ORIGINAL ARTICLE

Treatment response and stability of slow

maxillary expansion using Haas, hyrax, and
quad-helix appliances: A retrospective study
Thuylinh Huynh,a David B. Kennedy,b Donald R. Joondeph,c and Anne-Marie Bollenc
Rockville, Md, Vancouver, British Columbia, Canada, and Seattle, Wash

Introduction: In this retrospective study, we evaluated the short- and long-term effects of slow maxillary ex-
pansion with Haas, hyrax, and quad-helix appliances on posterior crossbite (PXB) correction stability, and
maxillary intermolar width and angulation, in the deciduous or early mixed dentition. Methods: The inclusion
criteria were models and treatment notes of patients with PXB at the start of treatment (T1), after PXB correc-
tion (T2), and at least 2 years posttreatment (T3). Exclusion criteria were craniofacial anomalies, fixed appli-
ance use, or more than 1 expander type. From 312 consecutive expansion patients, 74 Haas, 41 hyrax, and
45 quad-helix subjects were evaluated regarding PXB correction, intermolar width, and angulation and com-
pared with published norms to separate treatment effects from growth. The mean ages at T1, T2, and T3 were
8, 9, and 13 years. Results: There were no significant differences in PXB correction stability or treatment re-
sponse at T2 and T3 among the 3 expanders. Expansion increased intermolar width by 5 mm and tipped each
molar by 2.3 . At least 2 years after expander removal, molar width decreased by 1.3 mm, and the molars up-
righted by 6 . Compared with noncrossbite norms, PXB subjects had narrower intermolar width before treat-
ment and greater width after expansion, and were slightly wider at least 2 years posttreatment. Both younger
age at T1 and retainer use resulted in statistically greater intermolar width at T3. Conclusions: Eighty-four per-
cent of PXB correction remained with about one third of the initial expansion lost; retainer use and early treat-
ment provided increased intermolar width. Haas, hyrax, and quad-helix appliances were equally effective.
Slow maxillary expansion altered the PXB patients’ maxillary widths from narrower to slightly wider than the
widths of the noncrossbite norms. (Am J Orthod Dentofacial Orthop 2009;136:331-9)

