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Arch expansion

Arch dimensional changes with age
Need for arch expansion
Changes possible with orthodontic/orthopedic
Maxillary expansion
Mandibular expansion
Arch expansion and frequency of extraction
have very close but inverse relationship with
each other.

To Edward Angle and his followers in the early

20th century, extraction was anathema.
In their concept, extraction destroys the
possibility of ideal occlusion or ideal
esthetics, both of which require presence
of all the teeth in any case.

Hence any space required for aligning

dentition was achieved by expansion of
As it became clear that
arches could and did
collapse after
expansion despite
efforts to produce
ideal function,
extraction was
reintroduced in the
1930s in an attempt
to overcome relapse
Why did the first premolar extraction
percentages declined dramatically in the last few

Various long term studies demonstrated not much

difference between extraction and
nonextraction/expansion group regarding
esthetics, stability and occlusion.
In Class I crowding cases,
nonextraction treatment
increases the prominence of
the lips, extraction decreases

For satisfactory esthetics,

some patients require
extraction, some require
nonextraction treatment, and a
considerable group in the
middle could have acceptable
esthetics with either approach.
In the treatment of Class I
crowding, stability probably
is greater with extraction than
nonextraction treatment, but
the difference is not as great
as was believed at the height
of enthusiasm for premolar

As with esthetics, some

patients require extraction for
reasons of stability, some
require nonextraction, and a
large group in the middle could
have satisfactory outcomes
with either approach.
Satisfactory occlusal
function for the great
majority of patients, including
consideration of TMD, has little
to do with the presence or
absence of premolars.

A few patients would require

extraction or nonextraction
treatment for occlusal reasons,
but for almost all, either
approach is satisfactory from
an occlusion point of view.
How much dental arch dimensions can be
permanently changed by orthodontic
treatment ?

If the limits are tightly set by genetic

control, then long-term expansion is
unlikely to be successful.

Hence, tooth size jaw size ratios would be

a major diagnostic criterion.
On the other hand if arch dimensions are greatly
influenced by environment as Angle believed,
then major changes should be possible.

This view has reappeared in recent years

supported by studies that show little genetic
determination of occlusal variations. (Corrucini,
Sharma , Potter, 1986).
It is difficult to know how much change is
possible regarding arch width, but a
strong possibility of arch expansion
certainly encourages attempts of
nonextraction treatment.
Arch width changes with age
There are clinically significant differences
in the magnitude and manner of width
changes in the maxilla and mandible.

Dental arch width increases correlate with

vertical Alveolar process growth, whose
direction is different in the upper than in
the lower arch.
Maxillary alveolar processes diverge while
the mandibular alveolar processes are
more parallel.

As a direct result, maxillary width increases

more than mandibular arch due to vertical
alveolar development , a important clinical
The maxillary permanent cuspids are
placed further distally in the arch than their
primary counterpart and erupt pointing
mesially and labially.

Hence their arrival is another important

factor contributing to expansion of
maxillary dental arch.
The intercanine diameter
increases only slightly in
the mandible, and some
of this increase is the
result of the distal
tipping of the primary
cuspids into the primate
space, since the
mandibular incisors are
not normally moved
labially through time.
Furthermore, dental arch width changes
are closely related to the events of dental
development rather than endocrinally
mediated events of overall skeletal growth
such as the adolescent spurt in stature.
Bicanine width
increments versus
dental age
age. 0 = moment of
arrival of first
permanent incisor.
Need for arch expansion
To correct lateral Malrelationships of
Dental Arches
Failure of the two dental arches to occlude
normally in lateral relationship, known as
lateral or posterior crossbite, may be due
to localized problems of tooth position or
alveolar growth, or to gross disharmony
between maxilla and mandible.
crossbite with good
apical base width
(left) and crossbite
with a deficient apical
base width (right).
Lack of harmony between the maxillary
and mandibular widths usually is due to a
bilateral constriction of maxilla.

In such cases, the muscles shift the

mandible to one side to acquire sufficient
occlusal contact for mastication, causing
unilateral crossbite though the constriction
is bilateral.
Rarely, there may be true unilateral
crossbite due to asymmetric lateral growth
of maxilla e.g in case of hemifacial
A more severe
condition is that in
which the mandibular
denture occludes
completely within the
maxillary arch
When lateral problem is combined with a
skeletal Class II / Class III malocclusion,
lateral discrepancy get exaggerated
because of antero-posterior morphology of
The effect of anteroposterior position of the arches on
buccal overjet is shown when a normal occlusion (B) is
shifted to a Class II molar position (A) that increases
buccal overjet and to a Class III molar position (C) that
decreases buccal overjet.
Dimensional Changes possible
with Orthodontic Therapy

It is relatively simple to increase the

maxillary dental arch width and length, but
difficult to increase and retain the
mandibular dental arch width.
Maxillary expansion

1 Orthopedic: width of underlying basal bone is increased by means of

splitting mid palatal suture.
Orthopedic expansion may be rapid or slow depending on rate of

2. 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.

