METHODS

OF
GAINING SPACE-

EXPANSION
 Emerson C. Angell, For the first time in 1860,
used a Jack screw type of device. (Considered
the father of rapid maxillary expansion)

• Walter coffin in 1877 introduced a spring called “Coffin spring” for

expanding the arch - not accepted by orthodontic community at that time.

• This technique was popularized by Oral & ENT surgeons in the early part
of last century.

• Korkhaus & Andrew Hass during the 1950’s re-introduced RME to the
Orthodontic community.
 Estimation of. need for expansion
Based on cephalogram ,model analysis: to quantify arch length
tooth material discrepancy. Up to 5mm

A) M-B cusp tips of the upper 1st molar.

B) Buccal groove at the middle of the buccal surface
of the lower molar.
Subtract B from A
Mean difference in normal occlusion:
Males: 1.6mm
Females:1.2mm
2. Ashley Howe’s index.

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 CLASSIFICATION
• Orthopedic: Width of underlying basal bone is increased by
splitting mid palatal suture.
– rapid or slow depending on the rate of expansion.

• Orthodontic: Expansion produced by conventional fixed appliances

or removable expansion plates. The crowns of involved teeth are
tipped buccally with resultant lingual tipping of roots. Resistance of
muscular envelope may lead to relapse.

• Passive: When the muscle forces (buccal & labial) are shielded
away from the dentition, widening of dental arches occurs. This
expansion is the result of intrinsic forces produced by tongue.
 Skeletal
Expansion: Dentoalveolar

Removable Fixed

Coffin springs Slow expansion RME Quad helix W arch Arch Wire
Screws.

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 Rapid Palatal Expansion
It is a skeletal type of expansion
that involves the separation of the
mid-palatal suture and movement
of the maxillary shelves away
from each other.
ANATOMY
• Midpalatal suture is
formed by the junction of
the three opposing pairs
of bones namely
– Premaxillae
– Maxillae
– Palatine Bone
 ANATOMY
• First stage : Covering the infantile period. The
suture is very broad and Y shaped with the
vomerine bone placed in a V shaped groove
between the two halves of the maxilla.

• Second stage : In the juvenile period, the junction

b/w’n three bones becomes higher and assumes
more of a ‘T’ shape with the inter-palatal section
taking a serpentine course.

• Third stage : By adolescence, the oro-nasal course

of the suture may become so inter-digitated that
mechanical inter-locking is as in a jig-saw puzzle
and islets of bone are formed.
 Sutural patency
• Vital to RME.
• when and how quickly synostosis takes place?
• Studies.
• Earliest – 15yr girl. Oldest unossified-27yr woman.
• In general, bony spicules : 15-19yrs.
• Greater obliteration posteriorly.
• On avg, 5% closed by age of 25 yrs.
• Optimal age-before 13-15yrs. Later unpredictable.
• OCCLUSAL RADIOGRAPH.
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 Principle

Rapid heavy force to teeth

• No sufficient time for teeth to respond.
• Transferred to the suture, which opens.
• While teeth move minimally relative to their
supporting bone.

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 INDICATION OF R.M.E
1. In subjects, with severe maxillary constriction.

2. Unilateral or bilateral posterior cross bites involving several

teeth with real or relative maxillary deficency.

3. Patients with Class III malocclusions having maxillary

constriction or posterior crossbite.

4. Cleft lip and palate patients with collapsed maxillae.

5. To gain arch length - moderate maxillary crowding.

6. Narrowness of the maxillary arch and nasal stenosis.

7. Sleep apnea

8. Face mask therapy (loosen circum maxillary sutures).

 Medical Indications

1. Poor Nasal airway

2. Septal Deformity
3. Recurrent ear, nasal (or) sinus infections
4. Allergic rhinitis.
5. As a preliminary to septoplasty.
 CONTRA INDICATIONS
• Un-cooperate patients(frequent activation & good oral
hygiene).
• Single tooth in cross bite.
• Skeletal asymmetry of the maxilla or mandible.
• Server anteroposterior and vertical skeletal
discrepancies. (Anterior open bite).
• Ossified mid palatal suture(require surgical assistance)
• Periodontally weaker posterior dentition.
 Diagnostic Aids

• Case History
• Clinical examination
• Study models
• Radiographs –
– Maxillary occlusal
– P.A. cephalogram
EFFECTS OF R.M.E
 On the maxilla

• Krebs (1964) : 2 halves of maxilla rotate in

– Sagittal

– Coronal

• The maxillary posterior teeth are used as handles to

apply a transverse and reciprocal force so as to

open the mid-palatal suture.
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 Sagittal plane

rotate in downward and

forward direction
RME produces, downward and forward rotation of the
palatal plane.
Increase in the upper anterior facial height (N to ANS)
Point A is also moved anteriorly.