improved.7 By contrast, adults with untreated unilateral

P
osterior crossbite (PXB) occurs with a relatively
narrower maxilla than mandible.1 The preva-
lence of PXB is 8% to 23% in the deciduous
and mixed dentitions,2-5 with less than 16% incidence
of self correction.6 More than 90% of children with
PXB are unilateral in centric occlusion. The maxilla is
usually symmetrical, with bilateral presentation in cen-
tric relation.5 In habitual occlusion, the child shifts the
mandible to 1 side, called a functional shift, resulting
in the unilateral PXB in centric occlusion.5,7,8 Children
with unilateral PXB exhibit asymmetric occlusion and
condylar position, and, after treatment, symmetry is
a
Private practice, Rockville, Md.
b
Private practice, Vancouver, British Columbia, Canada.
c
Professor, Department of Orthodontics, School of Dentistry, University of
Washington, Seattle.
Supported by the University of Washington Orthodontic Alumni Association.
The authors report no commercial, proprietary, or financial interest in the
products or companies described in this article.
Reprint requests to: Anne-Marie Bollen, Department of Orthodontics, School of
Dentistry, University of Washington, Box 357446, Seattle, WA 93195; e-mail,
mine@u.washington.edu.
Submitted, April 2007; revised and accepted, August 2007.
0889-5406/$36.00
Copyright Ó 2009 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2007.08.026
PXB have skeletal asymmetry, indicating that untreated
unilateral PXB in a child might lead to mandibular
asymmetric development in adults.9-14 Early treatment
of PXB aims to expand the maxilla, eliminate the func-
tional shift, and restore condylar and facial symmetry
for normal occlusal development.7 Thus, PXB is usually
considered an indication for early treatment.8,15
In growing PXB patients, maxillary expansion has
long been the treatment of choice with intermolar width
deficiency.1 The most popular modality is rapid maxil-
lary expansion (RME).16,17 RME is usually defined as
2 turns per day (0.5 mm expansion) and has a cumulative
force of approximately 100 N across the midpalatal su-
ture.18,19 In theory, RME applies forces to the posterior
teeth without giving sufficient time for tooth movement
to occur, so that the force is transferred to the palatal
suture, resulting in more sutural opening than dental
expansion.18,20 Some RME studies reported side effects
such as microtrauma of the midpalatal suture21 and
relapse.22 Linder-Aronson and Lindgren23 reported
about 55% expansion loss at 5 years postretention for
RME without fixed appliances (FA). Spillane and
McNamara24 reported a 20% loss of the 6 mm of initial
331
332 Huynh et al
expansion 2.4 years postexpansion in a mixed RME
sample that included other simultaneous treatments.
A different modality is slow maxillary expansion
(SME). SME is defined as 1 turn (0.25 mm of expan-
sion) every second day for a Haas or hyrax appliance,
or 1 molar width activation for a quad-helix, with 5 to
20 N of force.1,25 The theory is that the main resistance
to the opening of the midpalatal suture is not the suture
itself but the surrounding tissues such as the circum-
maxillary structures and midface sutures.18,25,26 In
young patients, SME is said to provide the maximum
rate at which the midface sutures can adapt, with mini-
mum tearing and hemorrhaging compared with
RME.18,21,25-27 Animal and histologic studies indicate
that SME improves conservation of the suture and can
produce a more stable result than RME.28-30 Some clin-
ical studies also suggest that SME is more stable than
RME25,31; however, these samples were small, and
data collection was short term. Therefore, clinical
SME studies with larger samples and long-term data
are needed to validate its use.
As age increases, the facial sutures become more in-
terdigitated, especially after puberty.1,18,25,32 Sex also
influences the maturation rate, with girls reaching skel-
etal maturity before boys.1 After puberty, greater force
is required to open the sutures; this can surpass the
capacity for physiologic adaptation.18,25,33
Various maxillary expander designs are believed to
result in different skeletal-to-dental ratios of expansion
and could lead to differences in treatment stability, but
this assumption is not proven.34,35 To do so requires in-
vestigation of different SME appliances without other
appliances to assess the pure effect of expansion type.
Treatment effects and long-term outcomes have consid-
erable clinical importance.22,34,36
Studies on early treatment of unilateral PXB con-
cluded that canine grinding is a treatment of choice in
the deciduous dentition.16,34 Most mixed dentition ex-
pansion studies have problems of small sample size,
bias, confounding variables, lack of method analysis,
lack of long-term data, no blinding for measurements,
deficient statistical methods, and lack of controls.34
Lagravere et al36 reviewed SME without other simulta-
neous treatments and concluded that, without control
groups, no strong conclusion can be made regarding
the dental or skeletal changes after SME, but SME
might be more stable than RME, and also expansion sta-
bility was related to age. In a maxillary expansion meta-
analysis review, 4 long-term studies met the inclusion
criteria with 2 studies of RME with FA,24,37 1 with
RME alone,23 and 1 with SME alone.38 RME without
FA seemed no better than SME, and the results of
RME with FA do not have the pure effects of RME.22