3. Passive: When the muscle forces (buccal & labial) are shielded away
from the dentition, a widening of dental arches occurs. This
expansion is a result of intrinsic forces produced by tongue.
Ex. F.R. Appliance, Lip Bumper
Rapid maxillary expansion

The problems associated with a narrow maxilla

and the need for expansion has been
recognized since long time.

In 1860, E.C. Angell successfully splitted maxilla

using a jack screw appliance. He is considered
the father of rapid maxillary expansion.
However his work failed to gain popularity in the
orthodontic community.
In 1877, Walter coffin introduced coffin spring for arch
expansion. This spring was believed to cause separation
of the mid palatal suture in young children.

Farrar (1888) and Clark C. Godard (1893) also

discussed the feasibility of lateral expansion with mid
palatal suture opening.

Around beginning of 20th century, ENT surgeons showed

interest in this technique of orthopedic expansion of
EyselL, a rhinologist believed that rapid
expansion could bring about a change in nasal
configuration and airflow.

Wright in 1912 reported a 6.5mm widening of

nasal cavity with rapid maxillary expansion.

During early 1970s, Hass started using rapid

maxillary expansion extensively.
HAAS (1980) evaluated the stability of maxillary
expansion achieved with rapid palatal

He wrote totally stable 4 and 5mm intercanine

expansions in the lower arch many years out of
retention. and upper buccal teeth expanded 9
to 12mm with the expansion remaining
absolutely stable.
Mid palatal suture

Latham (1971) believed that growth at the

midpalatal suture ceases at the age of 3 years.

By means of implants, Bjrk and Skieller (1974)

found that growth at the suture might be occurring
as late as 13 years of age.
Persson and Thilander (1977) in a study on
cadavers found that 5% of the suture was
obliterated by age 25 years, yet the variation was
such that a 15-year-old cadaver had an ossified
suture, while a 27-year-old cadaver had an
unossified suture.

Epker and Wolford (1980) stated, In patients

over the age of 16 years, attempted orthopedic
rapid maxillary expansion is frequently
associated with significant difficulties.
Difficulty is usually the resultant fusion of various
craniofacial sutures, which results in a lack of suture
opening on expansion.
Most important effect is produced by zygomatic buttress
which resist lateral movements of two maxillae.

The optimal age for expansion is, therefore, before 13 to 15

years of age.

Although it may be possible to accomplish expansion in

older patients, the results are neither as predictable nor
as stable.
According to Haas, the following five conditions
are recognized to be primary indications for
1. Transverse maxillary discrepancy resulting in
posterior cross bite.
2. A-P maxillary deficiency cases with negative
ANB that would benefit from maxillary
protraction. In such cases RME is required to
loosen the maxilla.
3. Cleft palate cases with collapsed maxilla.

4. Cases of nasal stenosis characterized by

mouth breathing & constricted nasal

5. Moderate arch length problems in

patients of 14-16 yrs age.
1. Periodontally compromised dentition
2. Single tooth cross bite
3. Ossification of suture is completed
4. Poor patient co-operation

Removable appliance removable plate with jack screw

Fixed appliances:
Fixed tooth & tissue borne appliances
- Derischsweiler type
- Haas type
Fixed tooth borne appliances
- Isaacson type
- Hyrax appliance
Removable plates
These appliances usually consist
of an expansion jack screw with
palatal coverage & claps for
retention of appliance.

They are general advocated

during deciduous / early mixed
dentition to bring about desired
skeletal changes.

Retention during expansion

procedure is difficult as they
easily get dislodged. Patient co-
operation is essential.
Derischsweiler expander
In this type of expansion
device, the screw is
embedded in acrylic which
covers the palatal vault &
alveolar ridges. The first
premolars & molars are
Wire tags soldered to the
palatal aspect of the bands to
facilitate attachment of acrylic.
The acrylic extends to the
palatal aspect of all non
banded teeth except incisors.
Haas expander

The first premolars & first molars are banded.

