Original Article

Three-dimensional evaluation of hybrid expander appliances:

A pilot study
Mehmet Akina; Yasin Erdem Akgulb; Zehra Ileria; Faruk Ayhan Basciftcic

ABSTRACT
Objective: To evaluate transverse dimensional changes in dentoalveolar and skeletal structures
caused by hybrid expander, using cone-beam computed tomography (CBCT).
Materials and Methods: The CBCT records of nine patients (five boys and four girls) (mean age
13.61 6 0.72 years) treated with hybrid expander were examined. CBCT images were taken at
pretreatment and after the expansion. ELSA (point equidistant to both foramina spinosa) was
determined as a reference point to compare the distances in all three dimensions. Nineteen
transversal dimensions and four angles were measured for both right and left sides. Wilcoxon
signed rank test was used for statistical comparison at P , .05 levels.
Results: A V-shaped expansion of suture was successfully achieved in all patients without teeth
support. The amount of opening was greater in anterior than posterior and in inferior than superior.
An 8.75-mm screw expansion was achieved for all patients. Expansion effects reverberated to
maxillary central incisor, canine, first premolar, and first molar at 70%, 75%, 92%, and 89%,
respectively. The molar teeth tipped buccally (right 3.06u and left 3.24u) as did premolars (right
2.88u and left 3.02u).
Conclusion: The hybrid expander, minimally invasive expansion appliance that protects teeth by
including bone support, can be used easily for rapid maxillary expansion treatment. (Angle Orthod.
2016;86:8186.)
KEY WORDS: Bone-borne expansion; CBCT; Hybrid expander

INTRODUCTION introduced for a constricted maxilla. The most common

Maxillary constriction is a common orthodontic
problem and usually accompanied with unilateral or
bilateral posterior crossbite.1,2 Rapid maxillary expan-
sion (RME) has become a useful treatment method for
severe transversal maxillary constriction and posterior
crossbite1,35 since its introduction by Angell6 in 1860
and its increased popularity in the 1900s. Different
types of appliances and treatment protocols have been
a
Assistant Professor, Department of Orthodontics, Faculty of
Dentistry, Selcuk University, Konya, Turkey.
b
Research Assistant, Department of Orthodontics, Faculty of
Dentistry, Selcuk University, Konya, Turkey.
c
Professor, Department of Orthodontics, Faculty of Dentistry,
Selcuk University, Konya, Turkey.
Corresponding author: Dr Mehmet Akin, Selcuk Universitesi,
Dishekimligi Fakultesi Ortodonti AD, Selcuklu 42079, Kampus/
Konya, Turkey
(e-mail: drmehmetakin@selcuk.edu.tr)
Accepted: February 2015. Submitted: December 2014.
Published Online: April 29, 2015
G 2016 by The EH Angle Education and Research Foundation,
Inc.
RME appliances are tooth-borne.79
To obtain separation of maxillary midpalatal suture
interlocks, heavy force is needed. This heavy force
produces mechanical stress on teeth and adverse
effect on teeth such as buccal tipping, gingival
recession, fenestration of buccal cortex, and root
resorption of the posterior teeth.1012 To avoid such
complications, clinicians have designed RME appli-
ances that attach directly to the palatal surfaces of the
maxilla. Use of palatal distractor types of these bone-
borne RME appliances has not been become wide-
spread.
To minimize the surgical procedure and cost, mini-
screw has begun to be used as a boneanchor.13,14
Popular types of these appliances are used: (1) two
mini-screws on rugae as anterior anchorage unit and
first maxillary molars as posterior anchorage unit and
(2) four mini-screws for total anchorage unit. We
designed an alternative to these methods and pro-
duced new bone-borne RME appliances used with two
mini-screws and acrylic palatal pad (Figure 1). Since
this appliance comprises two mini-screws and palatal
pad, it could be named a hybrid expander.