American Journal of Orthodontics and Dentofacial Orthopedics
September 2009
Therefore, a clinical SME study was needed with
a large sample to evaluate the pure effect of expansion
without supplementary appliances, considering growth,
age, sex, and appliance design. We conducted a retro-
spective clinical study to evaluate the short- and long-
term effects of SME on PXB correction stability, and
maxillary intermolar width and angulation, in patients
in the deciduous or early mixed dentition with PXB
treated with a Haas, hyrax, or quad-helix appliance.
MATERIAL AND METHODS
Our subjects were 312 consecutive, nonrandomized
maxillary expansion patients, treated in the private ortho-
dontic practice of an author (D.B.K.) in Vancouver,
British Columbia, Canada, between January 1981 and
November 2003. They were screened for inclusion in
this retrospective study. Inclusion criteria were either uni-
lateral or bilateral PXB at preexpansion (T1), treated with
SME by using either a Haas, hyrax, or quad-helix appli-
ance (Fig 1), and postexpansion and retention records
with no PXB (T2). Records were taken a minimum of
2 years later (T3) in the permanent dentition. To prevent
sample selection bias, patients who used a retainer be-
tween T2 and T3 were not excluded from the study. Sub-
jects with surgical interventions, birth defects (clefts), or
other simultaneous treatment, except for an anterior seg-
mental archwire and a removable retainer, were excluded.
The records and models were coded by someone not
involved with the study. The coded models were given
to the principal investigator (T.H.). Ages and dates
were also obtained from the models. To prevent mea-
surement bias, this investigator was blinded with regard
to expander type, sex, and retainer use between T2 and
T3. Models from T1, T2, and T3 were assessed sepa-
rately; afterwards, they were sorted by expander type,
sex, and retainer use. Coded records were reviewed in
detail to verify expander type, expansion and retention
protocol, retainer use, and any other treatment.
SME was defined as no more than 1 turn every
2 days (0.25 mm every 2 days) for the Haas and the
hyrax, or 1 molar width of activation for the quad-helix,
until the PXB was mildly overcorrected so that the lin-
gual incline of the mandibular buccal cusp contacted the
buccal incline of the maxillary lingual cusp. The quad-
helix was removed, activated, and recemented as
needed. No subject was brought into buccal crossbite.
The expander was left intraorally in a passive state for
retention for a minimum of 6 months. A set of models
in centric occlusion was taken after removal of the ap-
pliance (T2). At the minimum follow-up of 2 years later,
progress models were taken in the early permanent den-
tition before further treatment if needed (T3).
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 136, Number 3
Fig 1. SME appliances: A, Haas; B, hyrax; C, quad-helix.
Fig 2. Intermolar width was measured from the models as the intercentroid distance in millimeters
between the maxillary first permanent molars.
Appliance choice and design were made indepen-
dently of the crossbite severity by the treating clinician
(D.B.K.). Quad-helices were used for expansion and
when patients needed first permanent molar rotations cor-
rected. Haas appliances were used when correction of dig-
ital habits was also needed. In the absence of these needs,
either hyrax, Haas, or quad-helix appliances were used.
The decision to use a removable retainer postexpansion
was made by the clinician based on the patient’s needs.
The study protocol was approved by the University
of Washington’s Institutional Review Board.
There were 2 components to the study as outlined.
Part A included stability of crossbite correction.
Models were evaluated by visual inspection for recur-
rence of PXB at T3. Subjects without models at T2,
but with T3 models taken more than 2.5 years after
T1, were included in part A. All subjects were relatively
young with unerupted second permanent molars at T1
and T2; consequently, PXB of the second molars at
T3 was not considered as relapse. Subjects with border-
line recurrence of PXB at T3 were reviewed by a second
investigator (A.B.), and consensus was reached.
Part B included measurements of intermolar width
and angulation, and comparison with norms. Intermolar
Huynh et al 333
widths and angulations were measured for subjects with
maxillary first permanent molars at T1, T2, and T3. Pre-
dicted normal intermolar width was calculated with
a quadratic interpolation by using published norms
matched with the sex and chronological age of the sub-
jects (years and months).39 Comparisons of intermolar
width were made.
The following measurements were made from the
models.
1. Intermolar width (W) is the intercentroid distance
in millimeters between the maxillary first perma-
nent molars, using the method described by Moyers
et al39 (Fig 2).
2. Intermolar angulation is the angle of intersecting
lines tangent to the mesiobuccal and mesiolingual
cusp tips of the maxillary right and left first perma-
nent molars as described by Handelman40 and Han-
delman et al.41
3. The angulation changes from T1 to T2 and T1 to T3
were calculated as half of the angular change: a neg-
ative number for molar tipping to the buccal aspect,
and a positive number for uprighting, with T1 as the
baseline (Fig 3).
334 Huynh et al American Journal of Orthodontics and Dentofacial Orthopedics
September 2009