1.2 mm diameter stainless steel wire is soldered

onto the buccal & palatal surfaces of these bands
connecting the premolar to the molar.

Disadvantage of Hass type expander is pressure

necrosis of palatal mucosa under acrylic
The lingual bar is over
extended anteriorly and
posteriorly and is bent
palatally to aid in
attachment to palatal
A midline screw is
incorporated in the split
acrylic base plate.
The acrylic falls short of Haas type expander
the rugae anteriorly and
lingual gingival areas.

Isaacson type:
This appliance uses a special spring loaded
screw called Minne expander.

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

Disadvantage of minne
expander is poor oral Minne expander
Hyrax appliance.
(hygienic rapid
palatal expander)

A fixed wire appliance

cemented to the first
permanent molars and
first premolars with
centrally located Banded Hyrax
Tooth extrusion, dental tipping, and an
increase in the vertical dimension are
often encountered with expansion

Bonded Hyrax using interocclusal acrylic

may control the vertical dimension and
expand the maxillary halves in a more
bodily and symmetrical fashion.
A. Hyrax appliance design.
B. Bonded Hyrax design.
In one study (Steven Asanza, George J. Cisneros, Lewis
G. Nieberg. 1997) , the results suggest that :
1. The bonded RME appliance displayed less inferior
movement of the posterior aspect of the palate as
measured by SN-PNS in mm.
2. The bonded appliance showed less anterior
displacement of the maxilla than the Hyrax appliance as
measured by S-A pt. in mm.
3. The Hyrax appliance showed a greater increase in
vertical facial height as measured by ANS-Me in mm.
4. Both appliances resulted in tipping of the posterior teeth,
which was highly variable and asymmetric.
Expansion screw
A typical screw consists of an oblong body
divided into two halves, each half has a threaded
inner side to receive one end of a double ended
The screw has a central bossing that has four
holes. These holes receive a key to activate the
A single adjustment of the screw brings about
1/4 revolution causing 0.18mm linear

Zimring & Isaacson:

In young growing patients, two turns each day for 4-5 days and later
one turn per day till desired expansion is achieved.

In adults (non growing patients) two turns each day for first two
days, one turn per day for the next 5-7 days and one turn every
other day till desired expansion is achieved.

1. Up to 15 yrs : 90 rotation once in the morning & once in the

2. 15-20 yrs : 45 activation 4 times a day

Period of retention:
The objective is to maintain the expansion
achieved while all forces generated during the
procedure have decayed.
Hass : Recommends 2 yrs of full time retention
followed by 1/1/2 - 2 years of part time retention.

Isaacson :Use RME appliance for retention. The

screw is immobilized with acrylic.
Chaconas and Caputo (1982) compared these
expansion appliances with respect to force
delivered and change in width of appliance.

The Haas and Hyrax appliances delivered very

high orthopedic forces that were similar.
The removable appliance, when fully and
firmly seated, delivered the highest force
of all appliances tested.

When unstable, however, the removable

appliance was only capable of much lower
forces, similar to those of the Minne-
Pattern of stresses produced during
Stresses produced by
appliances are
concentrated in the
anterior and posterior
regions of the palate.
Darker shading represents
areas of higher stress.
Stresses radiate from
the junction of the
palatine bones to
deeper structures via
the perpendicular
plates of the palatine
Darker shading represents
areas of higher stress.
Stresses radiate from
the maxillary
tuberosity to the base
of the medial
pterygoid plate.
Darker shading represents
areas of higher stress.
Concentration of
stresses at the
Darker shading represents
areas of higher stress.
Concentration of
stresses at the
junction of the nasal
and lacrymal bones.
Darker shading represents
areas of higher stress.
Displacement of various structures
during RME
Movement of Maxillary teeth
Anteriors : Appearance of space between
the maxillary central incisors is the earliest
clinical evidence that midpalatal split is

It is estimated that the incisors separate

approximately half the distance the screw
is opened (Haas).
Clinical features

X-ray picture before expansion, after

expansion, and three months later.

Initial bending of alveolar process & compression

of periodontal ligament is accompanied by
change in long axis of posterior teeth (buccal

This is also partly due to the tipping of teeth in

the alveolar bone and partly because of
extrusion of maxillary posteriors.
Direction of palatal split

In the frontal view, the suture separates in a

triangular fashion with base towards the oral
cavity & apex towards nasal cavity.

