillary expansion have been primarily observed in pre-
vious studies. Furthermore, to evaluate the skeletal
changes of the maxilla, including midpalatal suture
opening and morphologic changes of the palatal vault
in growing children, cone-beam computed tomography
(CBCT) is used periodically.
However, with 3-dimensional (3D) study model scan-
ning and analysis programs, it is possible to detect
changes in dentition and maxillary skeletal changes. As
tooth movement affects the remodeling of the peri-
odontal tissue, including the alveolar bone, opening
the midpalatal suture and subsequent maxillary expan-
sion would alter the shape of the palatal soft tissue.
Recent advances in 3D technologies can provide infor-
mation that could not be observed using previous
methods, such as posteroanterior cephalogram or dental
plaster model analyses. Moreover, 3D model scanning
has excellent precision and reproducibility13 and pro-
vides information on various sections to show the
changes, such as remodeling or expansion patterns in
both the teeth and palatal soft tissue.
Therefore, this study aimed to evaluate and compare
the dentopalatal expansions of different positions in 3D-
scanned dental models using 2 RME types, bonded and
band-type RME, in growing children.
MATERIAL AND METHODS
This is a retrospective study conducted after review
and approval by Gangnam Severance Hospital Institu-
tional Review Board (no. 3-2017-0320).
Initially, 146 patients who had visited the Department
of Orthodontics, Gangnam Severance Dental Hospital,
between 2012 and 2018 and received maxillary expan-
sion treatment using either RME (79 patients) or bonded
RME (67 patients) were enrolled. RME was selected
because of dental crowding and transverse discrepancy,
including posterior crossbite. RME and bonded RME
were allocated according to the eruption state of the
maxillary first premolars. Patients who satisfied the
following conditions were included in the expansion
groups: (1) availability of dental plaster models before
(T1) and after maxillary expansion (T2), (2) no appliance
detachment or breakage during treatment, (3) no defects
or interference from inflammation-related edema with
the measurement of the plaster model, (4) no specific sys-
temic disease or jaw deformity, (5) no prior experience of
orthodontic treatment, and (6) no changes in crown
morphology (eg, because of a prosthesis or trauma).
A total of 39 subjects were finally included in the
RME group: 20 patients (4 males, 16 females; median
age, 8.71 years) for the bonded RME group and 19
January 2024  Vol 165  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Jang et al
patients (10 males, 9 females; median age 11.63 years)
for the RME group.
A Biederman-type expander was used in the RME
group to band the first premolars and molars bilaterally.
For bonded RME, the same expander type was used with
occlusal bite blocks of 1-3 mm thickness to cover the
bilateral posterior teeth (Fig 1). For both RME and
bonded RME groups, the patients were instructed to
turn the expander by one-quarter of a turn per day.
The expansion was performed until the palatal cusps
of the maxillary posterior teeth did not move beyond
the buccal cusps of the mandibular posterior teeth using
RMEs. Using bonded RMEs, the expansion continued
until the entire palatal cusps in the bite-block main-
tained the occlusal contact with the mandibular buccal
cusp. The articulating paper was used to check the
occlusal contact in the bonded RME group.
To evaluate chronological changes by normal growth,
we enrolled 2 control groups from the archives of Insti-
tute of Craniofacial Deformity, College of Dentistry, Yon-
sei University based on the same criteria. The control
group had no orthodontic treatment history, and plaster
dental models were collected yearly. Control group 1 (n 5
19; 6 boys and 13 girls; median age, 9.0 years) was
selected to match the age of the bonded RME group,
whereas control group 2 (n 5 19; 9 boys and 10 girls;
median age, 12.0 years) was selected to match the age
of the RME group. The characteristics of the RME and
control groups are summarized in Table I.
Impressions were taken as a regular procedure at T1
and T2 to evaluate the degree of expansion. The dental
models at T2 were fabricated after the appliance removal
and 3-6 months of maintenance after the expansion had
been completed. In case of severe gingival swelling at T2,
the patient was recalled 1 week later to confirm the sub-
sidence of the swelling and take the impression.
The dental models at T1 and T2 were scanned using a
3D model scanner (Freedom HD; DOF, Irvine, Calif). The
3D digital models at T1 and T2 were superimposed (Rap-
idform2006; Inus, Seoul, South Korea) on the basis of
the medial parts of the anterior third palatal rugae and
the median raphe, which are known to be stable struc-
tures (Fig 2).14,15
For measurements, we defined bilateral landmarks on
the digital model at T1 and T2: the cusp tip of the (decid-
uous) canine (C3R and C3L); the most prominent point of
the palatal gingival margin of the (deciduous) canine
(G3R and G3L); mesiopalatal cusp of the first molar (C6R
and C6L); the point in which the palatal groove of the first
molar met the gingival margin (G6R and G6L); and esti-
mated center of resistance of the first molar, which was
located 5 mm below the G6 point (P6R and P6L).16-18
The line connecting G6R and G6L was registered as the
Jang et al 105