Table III. Means and standard deviations for age, inter-

molar width, and intermolar angulation at T1 for sub-
jects with first permanent molars at T1
Haas Quad-helix Hyrax All
(n 5 57) (n 5 43) (n 5 32) (n 5 132)

Mean (SD) Mean (SD) Mean (SD) Mean (SD)

Fig 3. Angulation changes from T1 to T2 and T1 to T3
were calculated as half of the angular change: a negative Age at T1 (y) 8.1 (1.1) 8.3 (1.0) 7.8 (1.1) 8.1 (1.1)
Age at T2 (y) 9.2 (1.3) 9.4 (1.3) 8.8 (1.3) 9.2 (1.3)
number for molar tipping to the buccal aspect and a pos-
Age at T3 (y) 13.2 (1.7) 13.3 (1.6) 13.0 (1.3) 13.2 (1.5)
itive number for uprighting, using T1 as the baseline.
Width at T1 41.4 (2.5) 42.6 (2.5) 42.8 (2.6) 42.1 (2.6)
T(2,1) 5 (154 – 166 )/2 5 6 (tipping). (mm)
Angulation 156.1 (6.8) 154.3 (9.9) 155.7 (7.2) 155.4 (8.0)
at T1 ( )
Table I. Included subjects
Expander Part A: PXB Part B: intermolar
type correction (n) width and angulation (n) Table IV.Percentages and numbers of subjects by sex,
those using a retainer or no retainer, and those experi-
Haas 74 57 encing relapse at T3 as a total group and as a no-retainer
Hyrax 41 32
group
Quad-helix 45 43
Total 160 132 Haas Quad-helix Hyrax All
(n 5 74) (n 5 45) (n 5 41) (n 5 160)

Percent (n) Percent (n) Percent (n) Percent (n)

Table II. Excluded subjects
Female 68.9 (51) 73.3 (33) 63.4 (26) 69.2 (110)
Exclusion reason Subjects (n)
Male 31.1 (23) 26.7 (12) 36.6 (15) 31.3 (50)
T1 (PXB–) 12 Retainer 10.8 (8) 8.9 (4) 26.8 (11) 14.4 (23)
T2 (PXB1) 9 No retainer 89.2 (66) 91.1 (41) 73.2 (30) 85.6 (137)
RME used 15 Total relapse 13.5 (10) 20.0 (9) 14.6 (6) 15.6 (25)
FFA, 2 3 4, headgear, Nance 20 Relapse, no 15.2 (10) 17.1 (7) 16.7 (5) 16.1 (22)
Craniofacial anomaly 5 retainer
Other expander (RA and W arch) 15
Missing models 59
the null hypothesis of no difference between observed
Incomplete record 39
T2-T3 \ 2 y 10 and predicted widths by using 1-sample t tests. We re-
T1-T3 \ 2.5 y 5 jected the null hypothesis if the P value was less than
0.05 because it results in a 5% type 1 error probability.
, no crossbite present; 1, crossbite present.
Twenty subjects were randomly chosen, and inter-
molar width and angulation were remeasured and the
4. Intermolar expansion (E): E(2,1), E(3,1), E(3,2) re- measurement error calculated according to Dahlberg’s
flect the intermolar expansion between T1, T2, and formula.42 Measurement errors were insignificant. Stan-
T3. For example, E(2,1) 5 width at T2 – width at dard deviations for width measurements ranged from
T1, or the intermolar expansion at T2. 0.04 to 0.16 mm with correlation coefficients of 0.99
5. Elapsed time was calculated as T3 minus T2, the to 0.999. Angular measurements showed standard devi-
time between T2 and T3 in months. ations of 0.95 to 1.5 with correlation coefficients of
0.91 to 0. 97.
Statistical analysis
Regression models were used to evaluate associa- RESULTS
tions between variables. We found that these models Of the 312 consecutive expansion patients, 160 PXB
were not significantly affected by outliers. Expander subjects satisfied the inclusion criteria (Table I). The rea-
type, sex, and retainer use were adjusted to eliminate sons for excluding the other 152 patients are given in
confounding by these variables. The expansion amount Table II. Twenty-eight subjects from part A were
at T2, tipping at T2, and elapsed time were also excluded in part B (20 because of unerupted first molars
adjusted. Differences between the observed intermolar at T1, and 8 because of missing T2 models) (Tables I
widths and predicted normal values were tested with and II).
American Journal of Orthodontics and Dentofacial Orthopedics Huynh et al 335
Volume 136, Number 3

Table V. Logistic regression for association between risk Table VII. Results of linear regression model for associ-
of relapse and appliance, sex, age, retainer use, elapsed ation between the changes in intermolar width from T1
time, and expansion amount at T2 to T2 and appliance, sex, and age
OR 95% CI P Coefficient 95% CI P