From occlusal view, the split occurs in a wedge

shaped manner with maxilla opening anteriorly.
This resembles the opening of a fan evident on
an occlusal radiograph.
A. Triangular pattern of maxillary expansion in
the frontal plane includes orthopedic and
orthodontic movement. Orthopedic changes
may involve separation at sutural sites with a
lateral rotation or tipping of the palatal
halves, widening of the nasal processes, and
subsequent bony remodeling. Orthodontic
changes may involve lateral tipping and
bodily translation of maxillary teeth, transient
midline diastema, and mild expansion of
mandibular teeth.

B, Occlusal view of maxillary expansion

illustrating midpalatal suture opening with
greatest separation occurring anteriorly,
lateral rotation of palatal halves, bony
remodeling of maxillary elements, and
lateral/rotational movement of the maxillary
Effect on alveolar bone

The alveolar process being resilient, RME forces

initially leads to its lateral bending. This is due to
the arcing of the bones themselves and some
amount of lateral tipping of teeth.

Walters, however contradicted these findings and

reported a lateral & upward rotation of the maxilla
Effect on Palatal vault

Haas & Krebs reported lowering of the palatine

process due to outward tilting of the alveolar
This contributes partly in straightening of DNS
(Korkhaus), widening of nasal floor & flattening of
palatal vault.
Effect on palatal mucoperiosteum &
PDL tissues.

As the maxillary halves separate, the

palatal mucoperiosteum is stretched.
During the post-expansion period, recoil of
the stretched fibers causes a decrease in
the inter-molar angulation.
Surgically Assisted Rapid Palatal

Surgically assisted palatal expansion is an

method of reducing the resistance of
ossified midpalatal suture to facilitate
expansion by mechanical procedures.
Surgical Procedure
A paramedian incision is made under local
After the mucoperiosteum is released,
midpalatal suture is separated with a
midline cut, about 3mm deep but not
reaching the foramen incisivum.
The mucosal and bony cuts should not
Surgical procedure:
Mucosal (solid
line) and bony
(dashed line) cuts
on palate (A) and
lateral maxillary
buttress (B).
Two bony cuts each about 4mm long, are
then made on each side of the lateral
maxillary buttress above the root apices
and parallel to the occlusal plane.
After the osteotomy, the maxillary segments are not fully
detached, but can be separated by rapid expansion with
a jackscrew appliance.

The expansion appliance should be cemented in place

before surgery and activated three or four quarter-turns
by the surgeon after the bony cuts are made.

The rest of the expansion is achieved in daily increments

for about two weeks after surgery. Overcorrection of
about 2.5mm per side (5mm total) is usually advisable.
Modular Palatal Disjunctor Appliance
(Jean-luc pruvost, 1989)

Development of a modular, easily

removable palatal expander was
prompted by the need for increased
precision and working comfort during
maxillary surgery.
The appliance is made of cast, etchable
nickel chromium, which has a high
resistance to breakage and torsion.

The three parts of the appliance can be

joined by Allen screws.
Rapid Maxillary Expansion in Cleft Lip
and Palate Patients

Because of their tendency toward skeletal

segmental collapse, bilateral complete cleft lip
and palate patients often require rapid maxillary

As in normal individuals, the pattern of

expansion is triangular with a greater opening in
the anterior region
In cleft patients, however, the separation
occurs in the suture between the maxilla
and the premaxilla, with no osseous gain.

The increase in maxillary arch width and

the orthopedic effect can correct the
transverse maxillomandibular relationship.
In growing cleft palate individuals, the
opening of the sutures can displace the
maxilla forward and downward, opening
the bite and moving Point A anteriorly.

In most instances, however, these effects

are only temporary.
Activation schedule in cleft patients

The appliance is first activated with four quarter-turns 24

hours after placement.

For the next four days, the screw is activated two quarter-
turns in the morning and two quarter-turns in the

At this point, the orthopedic force should be sufficient,

and activation can be reduced to a more comfortable
one quarter-turn in the morning and one in the evening.
The average activation period is from one
to two weeks, depending on the degree of
maxillary constriction and the resistance of
the patient's maxillofacial structures.

A 2-3mm overcorrection at the molars is

recommended to counteract a relapse that
has been reported to reach 30-50%, or
even 75% at the canines.
A. Upper arch before expansion. B. Haas-
type expander in place.
After full expansion
Once the desired expansion is obtained, the
screw is immobilized by acrylic.

The appliance is kept in place for three months

of retention, which further reduces the possibility
of relapse.

The expander is then removed, and impressions

are taken.
A removable palatal plate, without clasps
that might interfere with any remaining
orthodontic movement or with proper
tongue position, is worn as a retainer until
the end of treatment.
Nickel Titanium Expander
Unlike normal patients, one has to be very
careful regarding force level in cleft patients.