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Coronal plane
• 2 halves move away from each other.
• Fulcrum of rotation around the fronto-
maxillary suture.

Amount of expansion achieved:

• An increase in maxillary width upto 10mm can
be achieved by RME.

• The rate of expansion is about 0.2 - 0.5 mm per

day.
The typical triangular opening of the median palatal
suture confirms the separation of the maxillary
process. (More anteriorly & less posteriorly)

The mid palatal suture opens with an inverted V

shape.(Max-oral side, less on nasal side)

The median palatine suture is repaired totally after 90

days of active phase of expansion.
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 1.

2.

3.

1. Before treatment. 2. During treatment. 3. After treatment

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 Effects on :Maxillary anterior teeth
Mid line Diastema

½ the distance the screw has opened.

By 3-4months the diastema closes by the elastic recoil of the

trans-septal fibers.

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 Maxillary posterior teeth

The appliance compresses the

periodontal ligament, bends
the alveolar processes, tips
the anchor teeth, and
gradually opens the midpalatal
suture.
 Changes in angle of tooth inclination

The angulations between the right

and left molars increased from 1° to
24° during expansion.

Need to overcorrect to compensate

for the subsequent up righting of the
teeth.
1st during active RME

2nd after RME during controlled

relapse.
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Effect on Palatal vault
Lowering of the palatine process due to outward tilting of the
alveolar processes.

Flattening of palatal vault.

Effect on palatal Mucoperiosteum

& PDL tissues
Palatal mucoperiosteum is stretched.

During the post-expansion period, recoil of the stretched fibers

causes a decrease in the inter-molar angulation.

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 Effect on mandible

• Downward & backward rotation of mandible following

RME

• Slight increase in FMA. (Increase in lower

Facial Height)
• Mandibular rotation is due to extrusion & buccal tipping
of maxillary molars.
 Effects On Nasal Air Flow

• Increase in width of nasal cavity at the floor, Outer walls of the

nasal cavity move laterally.
• RME causes a relative reduction in the nasal airway resistance
by disarticulating the maxilla from other bone particularly
Septal and palatine bone
• Air flow resistance reduced by 45% thereby improving nasal
breathing.
• Total Effect: Increase in the inter nasal capacity.
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Effects of RME on adjacent
facial structures.

All craniofacial bones directly articulating with the

maxilla were displaced except the sphenoid bone.
 Classification Of R.M.E
• Removable appliance

Removable plate with jack screw

Fixed appliances:

Fixed tooth & tissue borne appliances

Derichsweiler type

Haas type

Fixed tooth borne appliances

Isaacson type

BANDED BONDED
Hyrax appliance
 Removable appliances
Reliability of these appliances in producing skeletal
expansion is highly questionable.
• If used during the deciduous (or) early mixed dentition
phase produces some effects.
• Consists of a split acrylic plate with a midline screw
retained using clamps on posterior teeth.

• Disadvantages:-
1. Need for patient co-operation

2. Difficulty in retaining the plate inside the mouth.

 Derichsweiler (tooth & tissue borne)
• 1st premolars & 1st molar are
banded
• Tags are welded & soldered to
palatal aspect of bands to
provide attachment for acrylic
which is extended to palatal
aspect of non-bonded teeth.
• Screw is in the mid line.
 Haas (tooth & tissue borne)
• 1st premolars & 1st molar are banded
• A thick stainless steel wire of 1.2mm
diameter is soldered on the buccal and
lingual aspects connecting the premolar
and molar bands.
• The plate does not extend over the
rugae area.
• Screw is in the mid line.
• Disadvantage : pressure necrosis
of palatal mucosa under acrylic.
Issacson (tooth borne)
• This is a tooth borne appliance with out any acrylic palatal
covering
• This appliance uses a special spring loaded screw called

Minne expander. (Developed by University Of Minnesota

Dental School)
• The Minne expander is soldered on to the metal flanges
running from banded first premolar and first molar.
• Spring is activated by turning the adjustment screw, thereby
compressing the coil spring.
 Hyrax appliance. (Hygienic rapid
palatal expander) (tooth borne)
• A fixed wire appliance cemented to the
first permanent molars and first
premolars with centrally located
jackscrew.
• Tooth extrusion, dental tipping, and
an increase in the vertical
dimension are often encountered
with expansion appliances.
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 Bonded RME
These have splint covering variable number
of teeth on either side to which the jack
screw is attached.
Splints can be of two types:
1. Cast cap splints
2. Acrylic Splints
• Bonded Hyrax using inter-occlusal acrylic
may control the vertical dimension and
expand the maxillary halves in a more
bodily and symmetrical fashion.
 SCREWS
• Three types.
– Maximum (Maxi)
– Medium
– Minimum (Mini)

• Hyrax expansion screw

• Fan type expansion screw

– For sectional expansion of maxillary anteriors. Plate sections are
opened up fan wise.