Appliance Appliance
Haas (relative to quad-helix) 0.68 0.23, 1.96 0.47* Haas (relative to Quad-helix) 0.06 0.85, 0.74 0.89*
Hyrax (relative to quad-helix) 0.33 0.06, 1.30 0.13* Hyrax (relative to Quad-helix) 0.49 1.44, 0.46 0.31*
Male (relative to female) 0.68 0.20, 2.01 0.51* Male (relative to female) 0.20 0.54, 0.94 0.59*
Age at T1 0.93 0.56, 1.51 0.76* Age at baseline (T1) 0.09 0.43, 0.24 0.58*
Retainer use (relative to no 0.94 0.18, 3.77 0.94*
retainer use) *Not significant.
Elapsed time (T2-T3) 0.91 0.60, 1.30 0.63*
Expansion at T2 (W2-W1) 0.85 0.62, 1.11 0.26*
Tipping at T2 0.88 0.76, 1.01 0.07* Table VIII. Results of linear regression model for associ-

OR, Odds ratio.

ation between change in intermolar width from T1 to T3
*Not significant. and appliance, sex, age, and time between T2 and T3
Coefficient 95%Cl P
Means and standard deviations for age, inter-
Table VI.
Appliance
molar widths, and expansions for subjects with first per- Haas (relative to Quad-helix) 0.45 0.30, 1.19 0.24*
manent molars at T1 Hyrax (relative to Quad-helix) 0.15 1.04, 0.75 0.74*
Male (relative to female) 0.19 0.53, 0.90 0.60*
Haas Quad-helix Hyrax All
Age at baseline(T1) 0.42 0.76, 0.09 0.01†
(n 5 57) (n 5 43) (n 5 32) (n 5 132)
Retainer use (relative to no 0.98 0.03, 1.92 0.04†
Mean (SD) Mean (SD) Mean (SD) Mean (SD) retainer use)
Elapsed time (T2-T3) 0.12 0.11, 0.35 0.29*
Width at T1 (mm) 41.4 (2.5) 42.6 (2.5) 42.8 (2.6) 42.1 (2.6) †
Width at T2 (mm) 46.6 (2.7) 47.7 (2.8) 47.5 (2.8) 47.2 (2.8) *Not significant; significant.
Expansion at 5.3 (1.8) 5.1 (2.1) 4.7 (1.3) 5.1 (1.8)
T2 (mm) tically significant association was found between the
Width at T3 (mm) 45.3 (2.8) 46.0 (2.6) 46.4 (3.0) 45.8 (2.8) intermolar width change and expander type, sex, and
Expansion at 4.0 (2.2) 3.4 (1.8) 3.6 (1.6) 3.7 (1.9)
T3 (mm)
age (Table VII).
At T3, intermolar width change was significantly
negatively associated with age at treatment and posi-
Sample demographics are given in Table III. There tively associated with retainer use (P\0.05) but not sig-
were no statistical differences in age, sex, intermolar nificantly associated with appliance type, sex, and
width, and intermolar angulation among the 3 expander elapsed time between T2 and T3 (P .0.05). All other
types at T1. This confirmed an unbiased assignment to variables being equal, for each year earlier that treat-
the appliances. The average ages at T1, T2, and T3 ment started, the patients had 0.42 mm more expansion
were 8, 9, and 13 years (Table III). Of the 160 patients, in the long term. Similarly, other variables being equal,
23 used a removable retainer between T2 and T3 (Table the retainer group maintained 0.98 mm more intermolar
IV); 69% of the sample were girls, and 31% were boys width in the long term, compared with the nonretainer
(Table IV). group (Table VIII).
The overall PXB relapse in 160 subjects was 15.6% Because expander type had no effect on intermolar
(Table IV); of the137 subjects without a retainer, the widths at T2 and T3, all 3 subsamples were grouped to-
probability of relapse was slightly higher: 16.1%. Re- gether (n 5 132) to characterize the effect of SME.
lapse rates were lowest for Haas, followed by hyrax, Paired t tests indicated that the 3.7 mm of expansion
and then quad-helix, but the differences were not statis- from T1 to T2 was highly statistically significant, as
tically significant (Table V). Appliance type, sex, age of was the relapse of 1.3 mm in width between T2 and
treatment, retainer use, elapsed time, expansion amount T3 (P \0.0001).
at T2, and tipping at T2 were not associated with relapse On average, the molars tipped 2.3 during treatment
at T3 (Table V). and then uprighted 6 after removal of the expander (Ta-
Although relapse of PXB occurred in only 15% of ble IX). No significant association was found between
the patients, Table VI shows that only 3.7 mm of an av- intermolar angulation from T1 to T2 and appliance
erage 5-mm expansion at T2 remained at T3. No statis- type, sex, and age (P .0.05) (Table X). Intermolar
336 Huynh et al American Journal of Orthodontics and Dentofacial Orthopedics
September 2009