DOI: 10.2319/121214-902.1 81 Angle Orthodontist, Vol 86, No 1, 2016

82
Figure 1. Hybrid expander appliance.
Conventional records, such as cephalometric radio-
graphs, panoramic radiographs, and dental cast
models provide limited information because of super-
imposition of the anatomic structures and difficulties in
landmark identification.15,16
Three-dimensional volumetric imaging, such as
cone-beam computed tomography (CBCT), not only
permits the acquisition of an overlay-free image, but
also allows minimal image distortion, superimposition,
and low radiation dosage that are comparable to a full-
mouth series of periapicals.1719
The aim of this pilot study was to assess the clinical
applicability of this bone-borne hybrid expander and
evaluate the three-dimensional analysis of the move-
ment of teeth, alveolar processes, and skeletal
structures caused by this appliance.
MATERIALS AND METHODS
Ethical approval for this study was obtained from the
Selcuk University Medicine Faculty Research Ethics
Committee (2013/51), and informed written consent
was obtained from all the study participants. The
sample consisted of five boys and four girls, 13.61 6
0.72 years old undergoing RME with the hybrid
expander. Subjects were recruited from the patients
at the orthodontic clinic of Selcuk University, Konya.
Inclusion criteria were as follows:
N maxillary transverse deficiencies,
N no developmental deformity,
N skeletal Class I malocclusion,
N no cleft and palate,
N 2- to 3-mm overbite, and
N need for nonextraction fixed orthodontic treatment.
Expansion was made minimally invasive by using
a hybrid expander. It was designed to be fixed on hard
palate with one mini-screw on each side, for a total of
two mini-screws. Two self-tapping mini-screws (Excal-
ibur, SIA, Caserta, Italy) (1.6 mm in diameter, 10 mm)
were inserted bilaterally between the upper second
premolars and first molars on the palate at a 45u. The
dental cast was obtained, and we signed mini-screw
Angle Orthodontist, Vol 86, No 1, 2016
AKIN, AKGUL, ILERI, BASCIFTCI
Figure 2. Reference ELSA points.
points on this model. Hyrax screw (G&H Orthodontics,
Franklin, Ind) was adapted as deep as possible on the
midline of the palatal vault. The hybrid expander
appliance was produced, which had acrylic palatal
pad not covering any teeth (Figure 1). The hybrid
expander gets support only from palate and the mini-
screws, not covering teeth. That which makes this
appliance more hygienic than tooth-borne palatal
expanders. The appliance was cemented to the mini-
screws with resin composite (Transbond XT, 3M
Unitek, Monrovia, Calif). The appliance activation
was made two times a day (23 quarter turn 5
0.5 mm) for the first week to overcome the resistance
of the mid-palatal sutures, and then one time a day for
3 weeks. Thirty-five quarter turns of 0.25 mm caused
8.75 mm of maxillary expansion.
Pretreatment and posttreatment CBCT images were
obtained by using Kodak equipment (Model CS 9300,
Carestream Health Inc, Rochester, NY) set as follows:
exposures were made at 8.0 mA and 70 kV for 6.15
seconds, and with an axial slice thickness of 0.18 mm.
The patients were asked to put their head in Frankfort
horizontal position for the CBCT scans. The Digital
Imaging and Communications in Medicine (DICOM)
images were imported, and cross-sectional slices were
made with the Simplant Software (13.01 Version,
Materialise, Leuven, Belgium). By using the Simplant
Software program, the three-dimensional image re-
constructions were standardized by using the Frankfort
horizontal plane (represented by a line on the image)
as the x-axis, the transporionic plane as the y-axis, and
the midsagittal plane as the z-axis. To establish the
standard orientation of the craniofacial structures,
three-dimensional reference planes were initially set
according to the reference point ELSA (Figure 2).20
The center of the line connecting the geometric
centers of each foramen spinosum was identified as
ELSA. The horizontal plane was defined as the plane
that passed through the auditory external meatus and
ELSA. The vertical plane was defined as the plane that
was located perpendicularly to the horizontal plane
passing through the medial edge of the foramen
magnum. The frontal plane was located perpendicular
HYBRID EXPANDER 83