Fig 1. Expansion appliances used in this study: A, Bonded RME; B, RME.

Table I. Demographic features of maxillary expansion and control groups

Variables Bonded RME (n 5 20) Control 1 (n 5 19) P value RME (n 5 19) Control 2 (n 5 19) P value
Sex 0.408 0.746
Male 4 (20.0) 6 (31.6) 10 (52.6) 9 (47.4)
Female 16 (80.0) 13 (68.4) 9 (47.4) 10 (52.6)
Age (y)
T1 8.71 (6.33-10.75) 9.00 (6.00-10.00) 0.718 11.63 (8.92-13.67) 12.00 (10.00-14.00) 0.967
T2 10.09 (7.08-11.66) 10.00 (7.00-11.00) 0.654 12.50 (10.17-14.83) 13.00 (11.00-15.00) 0.901
T2 T1 1.13 (0.25-1.91) 1.00 0.613 1.08 (0.42-1.42) 1.00 0.607
ANB ( )
T1 0.28 ( 2.21 to 5.01) 2.75 (0.70-5.80) \0.001*** 2.28 ( 1.99 to 5.96) 4.20 (1.95-5.98) \0.05*
T2 1.38 ( 2.83 to 3.24) 3.50 (0.90-6.60) \0.001*** 2.72 ( 0.75 to 5.66) 4.48 (1.65-6.29) \0.05*
T2 T1 0.56 ( 3.50 to 3.22) 0.25 ( 2.30 to 3.60) 0.988 0.20 ( 1.61 to 4.86) 0.01 ( 1.36 to 1.60) 0.977
Mp-SN ( )
T1 36.13 (29.10-41.74) 37.50 (30.00-41.70) 0.784 37.33 (31.51-41.47) 35.68 (32.80-39.90) 0.284
T2 37.58 (28.66-41.35) 36.80 (31.00-41.80) 0.791 38.44 (30.72-44.20) 35.98 (31.39-42.60) 0.223
T2 T1 0.14 ( 3.89 to 3.29) 0.20 ( 3.60 to 3.00) 0.355 0.88 ( 2.20 to 2.73) 0.10 ( 2.19 to 2.70) 0.370

Note. Data are presented as n (%) and median (range); Chi-square tests were used to compare gender between groups, whereas Mann-Whitney U
tests were used to compare age, ANB, and Mp-SN between groups.
*P \0.05; ***P \0.001.

x-axis, and the midpoint was defined as (0, 0, 0). The
line connecting (0, 0, 0) with the gingival embrasure
between the maxillary central incisors was the y-axis,
and the other axis was the z-axis. The plane containing
the x- and y-axes were defined as the horizontal
reference plane, whereas the planes perpendicular to
the horizontal reference plane and including the G3
and G6 points were defined as the anterior and
posterior vertical planes, respectively (Fig 3).
The transverse expansion was assessed for the canine
and first molar by measuring the distance between the
right and left sides: C3R-C3L, G3R-G3L, C6R-C6L, G6R-
G6L, and P6R-P6L (Fig 4).
The expansion ratios were defined as the relative
amount of transverse expansion of the teeth (C3R-C3L,
G3R-G3L, C6R-C6L, and G6R-G6L) and palatal soft tissue
(P6R-P6L) to assume the total expansion amount of the
bonded RME or RME appliance as 1. For example, if the
maxillary first molars showed 4.0 mm expansion on the
cusp tips with 5.0 mm of the appliances, the expansion
ratio would be 0.8. To verify the amount of appliance
expansion, the numbers of screw turnings were counted
by reverse turning the jackscrew after appliance removal.
In the anterior and posterior vertical plane before
expansion, the apex of the palatal vault was defined as
Aa and Ap, respectively. The angle connecting the bilat-
eral landmarks (C3, G3, C6, G6, and P6) to the apex of
the palatal vault was measured, and the angular expan-
sion was defined as the differences between T1 and T2
for each landmark (Fig 5).
The palatal expansion height ratio indicates the in-
flection point on the palatal soft tissue. On the posterior
vertical plane, the outline of the palate was drawn at T1
and T2 (Fig 6). The intersection points of the 2 outlines
were defined as the posterior palatal expansion points, in
which changes in the palatal soft tissue were observed.