Table IX. Means and standard deviations for ages, and intermolar angulations for subjects having first permanent mo-
lars at T1
Haas (n 5 57) Quad-helix (n 5 43) Hyrax (n 5 32) All (n 5 132)

Mean (SD) Mean (SD) Mean (SD) Mean (SD)

Age at T1 (y) 8.1 (1.1) 8.3 (1.0) 7.8 (1.1) 8.1 (1.1)
Angulation at T1 ( ) 156.1 (6.8) 154.3 (9.9) 155.7 (7.2) 155.4 (8.0)
Age at T2 (y) 9.2 (1.3) 9.4 (1.3) 8.8 (1.3) 9.2 (1.3)
Angulation at T2 ( ) 150.5 (9.4) 151.5 (11.3) 150.3 (9.1) 150.8 (9.9)
Tipping at T2 ( ) (T2,1) 2.8 (3.7) 1.4 (4.2) 2.7 (3.8) 2.3 (3.9)
Age at T3 (y) 13.2 (1.7) 13.3 (1.6) 13.0 (1.3) 13.2 (1.5)
Angulation at T3 ( ) 163.1 (7.1) 163.6 (8.9) 163.0 (7.4) 163.2 (7.8)
Uprighting T2-T3 ( ) (T3,2) 6.3 (4.5) 6.1 (4.7) 6.3 (4.4) 6.2 (4.5)
Uprighting at T3 ( ) (T3,1) 3.5 (4.1) 4.7 (3.3) 3.6 (4.0) 3.9 (3.8)

Table X. Results of linear regression of association be-
tween intermolar angulation from T1 to T2 and appli-
ance, sex, and age, with linear effects of appliance
relative to quad-helix
Coefficient 95% CI
Table XI. Results of linear regression of association be-
tween intermolar angulation from T1 to T3 and appli-
ance, sex, age, and time elapsed (T2-T3), with linear
effects of appliance relative to the quad-helix
P Coefficient 95% CI P

Appliance Appliance
Haas 1.25 2.83, 0.32 0.12* Haas 1.1 2.63, 0.42 0.15*
Hyrax 1.03 2.92, 0.85 0.28* Hyrax 1.05 2.87, 0.77 0.25*
Male 0.01 1.46, 1.47 0.99* Male 0.23 1.23, 1.69 0.76*
Age at baseline (T1) 0.40 0.27, 1.07 0.24* Age at baseline (T1) 0.3 0.38, 0.99 0.38*
Retainer use 0.14 2.08, 1.79 0.88*
*Not significant. Elapsed time (T2-T3) 0.54 0.08, 1.01 0.02†

*Not significant; †significant.