A tandem-loop, nickel titanium, temperature-

activated palatal expander with the ability to
produce light, continuous pressure is very useful
tool for arch expansion in cleft patients.
A Degree of
compression when
prototype appliance
was chilled to 20
below transition
B. Effect of shape
memory when
appliance was
warmed to body
This fixed-removable appliance has
adjustable stainless steel extensions and
is inserted into standard horizontal lingual
sheaths that are spot-welded to the molar

A locking indent on the lingual attachment

securely fastens the expander to the molar
band to ensure patient safety.
A. Passive appliance.
B. Initial activation and
insertion for
expansion and distal
molar rotation.
C. After expansion and
rotation correction.
Initially, RME was believed to cause more
skeletal than dental expansion.
However, when the expansion is
completed and bone is filling in the defect,
orthodontic tooth movement continues
causing skeletal relapse.
Hence although total expansion is
maintained, the % due to tooth movement
increases & skeletal expansion decreases.
With slow expansion, the total expansion is
half dental/half skeletal from beginning.
The final outcome of rapid versus slow
expansion at 10weeks is similar.
The rate of expansion in slow expansion is
1 mm per week compared to about 1 mm
per day with RME.

Slow expansion is achieved by activating a

spring to give 2-4 Ibs of force in contrast to
about 10 lbs force with RME.
Quad-helix or W expansion appliance was
popularized by Ricketts. Depending on age of
patient, quad helix can produce dento-skeletal
(SME) or dental effects.

It is fabricated from .040" blue Elgiloy wire and is

either soldered to the upper first molar or bent to
fit into a lingual sheath. The lingual arm of the
appliance extends to the premolar or cuspid.
The posterior helix is
beveled slightly to lay
against the palatal vault
and is as close to the
upper molar as possible
to prevent impingement
on the palatopharyngeus
The anterior helices are
brought as far forward as
The anterior segment of the W expansion
should be as wide as possible so that the
appliance is maintained away from the
swallowing position of the tongue.

All of the helices should roll to the top and

should be tightly wound to increase their
mechanical efficiency
Initial activation of quad-helix appliance
during insertion.

In Class II cases, most of

the arch form change
should occur in the
anterior portion of the
buccal segments.

As the upper molars are

expanded approximately
1cm per side, the anterior
segments are expanded
approximately 3cm
Intra-oral activation of quad-
helix appliance.

When an intraoral bend is

made in the anterior segment
to increase the amount of
overall expansion, a reciprocal
bend must be made in the
posterior section in order to
compensate for the tendency
for mesial rotation of the upper

Therefore, three intraoral

adjustment bends are usually
made at each activation.
Modifications of the quad-helix
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

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
Coffin spring (Walter
coffin 1877)
Removable appliance
incorporating omega shaped

The appliance is retained by

means of Adam's clasps. The
free ends of the spring as well
as retentive arms of clasps are

Activation is done by using

three pliers.
Porter lingual archwire.

This appliance is usually used for

correction of posterior crossbite in the
primary dentition.
Mandibular expansion
Historical background

Lack of adequate space in the mandibular

arch is often a critical factor in the decision
of whether to extract teeth or not.

In this regard, expansion of the

mandibular arch has gained interest in
non-extraction treatment
Reidel (1952) stated that arch form,
particularly in the mandibular arch, could
not be altered by appliance therapy.
Intercanine and intermolar widths
tend to decrease during the post-retention
period, especially when expanded during
In one study (Housley, Dale, Ram S.
Nanda, Frans Currier, 2003), only 8% of
the arch width increase at the canines was
maintained after retention, but, at the
premolars and the first molars area, about
60% to 70% of the expansion remained
Haas (1970), using a midpalatal suture-
opening appliance without any treatment
in the lower arch, observed that the
mandibular arch tended to follow the
maxillary teeth by tipping laterally.
He claimed that mandibular intercanine
width can be increased in the non growing
individuals if the apical base of the
maxillary complex is permanently
According to Sandstrom, Klapper, and
Papaconst (1998), this stability of the
expanded mandibular arch width may be
the result of an altered muscular balance
exerted on the dentition by the buccinator
muscles, which have been carried laterally
by the maxillary expansion.
Gardner (1978) has shown that the
cuspids are the greatest limiting factor in
arch expansion, but the very adjacent
tooth i.e first premolars offered great
opportunity for expansion regarding
Lestrel (1978) proposed a formula determining the ideal
dimension of the lower arch at the distal contact of the
The formula is as follows:
incisor mass: sum of mesio-distal
diameters of the four lower incisors
mandibular width: the distance between
the left and right antegonial notches.
Frankfort mandibular plane angle.
facial angle: Angle between facial plane
and Frankfort plane.
The formula shows that a patient with a
brachyfacial pattern (wide mandible + low
mandibular plane angle) will have a wider
mandibular arch than the dolichofacial
pattern (narrow mandible and a high
mandibular plane angle)
Therefore under certain circumstances,
expansion of lower arch is possible.