Table 1. Measured Dental and Skeletal Points

uI Interincisal coronal width (right and left) Landmark on mesial surfaces of both maxillary central incisors
uC Upper canine (right and left) Point on the middle of the buccal surface of the maxillary canines
uB Upper first premolar (right and left) Point on the middle of the buccal surface of the maxillary first premolars
uM Upper first molar (right and left) Point on the middle of the buccal surface of the maxillary first molars
uIa Interincisal apex width (right and left) Point in apices of both maxillary central incisors
uCa Upper canine apex (right and left) Point in apices of both maxillary canines
uBa Upper first premolar buccal apex (right and left) Point in apices of both maxillary buccal premolars
uMa Upper first molar buccal apex (right and left) Point in apices of both maxillary buccal molars
ep Endopremolare (right and left) Medial point on inner surface of alveolar ridge corresponding to first maxillary premolar
EP Ectopremolare (right and left) Medial point on outer surface of alveolar ridge corresponding to first maxillary premolar
em Endomolare (right and left) Medial point on inner surface of alveolar ridge corresponding to first maxillary molar
EM Ectomolare (right and left) Medial point on outer surface of alveolar ridge corresponding to first maxillary molar
epa Endopremolare apical (right and left) Point on inner surface of alveolar ridge corresponding to apex of first premolar
Epa Ectopremolare apical (right and left) Point on outer surface of alveolar ridge corresponding to apex of first premolar
ema Endomolare apical (right and left) Point on inner surface of alveolar ridge corresponding to apex of first molar
Ema Ectomolare apical (right and left) Point on outer surface of alveolar ridge corresponding to apex of first molar
O Low border of orbit (right and left) Point on the lowest part of the lower orbit border
P Piriform (right and left) Outermost point on the nasal wall
ANS Anterior nasal spine Anterior nasal spine located above Point A
PNS Posterior nasal spine Posterior border point of palatal process of maxilla
Z Zygomaxillare (right and left) Lowest point on suture between zygomatic and maxillary bones
A Point A Subspinale, the most dorsally located point on the contour of the maxilla
B Point B Supramental, the most dorsally located point on the contour of the mandible

to the horizontal and vertical planes. All transversal the two tracings was tested with a Wilcoxon test; no
linear and angular measurements were recorded for significant difference was found (P , .05), confirming
each scan before RME (T1) and after treatment (T2). the intraobserver reliability of the measurements.
One investigator performed the measurements. All
points measured are listed in Table 1 (Figure 3).
Table 2. Intraclass Correlation Coefficients and Interval for
Intragroup and Intergroup Agreement
Statistical Analysis
Interclass Intraclass
Statistical Package for the Social Sciences (SPSS Teeth
17.0, Chicago, Ill) was used for data analysis, and a P Maxillary central incisors (diastema) 0.958 0.923
value , .05 was considered statistically significant. Maxillary canines 0.963 0.954
Maxillary first premolars 0.970 0.919
Numerical data were given as mean 6 SD. Images of
Maxillary first molars 0.975 0.964
five patients were randomly selected, and the initial Apex of maxillary central incisors 0.953 0.987
measurements of each side were repeated by the Apex of maxillary canines 0.941 0.978
same investigator 2 weeks after the first measure- Buccal apex of first premolars 0.945 0.945
ments. Intraclass and interclass correlation coefficients Mesiobuccal apex of maxillary first 0.937 0.932
molars
were performed to assess the reliability of the
measurements as described by Houston21 in same Alveolar crest
images, and the coefficients of reliability for the Ectopremolare 0.929 0.925
Endopremolare 0.932 0.930
measurements were above 0.903 (0.9030.987) (Ta- Ectomolare 0.924 0.919
ble 2). In addition, the statistical difference between Endomolare 0.917 0.903
Skeletal structures
Lower margins of orbita 0.979 0.958
Piriform 0.983 0.943
Anterior nasal spine 0.934 0.951
Posterior nasal spine 0.915 0.942
Zygomaxillare 0.953 0.953
Point A 0.959 0.961
Point B 0.985 0.937
Teeth
Maxillary first premolar, right 0.919 0.972
Maxillary first premolar, left 0.925 0.960
Maxillary first molar, right 0.928 0.981
Figure 3. Skeletal points. Maxillary first molar, left 0.911 0.977