angulation change from T1 to T3 was significantly pos-
itively associated with elapsed time (P \0.05), but not
with expander type, sex, or age at T1 (P .0.05). All
other variables being equal, for each year longer than
2 years out of the appliance, the molar uprighted 0.54
more (Table XI).
Because expander type had no effect on intermolar
angulation, the 3 subsamples were pooled (n 5 132)
to show the effect of SME. Paired t tests indicated that
2.3 of tipping during treatment (T1-T2) and overall
3.9 of uprighting (T1-T3) were highly statistically sig-
nificant (P \0.0001).
Table XII shows that the correlations between inter-
molar angulation changes with intermolar width
changes were statistically significant. Subjects with
greater molar tipping tended to have greater expansion
at T2 and T3 (P \0.0001); subjects with greater tipping
at T2 tended to have greater tipping at T3 and greater ex-
pansion at T3.
Relative to age- and sex-specific normal values, in-
termolar widths were statistically significantly narrower
than the predicted normal values at T1 (P \0.05) and
significantly wider than the predicted normal values at
both T2 and T3 (P \0.0001) (Fig 4, Table XIII).
DISCUSSION
To our knowledge, this is the first SME study with
a large sample and several types of fixed expanders
with long-term data but without other simultaneous
treatments that could contribute to the expansion effect.
Based on the similarity of the 3 expander subgroups
at T1, the large sample, and the blinded measurements,
our data strongly support the conclusion that the Haas,
hyrax, and quad-helix are equally effective for PXB cor-
rection, intermolar expansion, and intermolar angula-
tion. This finding should carry more weight than
previous studies because of the large sample and the
long-term follow-up. Our data support the assessmemt
of Harrison and Ashby16 that there is no evidence of
a difference in treatment effect between bonded vs
banded expanders, or quad-helix vs removable ex-
pander in SME. Petren et al34 also reached a similar con-
clusion. A likely explanation is that, in young patients,
sutures open easily to allow expansion under light
forces regardless of expander type.18,33 Since there
was no difference among the 3 expanders, we will dis-
cuss them together as SME.
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 136, Number 3
Correlations between tipping and expansion
Table XII.
with 95% confidence intervals
Correlation 95% CI P Mean
Expansion T2, tipping T2 0.35 0.49, 0.19 \0.0001*
Expansion T3, tipping T3 0.51 0.63, –0.37 \0.0001*
Tipping T2, tipping T3 0.32 0.15, 0.46 0.0002*
Tipping T2, expansion T3 0.23 0.38, –0.06 0.0092*
P values are based on t tests.
*Very significant.
Fig 4. Relative to age- and sex-specific normal values,
intermolar widths were statistically significantly narrower
than the predicted normal values at T1 (P\0.05) and sig-
nificantly wider than the predicted normal values at both
T2 and T3 (P \0.0001).
Regarding PXB correction, after an average of 4
years after retention, SME with its relapse rate 15.6%
was quite stable in the hierarchy of stability.1
The prevalence of crossbites was significantly
higher in girls than in boys but similarly distributed
among the 3 expander types. This distribution was con-
sistent with the findings of previous studies about the
sex differences of PXB prevalence.43,44 Sex in our
data did not alter the outcome; this was probably be-
cause the subjects were prepubertal at T1 (age, 8 years).
Sexual dimorphism in growth is typically expressed
only after puberty.45
Intermolar width at T3 was inversely related to age
at T1. When the patients were treated at a younger age,
width at T3 was the greatest. As a patient ages, the su-
tures become more interdigitated, possibly making
them more prone to some expansion loss.18,19,25,33
This finding supports early treatment for better long-
term results.
By including subjects using retainers (n 5 23), we
avoided sample bias and confirmed a better long-term
expansion result with retention, as indicated by previ-
ously studies.22,25,38 The retainer group had 0.98 mm
more intermolar width at T3 than did the nonretainer
Huynh et al 337
Table XIII. Differences between predicted and observed
intermolar values at T1, T2, and T3
95% CI P
T1 0.456 0.868, 0.045 0.03*
T2 3.89 3.434, 4.347 \0.0001†
T3 0.861 0.398, 1.323 \0.0001†
*Significant; †very significant.
group. This was about 20% of the 5-mm expansion at
T2 and 27% of the 3.7 mm of remaining expansion at
T3. This finding was consistent with the trend in part
A; the nonretainer subgroup had a worse relapse rate
than the total group. The few (n 5 23) retainer subjects
was insufficient to follow a binomial distribution, but,
indirectly, it appears that the retainer subjects were
slightly less prone to relapse than those without
retainers.
Previously, Hesse et al7 used 61 PXB patients from
this sample at T1 and T2; although they used different
landmarks for intermolar width, the same 5-mm expan-