Till recently before the introduction of

distraction osteogenesis technique, it was
impossible to widen mandibular basal
Mandibular expansion appliances
Mandibular Schwarz appliance

The original mandibular Schwarz appliance

retained with ball end clasp is effective in
dentoalveolar expansion, but often
retention is problem.
Traditional mandibular
Schwarz appliance
with ball clasps for
Whether Adams clasps, C clasps, or ball
clasps are used as the primary method of
retention, the appliance is unstable
because the clasps do not fit well in the
undercuts of the lower deciduous molars.
Warren Hamula (1993)
modified Mandibular
Schwarz Appliance to
increase both
retention and strength
of appliance by
means of wire
reinforment. Posterior framework of .028"
round wire.
Modified mandibular
Schwarz appliance.
Buccal Shield Appliances for Mandibular Arch

- The lip bumper

- Frankel's buccal shields

These appliances are most effective for increasing the

arch width during the eruptive phase of dentition.
Lip bumpers

The lip bumpers are made

of malleable, 0.040"
stainless steel wire with
posterior adjustment
bends to allow

About 3mm of clearance is

recommended between
the bumper and the teeth
to allow proper lip contact
with minimum discomfort.
A.Displacement of buccal
mucosa by typical lip

B,C. Buccal mucosa may

roll over or under wire,
preventing arch
expansion by contacting

Hence for arch

expansion, vestibular
appliances are better
This problem of limited shielding effect by
lip bumper wire does not happen with
buccal shields of Frankel appliance.
The functional matrix and
the Frnkel appliance
OO, Obicularis oris.
B, Buccinator.
PMR, Pterygomandibular raphe.
SPC, Superior pharyngis constrictor.
LP, Labial pad.
VS, Vestibular shield.

The functional regulator provides a

larger functional matrix than the
teeth. The buccinator mechanism will
grow and adapt to whichever
functional matrix (soft-tissue capsule)
is present in the mouth.

This adaptation occurs primarily

during growth. After growth is
complete, very little, if any, change
can be expected.
Schematic view of the influence of vestibular
shields on eruptive path and dentoalveolar

Dense stippling shows

alveolar apposition
prompted by the
vestibular shield, whereas
lighter stippling shows the
more lateral position of
the permanent tooth.
The vestibular shield
creates tension at the
depth of the mucobuccal
fold in a lateral direction.
This tension is directed at
influencing the erupting
permanent teeth to erupt
further laterally than
normal, thereby resulting
in arch expansion.

Notice that less

influence is seen on
fully erupted teeth, as
shown by the open
Distraction osteogenesis

Distraction osteogenesis (DO), originally

developed by Russian orthopedic surgeon
Ilizarov, has produced significant results in limb

Mandibular symphyseal DO introduced by

Guerrero, provided a new paradigm for
increasing transverse dimension of mandible,
which once thought to be impossible.
Distraction protocol

A latency period is critical for DO. Without

allowing time for a callus to form, callus
manipulation cannot occur.

Without a good callus, the quality of the

regenerate bone can be adversely affected,
possibly creating bone of poor quality and other
The latency period is typically seven days.

In young children, healing is accelerated,

and may require a shorter latency period.

Older patients may require a slightly

increased latency period because of a
slower rate of healing.
The rhythm of distraction refers to the
number of increments required to reach
the preplanned daily rate of distraction.
The rate of 1mm/day can be performed all
at once or in various smaller increments.

A clinically efficient rhythm has been 0.25

mm four times a day or 0.50 mm twice a
Post DO retention
A fixed lower canine-to-canine wire will
adequately maintain the canine width and
anterior alignment, but cannot be expected to
aid in maintaining any posterior expansion.

Consequently, a Hawley retainer with integral

lingual support wire is a good form of mandibular
There is clear reversal swing of pendulum
towards non extraction treatment modality.

Most of the borderline cases which once

were considered for extraction are now
being attempted through non extraction
approach with required space being
provided by arch expansion.