Angle Orthodontist, Vol 86, No 1, 2016

84 AKIN, AKGUL, ILERI, BASCIFTCI

Table 3. Transverse Expansion Amounts Between Dental and Skeletal Structures and Statistical Comparison (in mm)a
Right Side Transverse
Expansion Left Side Transverse Expansion Total Expansion (8.75)
Measurement Values Mean SD Sig % Mean SD Sig % Mean SD Sig %
Teeth
Maxillary central incisors (diastema) 2.98 0.74 * 0.34 3.15 0.81 * 0.36 6.13 1.57 * 0.70
Maxillary canines 3.33 0.67 * 0.38 3.24 0.72 * 0.37 6.56 1.72 * 0.75
Maxillary first premolars 3.94 0.81 * 0.45 4.11 0.77 * 0.47 8.05 2.03 ** 0.92
Maxillary first molars 3.76 0.90 * 0.43 4.03 0.84 * 0.46 7.79 1.52 * 0.89
Apex of maxillary central incisors 2.10 0.56 * 0.24 2.28 0.61 * 0.26 4.38 1.25 * 0.50
Apex of maxillary canines 3.50 0.73 * 0.40 3.33 0.68 * 0.38 6.83 1.49 * 0.78
Buccal apex of first premolars 3.59 0.80 * 0.41 3.50 0.87 * 0.40 7.09 2.01 * 0.81
Mesiobuccal apex of maxillary first 3.59 0.74 * 0.41 3.68 0.83 * 0.42 7.26 1.84 * 0.83
molars
Alveolar crest
Ectopremolare 4.20 1.03 * 0.48 4.38 0.92 * 0.50 8.58 2.13 ** 0.98
Endopremolare 4.38 0.91 * 0.50 4.29 1.04 * 0.49 8.66 1.90 ** 0.99
Ectomolare 4.11 0.85 * 0.47 4.20 0.89 * 0.48 8.31 1.79 ** 0.95
Endomolare 4.20 0.97 * 0.48 4.29 0.79 * 0.49 8.49 2.08 ** 0.97
Skeletal structures
Lower margins of orbita 0.01 0.01 NS 0.00 0.00 0.02 NS 0.00 0.01 0.03 NS 0.00
Piriform 1.05 0.24 NS 0.12 0.96 0.32 NS 0.11 2.01 0.72 NS 0.23
Anterior nasal spine 2.28 0.70 * 0.26 2.54 0.83 * 0.29 4.81 1.17 * 0.55
Posterior nasal spine 0.70 0.31 NS 0.08 0.88 0.41 NS 0.10 1.58 0.73 NS 0.18
Zygomaxillare 0.04 0.01 NS 0.00 0.05 0.03 NS 0.00 0.09 0.06 NS 0.00
Point A 3.68 1.10 * 0.42 3.41 0.97 * 0.39 7.09 1.89 * 0.81
Point B 0.00 0.00 NS 0.00 0.00 0.03 NS 0.00 0.00 0.03 NS 0.00
a
Sig indicates statistical significance; NS, not significant.
* P , .05, ** P , .01.