American Journal of Orthodontics and Dentofacial Orthopedics January 2024  Vol 165  Issue 1
106 Jang et al

Fig 2. Superimposition of 3D models before (gray) and after (blue) expansion.

Fig 3. Axes (x, y, z) and reference planes.

The same procedure was performed for the anterior ver-
tical plane, and the intersection point was defined as the
anterior palatal expansion point.
From the line connecting G3R-G3L (or G6R-G6L), the
perpendicular distances to the palatal expansion point
and Aa (or Ap) were measured. The palatal expansion
height ratio was defined as the perpendicular distance
to the palatal expansion point divided by the perpendic-
ular distance to Aa (or Ap). A positive value indicated the
palatal soft tissue expanded from the palatal expansion
point to G6, whereas a negative value indicated constric-
tion. An approximation to 1 indicates more expansion of

January 2024  Vol 165  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Jang et al
Fig 4. Transverse expansion measurements between C3R-C3L, G3R-G3L, C6R-C6L, G6R-G6L, and
P6R-P6L.
the basal bone, whereas an approximation to 0 indicates
more dentoalveolar expansion.
Transverse expansion, angular expansion, and
palatal expansion height ratio were measured for the
expansion and control groups at T1 and T2. In the con-
trol groups, the 2 dental models with a 1-year interval
were used for the measurements.
Statistical analysis
Kolmogorov-Smirnov tests were used to determine
the normal distribution of the data, whereas chi-
square tests were used to compare the sex ratios be-
tween the expansion and corresponding control
groups. Mann-Whitney U tests were used to compare
age and expansion parameters between the expansion
and corresponding control groups. Friedman and Bon-
ferroni post-hoc tests were used to compare the expan-
sion parameters among different locations in each
expansion group.
American Journal of Orthodontics and Dentofacial Orthopedics
107
A single orthodontist (W.W.J.) measured the trans-
verse expansion, expansion ratio, angular expansion,
and palatal expansion height ratio. To account for mea-
surement errors, all the measurements were repeated 2
weeks later in samples from 10 randomly selected pa-
tients. Intraclass correlation coefficients of 0.945-
0.999 were recorded, showing high reliability. In addi-
tion, 10 patients were randomly selected for another
set of measurements done by another examiner; the
interclass correlation coefficients for this set were
0.915-0.960, showing high reliability.
A P \0.05 was considered statistically significant,
and all the data were processed using the SPSS (version
23; IBM, Armonk, NY).
RESULTS
The demographic features of the subjects are shown
in Table I. Although there were statistically significant
differences in ANB between the expansion and
January 2024  Vol 165  Issue 1
108
Fig 5. Angular expansion measurements between C3R-Aa-C3L, G3R-Aa-G3L, C6R-Ap-C6L, G6R-Ap-
G6L, and P6R-Ap-P6L.
corresponding control groups (P \0.05), sex, age, and
mandibular plane angle did not show significant differ-
ences between the groups (P .0.05).
The transverse linear measurements at T1 are shown
in Table II. Both maxillary expansion groups showed
narrower width in every location compared with the con-
trol groups, although statistically significant differences
were noted in the anterior and posterior cusp tips, pos-
terior gingival margin, and palatal soft tissue between
bonded RME and control group 1 (P \0.05).
Most transverse, angular, and palatal expansion
height ratio values were significantly larger in both
RME and bonded RME groups compared with those in
the corresponding control groups (P \0.05), except
the angular expansion in the anterior gingival margin
and anterior palatal expansion height ratio between
the RME group and control group 2 (Table III).
In the bonded RME group, the median expansion
amount of the appliance was 3.70 (2.00-6.80) mm.
January 2024  Vol 165  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Jang et al
Anterior and posterior teeth showed similar degrees of
transverse expansions (2.37-2.80 mm) and expansion
ratios (0.69-0.76). The posterior palatal soft tissue
showed 1.43 mm of transverse expansion and an expan-
sion ratio 0.42. Angular expansions ranged between
1.75 and 4.00 , showing no significant differences in
position (P .0.05). The palatal expansion height ratio
was significantly smaller in the anterior region (0.64)
as compared with that of the posterior region (1.00)
(P \0.001), indicating that expansion of the palatal
soft tissue occurred in a more occlusal location in the
anterior region compared with the posterior region
(Table IV).
In the RME group, the median expansion amount of
the appliance was 5.20 (2.80-8.00) mm. Larger trans-
verse expansion, expansion ratio, and angular expansion
values were observed at the posterior cusp tip (6.10 mm,
1.17, and 7.63 , respectively) and gingival margin (5.60
mm, 1.06, 7.19 , respectively) (P \0.001). The palatal
Jang et al 109