sion between T1 and T2 was found. The meta-analysis
of Schiffman and Tuncay22 included 4 other studies
with at least 1-year postretention data, 3 RME stud-
ies,23,24,37 and 1 SME study.38 Spillane and McNa-
mara24 and Moussa et al37 showed higher expansion
of 5.5 mm using RME with FA and retainers, but their
various appliances confuse interpretation. Linder-
Aronson and Lindgren23 used RME alone and achieved
3.6 mm of long-term expansion at T3 compared with an
initial 8-mm expansion at T2. This suggests that the end
result of RME is no better than SME. Using SME, Boy-
sen et al38 found that 3.6 mm of expansion remained af-
ter 5 mm of initial expansion at T2, with either a quad-
helix or a removable expander; the quad-helix caused
greater expansion and buccal translation, whereas the
removable expander gave more buccal tipping and
long-term relapse. Using meta-analysis, Schiffman
and Tuncay22 found that an average of 2.4 mm of expan-
sion remained after 3.88 mm of expansion at least a year
out of retention. However, their subjects were 3 years
older on average than ours. Our study predicted 0.44
mm less long-term expansion for each year of age at
T1. Thus, we would expect about 1.2 mm less final
intermolar width than in the study of Schiffman and
Tuncay; this was the case.
The significant buccal molar tipping at T2 was con-
sistent with the notion that dental tipping occurs during
expansion.46 We found 2.3 of tipping after expansion
and retention; this is mild compared with 3.7 of molar
tipping reported for RME with the hyrax.47 The 6 of
molar uprighting from T2 to T3 could be a result of
338 Huynh et al
expansion relapse and natural occlusal changes. Mar-
shall et al48 found 3.3 of molar uprighting naturally
from the mixed to the permanent dentition without or-
thodontic treatment. Interestingly, for every year be-
yond 2 years, there was 0.54 more uprighting, and
the residual buccal tipping at T3 compared with T2 im-
plied that not all dental tipping relapses. No previous
study either supports or refutes these findings.
The pattern of facial growth is established early in
life and rarely changes significantly without treatment.1
At T1, the PXB subjects had intermolar widths about
0.5 mm narrower than the norms; we presumed that
they would continue to be narrower than the treated
norms at T2 and T3. However, at T2 and T3, the treated
subjects were significantly wider than the norms. Due to
normal growth, Hesby et al49 found only 2.3 mm of
maxillary intermolar width increase in 36 untreated
Class I subjects from ages 7.6 to 12.9 years using differ-
ent landmarks. That finding was consistent with the
norms we used for 8- to 13-year-olds.50 In the long
term, we found a 3.7-mm intermolar width increase
from 8 to 13 year olds in treated PXB patients. Skieller51
showed that the rate of growth at the midpalatal suture
was significantly greater than growth during the fol-
low-up period, indicating that expansion stimulated
growth at the suture. Statistically, we can conclude
that SME altered the maxillary width of PXB patients
from narrow to at least normal in the long term.
As a retrospective study, the level of evidence is lim-
ited, even though appliance distribution appeared to be
unbiased. Furthermore, an untreated PXB control group
is needed to evaluate the potentially altered growth of
PXB patients. But such a study or randomized con-
trolled trial might not be ethical and realistic.
Another limitation was that our sample had a mixed
ethnic makeup, whereas the norms were from white
subjects. Similarly, a direct comparison between RME
and SME is difficult, because a valid study would re-
quire comparable RME and SME treated samples, hav-
ing the same pretreatment condition. Most RME studies
used older patient samples and involved FA in addition
to RME.17,32,37 Our sample included patients with both
unilateral and bilateral PXB. It might be valuable to sep-
arate the 2 types of PXB and quantify the differences, if
any, between these patients. Further comparisons be-
tween subjects in the deciduous, early, and late mixed
dentition might provide useful information.
CONCLUSIONS
Based on this SME study, we concluded the following.
1. For PXB correction, SME has a stability rate of
84%.
American Journal of Orthodontics and Dentofacial Orthopedics
September 2009
2. Haas, hyrax, and quad-helix produce similar
results.
3. No sex effects were observed.
4. Long-term results were improved by early treat-
ment and retainer use.
5. During treatment, the molars tipped about 2.3 ,
and, after removal of the expander, the molars up-
righted about 6 , with not all dental tipping lost in
the long term.
6. Expansion altered the maxillary width of PXB pa-
tients from narrower than the norms at T1 to at least
normal at T2 and T3.
We thank Sue Herring, Rebecca Hubbar, Lindsay
Kennedy, Dr Kennedy’s office staff, Greg Huang, Terry
Wallen, Jessica Lee, and Audrey Isaacson.
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