Because the size of the study group was only 9, the
statistical evaluations of these data were performed
using nonparametric tests. Statistically significant
differences between the T1 and T2 sides were
determined using the Wilcoxon test. Statistical signif-
icance was set at P , .05.
RESULTS
All 18 mini-screws were still stable when the
expansion finished. A V-shaped opening of the suture
and the dentition was observed with the greatest
amount of opening anteriorly and inferiorly directed in
the transverse dimension. The amount of transmitted
screw expansion (8.75 mm) on teeth and skeletal
structures is shown in Table 3. There was significant
expansion on all teeth and alveolar crest parameters
(P , .05). In skeletal structures, only anterior nasal
spine and A point significantly expanded (P , .05). The
maximum transverse increase (8.05 5 92%) was found
in the maxillary first premolar region on teeth. The
minimum transverse increase (4.38 5 50%) was found
on the apex of maxillary central incisors region on teeth.
Approximately the same amount of transverse increase
was obtained on maxillary first premolar region on teeth
with the amount of screw expansion. On the skeletal
structure, the maximum transverse increase (7.09 5
81%) was found in point A, the minimum transverse
increase (0 5 0%) was found in lower margins of orbita,
zygomaxillare, and point B.

Table 4. Buccal Tipping and Statistical Comparison of Teeth (in degrees)a

Before Expansion (Average After Expansion (Average
Tipping) Tipping) Mean Differences Sig
Measurement Values Mean SD Mean SD Mean SD
Teeth
Maxillary first premolar, right 13.27 2.34 16.33 3.04 3.06 1.41 *
Maxillary first premolar, left 14.43 3.12 17.67 2.97 3.24 1.53 *
Maxillary first molar, right 15.56 3.41 18.44 3.21 2.88 1.87 *
Maxillary first molar, left 14.52 2.94 17.54 3.42 3.02 1.74 *
a
Sig indicates statistical significance.
* P , .05.