Fig 6. Measurements of the palatal expansion height ratio showing the posterior vertical plane. The
positive palatal expansion height ratio indicates the palatal soft tissue expanded from the palatal expan-
sion point (red), whereas the negative palatal expansion height ratio indicates the palatal soft tissue
constricted from the palatal expansion point after expansion (yellow).

Table II. Transverse linear measurements of maxillary expansion and control groups before expansion
Transverse linear measurements (mm)

Locations Bonded RME (n 5 20) Control 1 (n 5 19) P value RME (n 5 19) Control 2 (n 5 19) P value
C3 29.22 (24.97-35.71) 32.43 (27.44-35.84) \0.05* 33.87 (29.61-41.08) 35.49 (32.79-39.54) 0.154
G3 23.39 (20.16-29.21) 25.73 (22.49-27.99) 0.055 24.75 (21.62-32.83) 26.75 (23.52-29.85) 0.151
C6 37.25 (32.35-46.91) 41.25 (36.24-44.37) \0.05* 41.09 (32.65-47.00) 43.08 (36.78-45.36) 0.297
G6 30.41 (27.30-38.84) 33.89 (29.40-37.28) \0.05* 33.64 (26.24-39.27) 35.79 (29.86-37.65) 0.354
P6 20.11 (16.94-29.67) 24.78 (18.86-28.50) \0.05* 24.35 (15.99-32.26) 26.77 (21.31-30.81) 0.212

Note. Data are presented as median (range); Mann-Whitney U tests were used for comparison.
C3, Cusp tip of the canine; G3, Most prominent point of the palatal gingival margin of the canine; C6, Mesiopalatal cusp of the first molar; G6,
Point in which the palatal groove of the first molar met the gingival margin; P6, Estimated center of resistance of the first molar, which was located 5
mm below from G6.
*P \0.05.

expansion height ratio was significantly larger in the
posterior region (0.99) compared with that of the ante-
rior region (0.23) (P \0.01) (Table V).
DISCUSSION
In this study, we investigated palatal expansions in
patients treated with bonded RME and RME at various
positions of the crown cusp tip, gingival margin, and
palatal soft tissue. Compared with control groups, both
expansion groups showed larger expansions in every
variable (transverse expansion, angular expansion, and
palatal expansion height ratio). The median expansion
amount of bonded RME was 3.70 mm, approximately
70% of RME (5.20 mm). This came from the different
amounts of crowding or arch shapes (narrow or broad)
between the 2 expansion groups.
In the bonded RME group, dental transverse expan-
sion was almost the same at the anterior and posterior
cusp tips and gingival margins. The expansion ratio
ranged from 0.69 to 0.76, implying that the dental
expansion efficiency of the bonded RME is approxi-
mately 70%. In addition, we found that the bonded
RME caused similar expansion of the teeth in the ante-
rior and posterior regions, suggesting parallel expansion
in the anterior and posterior regions, whereas the
angular expansions were increased to a similar degree
in every location (from 1.75 to 4.00 ). Summing up
the results, the maxillary expansion after using the
bonded RME could have a pyramidal pattern, starting
from the base of the maxillary bone and moving toward
the dental cusp tips. This is consistent with a report by
Wertz et al.19

American Journal of Orthodontics and Dentofacial Orthopedics January 2024  Vol 165  Issue 1
110 Jang et al