• Telescopic or spring loaded screws

– Telescopic stainless steel expansion screw with rectangular guide pin
for lateral expansion.
 ACTIVATION SCHEDULE

Zimring & Isaacson:

In young growing patients:
 2 turns each day for 4-5 days
 Later 1 turn / day till desired expansion is achieved.

In adults (non growing patients):

 2 turns each day for 1st 2 days,
 1turn / day for the next 5-7 days then
 1 turn every other day till desired expansion is achieved.

Timms:
Up to 15 yrs:
 90° rotation once in the morning & once in the Evening

15-20 yrs :
 45° activation 4 times a day. 36
 Clinical Tips
• 4/4 extraction postpone.

• No prior orthodontic movement.

• Activate, 15-30 min after insertion.

• String/dental floss tied to the activation key.

• See patient at regular intervals.(Monitor weekly- Occlusal X

ray)
• Retention: 3-6months.(TPA can be placed).

• Symptoms on premature removal

– Dizziness, heavy pressure, blanching of soft tissue. So remove
always seated 37
 How Much To Expand
• A stop when the maxillary palatal cusps are level with the
buccal cusps of the mandibular teeth.
 Period of retention
• The objective of retention is to hold the expansion while all
those forces generated by expansion have decayed away
• First 1-2 years after expansion to be critical
• the first 3 months the fixed expansion appliance acts as a
retention appliance. The screw is immobilized with cold
cure acrylic.
• After that fixed retention with TPA or removable plate can
be given.

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 SURGICAL ASSISSTED MAXILLARY
EXPANSION

SARPE = SURGERY + RME

• Surgically-assisted maxillary expansion -a mature
patient with a constricted maxillary arch.
• Unusual resistance to separation-surgical intervention.
• Females over 16yrs, males over 18yrs.
• Palatal osteotomy.
• Lateral maxillary osteotomy.
• Anterior maxillary osteotomy.
 Indications for SARPE(Adults)
1. To widen the arch and to correct a posterior crossbite.
2. Necessity for a large amount (>7mm) of expansion
3. To widen the arch following maxillary collapse associated
with a cleft palate
4. Extremely thin, delicate gingival tissue or presence of
significant buccal gingival recession in the canine-bicuspid
region of the maxilla
5. Significant nasal stenosis
Slow Maxillary Expansion
 Slow Maxillary Expansion
• It is a form of expansion which involves increase of arch
width by movement of few teeth (or) many teeth.

• Slow expansion has traditionally been termed dento-

alveolar expansion, although some skeletal changes can be
observed.

• Expansion is at a rate of 0.5-1mm per week.

 Removable appliances
Coffin spring
• Walter H. Coffin 1881

• Indications:
 Slow dentoalveolar exp
 Constricted upper arch

• Appliance Construction:
 1.25mm hard round S.S wire.
 U or Omega shaped wire.
 Stands 1mm away from palate.
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 Retention from Adam’s clasps on U6,U4 or E
 Appliance activation.
• Range of activation 2-4 mm before insertion.

Disadvantage
 Dislodgement of clasps from the teeth.
 Heavy intermittent force.
 Patient compliance.

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 Expansion plate
• Pierre Robin in 1902 was the
first one who constructed a split
plate which incorporated screw.

• Active plate - This serves as a

base in which screws or springs
are embedded and to which
clasps are attached.
Schwarz Appliance

• The appliance basically consists of an acrylic plate with a

midline split incorporating one / two expansion screws, the
acrylic does not cap the occlusal surface / incisal edges.

• The appliance in addition has a labial bow & is retained by

means of Adam's / ball end clasps.
 Y plate(

• The acrylic sectioning is done in a

“Y” shape. The appliance
incorporates two screws on each
side.