Angle Orthodontist, Vol 86, No 1, 2016

HYBRID EXPANDER
The amount of expansion caused tipping of teeth as
shown in Table 4. Tipping of posterior teeth was
significantly increased by the impact of expansion.
The most increased tipping was found on the maxillary
left first premolar tooth (3.24u), and the least increased
tipping was found on the maxillary right first molar
tooth (2.88u).
DISCUSSION
The objective of this study was to evaluate the
effects of bone-borne hybrid expander with two mini-
screws on maxillary teeth and maxillary bone. In
clinical experience, the transversal deficiencies of all
patients were successfully treated.
Posterior insertion of two mini-screws between the
second premolar and first molar, located approximate-
ly 56 mm from tooth, seems to be preferable and
harmless for teeth. This area has been described as
a safe place for mini-screws.22 Using the hybrid
expander appliance is a minimally invasive method
compared with the bone-borne RME appliance method
and minimally harmless for teeth compared with the
conventional RME and hybrid hyrax appliance meth-
od.13,23
Our data showed significant increases in oral cavity
width at the levels of the maxillary premolars and
molars (mean 5 8.05 mm; 92%, mean 5 7.79 mm;
89% of appliances expansion) after the expansion.
Bone segment were expanded (between 95% and
99%) more effectively than dental segment in alveolar
crest. Our results are compatible with the results of
Tausche et al.,5 who reported that the transverse
increase at the level of dental segment was maximum
in premolar and molar region and that alveolar crest
regions were expanded between 99% and 107%
according to the appliance expansion. They used
surgical approach in young adults, and RME was
obtained with Dresden distractor hybrid hyrax.
The V-shaped opening was obtained with hybrid
expander in midpalatal suture on horizontal and
coronal planes. Anterior nasal spine was affected
55%; however, the posterior nasal spine was affected
18% from the expansion. This result was different from
the results of Habersack et al.24 and Christie et al.,25
who described parallel opening on the midpalatal
suture. On the other hand, Wertz and Dreskin,26 Silva
Filho et al.,27 and Tausche et al.5 demonstrate that the
opening of midpalatal suture in the area of ANS was
wider than in PNS after RME. Perhaps, the nature of
the parallel opening on midpalatal suture could be
young age.25
In conventional RME, Christie et al.25 reported that
the amount of buccal tipping was 6.22u for the right
molar and 5.50u for the left molar. Similarly, Kilic et al.28
85
found that the amount of buccal tipping was 7.01u for
the right molar and 6.79u for the left molar in the hyrax
group when they compared the dentoalveolar inclina-
tion of patients treated with either a hyrax expander or
an acrylic expander. In our study, we determined that
the mean amount of buccal tipping was 2.88u for the
right and 3.02u for the left molar. Tausche et al.5
evaluated the dentoalveolar effect of bone-borne
Dresden distractor and found 3.5u buccal tipping for
the right molar and 2.5u for the left molar, similar to us.
The bone-borne expander caused molar buccal tipping
of approximately half that of the conventional Hass and
Hyrax expander as inferred in the literature. This
greater tipping could be regarded as an expansion
force transmission to bone via the teeth. On the other
hand, in the bone-borne expander, expansion force
transmission is to bone directly.
Hybrid expander appliance with only two mini-
screws, no tooth support, and with exchangeable
abutments is effective for RME. This appliance makes
RME more hygienic for teeth and gingival tissue. Fixed
orthodontic treatment could be begun immediately and
an expansion, retention period is unnecessary. Other
appliances could be used for retention such as
a transpalatal arch or Nance.
Further studies to evaluate the dentoalveolar and
maxillary three-dimensional effects of the hybrid
expander should be designed by comparing tooth-
borne and tooth-and-tissueborne appliances includ-
ing a control group. Another limitation of this study is
the small sample size. To overcome this limitation, the
same author performed all measurements, and the
high accuracy (a coefficient of more than 0.903) of the
quantitative measurements supports the reliability of
the results. Future studies with a large sample size are
needed for the further evaluation of this appliance.
CONCLUSIONS
N RME could be obtained and supported with two mini-
screws and palatal bone without the support of teeth.
N RME with hybrid expander appliance showed V-
shaped opening of suture on horizontal and coronal
planes.
N Hybrid expander appliance caused less buccal
tipping on posterior teeth than conventional RME
appliances when literature results were compared.