Table III. Comparisons of transverse expansion, angular expansion, and palatal expansion height ratio between
maxillary expansion and control groups
Bonded RME
Locations (n 5 20) Control 1 (n 5 19) P value RME (n 5 19) Control 2 (n 5 19) P value
Transverse expansion (mm)
C3 2.37 (1.62-6.99) 0.58 ( 0.39 to 2.12) \0.001*** 2.70 (0.82-6.35) 0.05 ( 0.50 to 1.20) \0.001***
G3 2.80 (1.26-6.54) 0.70 ( 0.53 to 2.45) \0.001*** 2.45 ( 1.26 to 4.07) 0.14 ( 1.52 to 0.59) \0.001***
C6 2.41 (1.29-6.58) 0.80 (0.15-1.60) \0.001*** 6.10 (2.50-9.53) 0.26 ( 0.64 to 1.63) \0.001***
G6 2.55 (1.43-6.76) 0.55 ( 0.28 to 1.52) \0.001*** 5.60 (2.80-8.60) 0.60 ( 0.64 to 1.83) \0.001***
P6 1.43 (0.17-5.48) 0.29 ( 0.55 to 1.34) \0.001*** 1.85 ( 2.36 to 5.90) 0.17 ( 0.90 to 2.15) \0.001***
Angular expansion ( )
C3 2.35 ( 2.37 to 14.50) 0.53 ( 4.05 to 3.70) \0.05* 2.36 ( 12.67 to 4.84) 2.14 ( 11.53 to 0.39) \0.05*
G3 1.75 ( 2.92 to 17.12) 1.20 ( 5.37 to 0.86) \0.01** 0.67 ( 15.63 to 7.22) 1.81 ( 8.81 to 2.13) 0.110
C6 4.00 (1.12-11.28) 0.55 ( 4.34 to 3.68) \0.001*** 7.63 (1.37-15.95) 1.83 ( 8.68 to 0.90) \0.001***
G6 3.75 ( 4.89 to 10.47) 0.67 ( 3.75 to 1.51) \0.001*** 7.19 (2.55-15.28) 1.44 ( 5.82 to 2.17) \0.001***
P6 3.05 (0.18-10.53) 0.81 ( 0.57 to 2.79) \0.01** 2.48 ( 3.83 to 7.80) 0.35 ( 1.39 to 4.12) \0.01**
Palatal expansion height
ratio
Anterior 0.64 (0.08-1.00) 0.34 ( 1.00 to 1.00) \0.01** 0.23 ( 1.00 to 1.00) 0.51 ( 1.00 to 0.49) 0.129
Posterior 1.0. (0.55-1.00) 0.24 ( 1.00 to 1.00) \0.001*** 0.99 ( 0.49 to 1.00) 0.31 ( 1.00 to 1.00) \0.001***

Note. Data are presented as median (range); Mann-Whitney U tests were used for comparison.
C3, Cusp tip of the canine; G3, Most prominent point of the palatal gingival margin of the canine; C6, Mesiopalatal cusp of the first molar; G6,
Point in which the palatal groove of the first molar met the gingival margin; P6, Estimated center of resistance of the first molar, which was located 5
mm below from G6.
*P \0.05; **P \0.01; ***P \0.001.

Table IV. Transverse expansion, expansion ratio, angular expansion, and palatal expansion height ratio in the
bonded RME group
Locations Transverse expansion (mm) Expansion ratio Angular expansion ( ) Palatal expansion height ratio
C3 2.37 (1.62-6.99)ab 0.74 (0.27-1.57)ab 2.35 ( 2.37 to 14.50)
G3 2.80 (1.26-6.54)b 0.76(0.45-1.62)b 1.75 ( 2.92 to 17.12)
C6 2.41 (1.29-6.58)ab 0.75 (0.32-1.27)ab 4.00 (1.12-11.28)
G6 2.55 (1.43-6.76)ab 0.69 (0.48-1.42)ab 3.75 ( 4.89 to 10.47)
P6 1.43 (0.17-5.48)a 0.42 (0.05-1.06)a 3.05 (0.18-10.53)
Anterior 0.64 (0.08-1.00)
Posterior 1.00 (0.55-1.00)
P value \0.05* \0.05* 0.167 \0.001***
Note. Data are presented as median (range); The median expansion amount of bonded RME was 3.70 (2.00-6.80) mm; Friedman tests were used for
comparisons; Medians followed by distinct superscripted letters (a, b) indicate a significant difference in medians within same column as determined
by Bonferroni corrected post-hoc test; a \ b.
C3, Cusp tip of the canine; G3, Most prominent point of the palatal gingival margin of the canine; C6, Mesiopalatal cusp of the first molar; G6,
Point in which the palatal groove of the first molar met the gingival margin; P6, Estimated center of resistance of the first molar, which was located 5
mm below from G6.
*P \0.05; ***P \0.001.