• The incisor segment is expanded

anteriorly whereas the posterior
segment moves laterally
 Expansion Screws (Jack screw)
Baseplate used as working part, divided and driven apart by
screws.
• An equal division-create reciprocal anchorage for both
parts.
• Unequal : larger-added anchorage for movement of smaller
part/s.
• 90 degrees-plates move apart by 0.2mm.(PDL-0.1mm on
each side)
• 254types.but basic principles same.
• SIZES
Encased screws Maxillary-broader
Mandibular-narrower
Skeleton screws
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Skeleton type. Encased screw.

Schematic sagittal section 50

 Activation of the screw
• 1mm/complete revolution.
• 0.25mm of tooth movement/quarter turn.
• Rate of activation: ¼ turn Only twice a week
• Turn screw with appliance in mouth.
• Don’t remove it for several hrs after activation-better
chance of fit.

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52
 Lower Schwartz appliance

Indications:
• Mild to moderate lower ant crowding,
• Lingual tipping of post teeth.

Activation: once/week
• 0.20 to 0.25mm of expn in midline.
• 3-4months; gain 4-5mm of arch length anteriorly.
 Fixed Expansion appliances
Quad/Tri/Bi- Helix
• Evolved- original coffin loop.

• 4 helices - increase range and springiness of the appliance.

• 38 mil S.St wire.

• Slow dentoalveolar expansion. 2mm/month.1mm on each side,

until cross bite over corrected.
• In primary and early mixed dentition- skeletal midpalatal splitting.

2 types:
fixed
removable
 Activation

• It can be pre activated by

stretching the two molar
bands apart prior to
cementation or by using
three prong pliers after
cementation.
 W ARCH
• Originally used by Ricketts.
• 36mil S.Steel wire.
• 1-1.5mm short of palatal soft tissue.

ACTIVATION:
• 2mm/month. Duration 2-3months.
• Remove and then activate.
• 3 months retention.

Unequal W arch - correct true

unilateral maxillary constriction.
• Side to be expanded- fewer teeth
than the anchorage unit.
 Nickel Titanium palatal expander

• Wendell V .Arndt,
• produce light, continuous pressure on mid palatal suture while
simultaneously uprighting, rotating & distalizing the maxillary
1st molars.
• Has adjustable stainless steel extensions and is inserted into
standard horizontal lingual sheaths that are spot welded to the
molar bands.
• Action of appliance is consequence of Ni-Ti shape memory &
transition temperature effects.
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• Ni-Ti as transition temperature of 94°F, when it is
chilled before insertion, it become flexible & can
easily be bent to facilitate placement.

• As the mouth begins to warm the appliance, the

metal stiffens, the shape memory is restored and the
expander begins to exert a light continuous force on
the teeth & mid palatal suture.

• Degree of compression at 20 degrees below the transition temp. B.

effect of shape memory when the wire is warmed to body
temperature. 58
 Nitanium Palatal Expander 2

• Maurice C. Corbett

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 APPLIANCE SELECTION
• Available in 10 sizes, from 26mm to 44mm.

• The clinician determines the appropriate size by measuring

the amount of expansion needed & then adding 3mm for
over correction

• NPE 2 delivers a force of 350g in 3mm increments.

• If 4mm expansion ,initial force higher, later return to 350g
once 3mm expansion occurs.
• Completed in 2-4months. Retention-2-3months.
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 Ligature should be
tied.

After Initial placement.

After 3 months of expansion with NiTi palatal expander 2 61

 Functional appliances

• Functional Regulator
• Lip Bumper: The lateral arms
remove the resting pressure of the
buccal musculature .Allow the
unopposed action of tongue –
increases arch width

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 T.P.A

• 0.036” S.Steel wire.

• Fixed or removable.
• Molar rotation. Maintain the inter molar width.

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 Arch Expansion in Fixed Appliances

• In conjunction with TPA / quad

helix

• 5mm of expansion in the molar

and the canine area.

• Overlay wires used for arch

expansion.

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SLOW EXPANSION
• By use of this force the teeth
alone are supposed to move
• Transmit forces ranging from 2-4
pounds.
• They cause dento alveolar
expansion. They can separate
maxillae, particularly in the
deciduous & mixed dentitions. .
• Rate of separation varies from 0.4
to 1.1 mm / week
• Intermolar width – 8mm
• Requires 2 – 6 months
• Skeletal changes –
16 – 30% of total change and vary
with age
• Less chances of relapse
RAPID EXPANSION
• Results in major change occurring in
basal structures of mandible and
maxilla
• More than 10-20 pounds
•
They can separate maxillae.
• Rate of separation varies from
0.2 to 1 mm / day
• Intermolar width – 10mm
• Requires 1- 4 weeks
• Skeletal changes – 50%
• More chances of relapse
66