N Hybrid expander appliance could prevent teeth from
root resorption, dehiscence, and fenestration be-
cause of no tooth support.
REFERENCES
1. Timms DJ. A study of basal movement with rapid maxillary
expansion. Am J Orthod. 1980;77:500507.
Angle Orthodontist, Vol 86, No 1, 2016
86
2. Haas AJ. The treatment of maxillary deficiency by opening
the midpalatal suture. Angle Orthod. 1965;3:201217.
3. Derichsweiler H. Gaumennahterweiterung. Munich, Ger-
many:Hanser; 1956.
4. Isaacson RJ, Zimring JF. Forces produced during rapid
maxillary expansion. Angle Orthod. 1965;35:178186.
5. Tausche E, Hansen L, Hietschold V, Lagravere MO, Harzer
W. Three-dimensional evaluation of surgically assisted
implant bone-borne rapid maxillary expansion: a pilot study.
Am J Orthod Dentofacial Orthop. 2007;131:9299.
6. Angell E. Treatment of irregularities of the permanent teeth
or adult teeth. Dent Cosmos. 1860;1:540544.
7. Shapiro PA, Kokich VG. Uses of implants in orthodontics.
Dent Clin North Am. 1988;32:539550.
8. Erverdi N, Okar I, Kucukkeles N, Arbak S. A comparison of
two different rapid palatal expansion techniques from the
point of root resorption. Am J Orthod Dentofacial Orthop.
1994;106:4751.
9. Parr JA, Garetto LP, Wohlford ME, Arbuckle GR, Roberts
WE. Sutural expansion using rigidly integrated endosseous
implants: an experimental study in rabbits. Angle Orthod.
1997;67:283290.
10. Garib DG, Henriques JF, Janson G, de Freitas MR,
Fernandes AY. Periodontal effects of rapid maxillary
expansion with tooth-tissue-borne and tooth-borne expan-
ders: a computed tomography evaluation. Am J Orthod
Dentofacial Orthop. 2006;129:749758.
11. Schuster G, Borel-Scherf I, Schopf PM. Frequency of and
complications in the use of RPE appliancesresults of
a survey in the Federal State of Hesse, Germany. J Orofac
Orthop. 2005;66:148161.
12. Baysal A, Uysal T, Veli I, Ozer T, Karadede I, Hekimoglu S.
Evaluation of alveolar bone loss following rapid maxillary
expansion using cone-beam computed tomography.
Korean J Orthod. 2013;43:8395.
13. Koudstaal MJ, van der Wal KG, Wolvius EB, Schulten AJ.
The Rotterdam Palatal Distractor: introduction of the new
bone-borne device and report of the pilot study. Int J Oral
Maxillofac Surg. 2006;35:3135.
14. Kang S, Lee SJ, Ahn SJ, Heo MS, Kim TW. Bone
thickness of the palate for orthodontic mini-implant
anchorage in adults. Am J Orthod Dentofacial Orthop.
2007;131:7481.
15. Matteini C, Mommaerts MY. Posterior transpalatal distrac-
tion with pterygoid disjunction: a short-term model study.
Am J Orthod Dentofacial Orthop. 2001;120:498502.
Angle Orthodontist, Vol 86, No 1, 2016
AKIN, AKGUL, ILERI, BASCIFTCI
16. Koudstaal MJ, Wolvius EB, Schulten AJM, Hop WCJ, van
der Wal KGH. Stability, tipping and relapse of bone-borne
versus tooth-borne surgically assisted rapid maxillary
expansion; a prospective randomized patient trial. Int J Oral
Maxillofac Surg. 2009;38:308315.
17. Mah J, Hatcher D. Current status and future needs in
craniofacial imaging. Orthod Craniofac Res. 2003;1(6
suppl):1016.
18. Maki K, Inou N, Takanishi A, Miller AJ. Computer-assisted
simulations in orthodontic diagnosis and the application of
a new cone beam x-ray computed tomography. Orthod
Craniofac Res. 2003;1(6 suppl):95101.
19. Scarfe WC, Farman AG, Sukovic P. Clinical applications of
cone-beam computed tomography in dental practice. J Can
Dent Assoc. 2006;72:7580.
20. Lagravere MO, Major PW. Proposed reference point for 3-
dimensional cephalometric analysis with cone-beam com-
puterized tomography. Am J Orthod Dentofacial Orthop.
2005;128:657660.
21. Houston WJB. The analysis of errors in orthodontic
measurements. Am J Orthod. 1983;83:382390.
22. Ludwig B, Glasl B, Bowman SJ, Wilmes B, Kinzinger GS,
Lisson JA. Anatomical guidelines for miniscrew insertion:
palatal sites. J Clin Orthod. 2011;45:433441; quiz 467.
23. Mommaerts MY. Transpalatal distraction as a method of
maxillary expansion. Br J Oral Maxillofac Surg. 1999;37:
268272.
24. Habersack K, Karoglan A, Sommer B, Benner KU. High-
resolution multislice computerized tomography with multi-
planar and 3-dimensional reformation imaging in rapid
palatal expansion. Am J Orthod Dentofacial Orthop. 2007;
131:776781.
25. Christie KF, Boucher N, Chung CH. Effects of bonded rapid
palatal expansion on the transverse dimensions of the
maxilla: a cone-beam computed tomography study. Am-
J Orthod Dentofacial Orthop. 2010;137:7985.
26. Wertz R, Dreskin M. Midpalatal suture opening: a normative
study. Am J Orthod. 1977;71:367381.
27. Silva Filho OG, Silva Lara T, Almeida AM, Silva HC.
Evaluation of the midpalatal suture during rapid palatal
expansion in children: a CT study. J Clin Pediatr Dent. 2005;
29:231238.
28. Kilic N, Kiki A, Oktay H. A comparison of dentoalveolar
inclination treated by two palatal expanders. Eur J Orthod.
2008;30:6772.