In the RME group, the largest transverse expansion,
expansion ratio, and angular expansion were observed
at the posterior cusp tip and gingival margin. The expan-
sion ratios were higher than 1 at the posterior cusp tip
and gingival margin, which was considered to be the
result of significant buccal crown tipping of the first mo-
lars. Therefore, when using an RME for treatment, it is
important to be cautious of periodontal issues, such as
gingival recession at the first molars. Kiliç et al9 per-
formed rapid expansion using a Hyrax appliance and
reported more dental and alveolar bone tipping at the
first molars using RME as compared with expansion us-
ing a bonded RME, consistent with the results of our
study.9 However, the expansion ratio in the anterior
area was 55%-60%, indicating that more than half of
dental expansion efficiency could be expected while
using RME. Previous studies using RME have reported
that the midpalatal suture would open in a pyramidal
pattern in an anteroposterior direction, inducing larger
anterior expansion than posterior teeth.10-12 The lower

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Jang et al
Table V. Transverse expansion, expansion ratio, angular expansion, and palatal expansion height ratio in the RME
group
Locations Transverse expansion (mm) Expansion ratio
C3 2.70 (0.82-6.35)a 0.60 (0.16-0.84)a
G3 2.45 ( 1.39 to 4.07)a 0.55 ( 0.28 to 0.76)a
C6 6.10 (2.50-9.53)b 1.17 (0.66-1.31)b
G6 5.60 (2.80-8.60)b 1.06 (0.60-1.29)b
P6 1.85 ( 2.36 to 5.90)a 0.36 ( 0.41 to 1.13)a
Anterior
Posterior
P value \0.001*** \0.001***
Note. Data are presented as median (range); The median expansion amount of RME was 5.20 (2.80-8.00) mm; Friedman tests were used for com-
parisons; Medians followed by distinct superscripted letters (a, b) indicate a significant difference in medians within same column as determined by
Bonferroni corrected post-hoc test; a \ b.
C3, Cusp tip of the canine; G3, Most prominent point of the palatal gingival margin of the canine; C6, Mesiopalatal cusp of the first molar; G6,
Point in which the palatal groove of the first molar met the gingival margin; P6, Estimated center of resistance of the first molar, which was located 5
mm below from G6.
**P \ 0.01; ***P \0.001.
expansion ratio of the anterior area in this study might
be that we measured the anterior dental expansion on
bilateral canines. The canines were not involved in the
appliances, showing fewer buccal crown tipping and
transverse expansion. Adkins et al20 and McNamara
et al21 used Hyrax and Haas-type RMEs, respectively,
reporting around half of the intercanine width expan-
sion to intermolar width expansion, consistent with
our study.
We measured the expansion ratio to evaluate the ef-
ficiency of the 2 maxillary expanders. The bonded RME
showed a consistent ratio of approximately 70% of
appliance expansion at the anterior and posterior teeth,
whereas the RME showed approximately 60% of appli-
ance expansion at the anterior teeth and approximately
110% at the posterior teeth. Both maxillary expanders
showed approximately 40% expansion ratios in the pos-
terior palatal soft tissues, smaller than in the hard tissue.
The dense keratinized gingiva might not allow the same
expansion as the hard tissue.
The palatal expansion height ratio is a novel concept
in this study that quantitatively shows maxillary expan-
sion and growth. We aimed to find the amount of palatal
expansion and vertical positions indicating where the
maxillary expansion or growth changes were observed.
We interpreted this variable as an indicator of the maxil-
lary skeletal expansion ratio. A higher value implies the
palatal vault expanded more from the apical position,
meaning the ratio of skeletal expansion is high. Using
bonded RME and RME, the palatal expansion height ra-
tio in the posterior area was larger than in the anterior
area. It could be interpreted that the expansion force
was delivered more efficiently through the larger roots
of the molars than through those of the anterior teeth,
American Journal of Orthodontics and Dentofacial Orthopedics
111
Angular expansion ( ) Palatal expansion height ratio
2.36 ( 12.67 to 4.84)a
0.67 ( 15.63 to 7.22)a
7.63 (1.37-15.95)b
7.19 (2.55-15.28)b
2.48 ( 3.83 to 7.80)a
0.23 ( 1.00 to 1.00)
0.99 ( 0.49 to 1.00)
\0.001*** \0.01**
resulting in larger skeletal expansion of the palate. How-
ever, the soft-tissue changes could be affected by the
skeletal expansion and alveolar bone bending or stretch-
ing of the palatal gingiva. This needs to be confirmed us-
ing CBCT to find how each part contributed to the
changes in palatal soft tissue.
This study has important clinical implications as
expansion patterns for teeth and palatal soft tissue
were evaluated using 2 maxillary expanders commonly
used in growing children. Furthermore, we used 3D
model scanning and superimposition to examine palatal
soft-tissue remodeling patterns, which are difficult to
analyze using conventional quantitative methods.
Among the various methods for comparing 3D
scanned models before and after maxillary expansion,
there is a quantitative method for comparing measure-
ments at each time point and a qualitative method
involving superimposing models from each time point
based on stable structures. The advantages of the latter
superimposition method are that the pattern of changes
can be understood by direct observation of each struc-
ture of interest. Furthermore, it is also possible to iden-
tify structural changes that were not measured.
To use the superimposition method in research, it is
first necessary to assess the reliability of the superimpo-
sition of models before and after expansion and growth.
Although there have been many studies on 3D model su-
perimposition before and after growth or orthodontic
treatment, its stability and reliability remain debated.22
However, several studies have recently reported that
the annual changes in the palate because of growth
are negligible,14,23 and that, in orthodontic treatment
combined with maxillary expansion, taking measure-
ments after the superimposition of pretreatment and
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112
posttreatment models based on stable structures is a
clinically acceptable method.15,24-26 In this study, we
measured the mean changes within 1 year, and
regarding previous studies that reported there can be
changes around the alveolar bone and the lateral areas
of the rugae when the arch is expanded, we performed
superimposition on the basis of the median raphe and
the medial parts of the anterior third palatal rugae.14,15
We used mean values for each tooth root length in a
Korean population because we could not measure the
length of individual dental roots using CBCT. This is
because CBCT imaging could not be performed at such
a short interval (6 months to 1 year) during pretreatment
and posttreatment in patients who were still growing.
We investigated the dentopalatal effects of the most
widely used maxillary expanders using 3D study model
analyses. Because of the study’s retrospective nature, a
comparison of the effectiveness between bonded RME
and RME could not be performed. The expanders were
allocated on the basis of the eruption state of the maxil-
lary first premolars, which led to the RME group being
older than the bonded RME group. Moreover, the
amount of expansion was determined according to the
individual state of dental crowding and transverse
discrepancy. Different eruption states of the permanent
canines between the 2 groups could cause different alve-
olar bone growth and remodeling around the teeth.
Thus, we expect that a prospective randomized trial
study would be necessary to match age (skeletal matu-
rity), amount of expansion, eruption state of the teeth,
and other factors comparing the effects of bonded
RME and RME in the future.
CONCLUSIONS
The dentopalatal expansions achieved using bonded
RME and RME were evaluated using 3D model analysis.
The bonded RME induced similar amounts of anterior
and posterior dental expansion, whereas the RME
induced larger dental expansion in the posterior than
the anterior area. The entire palatal soft-tissue slope
expanded in the posterior area, whereas the occlusal
part expanded in the anterior area using bonded and
nonbonded RMEs.
ACKNOWLEDGMENTS
The authors thank MJ Kim for her assistance in
manuscript preparation.
AUTHOR CREDIT STATEMENT
Woowon Jang contributed to conceptualization
and original draft preparation, Yoon Jeong Choi
January 2024  Vol 165  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Jang et al
contributed to methodology and software, Jung-Yul
Cha contributed to resources and project administration,
Yoon Goo Kang contributed to conceptualization and
supervision, Euiseong Kim contributed to validation
and supervision, and Kyung-Ho Kim contributed to vali-
dation and supervision.
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