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This paper describes four decades of research carried out at the University of
Michigan that has investigated the clinical alteration of the transverse
dimension of the face, with specific attention given to orthodontic and ortho-
pedic treatment of patients in the early mixed dentition. The results of a
series of clinical studies beginning in the late 1970s are described that con-
sider the etiology of dental crowding as well as treatment effects produced
by expansion in the late mixed/early permanent dentition and the early
mixed dentition. A treatment protocol for early treatment is described that
includes the lower Schwarz appliance, a bonded acrylic splint expander and
the placement of anterior brackets. A series of retrospective and prospective
studies are presented, including a study investigating the spontaneous
improvement of Class II malocclusion following increases in the transverse
dimension. The effect of maintaining or increasing anterior arch length on
subsequent mandibular second molar eruption is evaluated. The ideal timing
for rapid maxillary expansion is before puberty. An individual assessment of
the midpalatal suture using cone-beam computed tomography (CBCT) images
can be useful when making a clinical decision between conventional and sur-
gically assisted RME, especially for adolescent and young adult patients.
(Semin Orthod 2019; &:1–13) © 2019 Elsevier Inc. All rights reserved.
he focus of this paper is the alteration of the combined with a bonded expander,2 facilitating
T transverse dimension in patients treated at
various stages of dental development, with
the eruption of impacted canines or incisors,3,4
encouraging spontaneous sagittal improvement
emphasis on intervention in the early mixed den- of Class II malocclusion,5 “broadening the
tition. Expansion treatment can be undertaken smile,”6 and enlarging the nasal airway.7
for a variety of reasons, including correcting pos- A major reason why expansion protocols initially
terior and/or anterior crossbite and increasing were of interest clinically was in the correction of
available arch space to avoid extraction.1 Other unilateral or bilateral posterior crossbite by divid-
major goals for using this approach include cor- ing the two parts of the maxilla orthopedically.8 A
recting Class III malocclusions with a facial mask less obvious but far more frequently observed
orthodontic problem related in part to the trans-
Department of Orthodontics and Pediatric Dentistry, School of verse dimension is the discrepancy between tooth
Dentistry, Department of Cell and Developmental Biology, School of size and the sizes of their bony bases. The most fre-
Medicine and Center for Human Growth and Development, The Uni- quently observed type of malocclusion in routine
versity of Michigan, Ann Arbor, MI, USA; Department of Experimen-
orthodontic practice is dental crowding, an under-
tal and Clinical Medicine, Section of Dentistry (Orthodontics), The
University of Florence, Florence, Italy; Department of Orthodontics lying imbalance between aggregate tooth size and
and Pediatric Dentistry, School of Dentistry, The University of Michi- available bony arch perimeter. This relationship
gan, Ann Arbor, MI, USA; Department of Orthodontics, The Univer- occasionally may be expressed not as crowding but
sity of Michigan, Private practice of orthodontics, Ann Arbor, MI, as protrusion and flaring of the teeth relative to
USA.
their associated basal bone, particularly in the max-
Corresponding author. E-mail: mcnamara@umich.edu
illary incisor region.
© 2019 Elsevier Inc. All rights reserved.
1073-8746/12/1801-$30.00/0 Preparing such a paper for publication in a
https://doi.org/10.1053/j.sodo.2019.02.002 themed issue of Seminars in Orthodontics has
2 McNamara et al
allowed us to write an overview of our research uprighting of the lower posterior teeth. The
dealing with expansion that has been conducted forces produced by the adjacent soft tissues are
over the last four decades. Our research projects kept away from the developing dentition, allowing
have been undertaken in association with many for the passive widening and uprighting of these
investigators, including colleagues at the Univer- teeth, especially in the maxilla.
sity of Florence in Italy and Guarulhos University The clinical results of FR treatment were
in Guarulhos, Brazil, as well as with many former observed first hand by the lead author in 1975
orthodontic residents at the University of Michi- and again in 1979 when he visited Fr€ankel’s
gan who typically are listed as the lead author on clinic in what was then the German Democratic
the projects that they conducted. Republic (East Germany). Observing an esti-
The ideas emerging from our initial clinical mated 75 patients over the two visits and measur-
experiences in a private practice setting have led ing available serial dental casts indicated that
us to ask series of questions that range from the stable expansion of the dental arches was possi-
etiology of dental crowding to the treatment ble over the long-term.10 Subsequently, after con-
effects produced following expansion in the ducting two clinical studies of our own FR
mixed dentition by way of a bonded acrylic splint patients,11,12 and with the simultaneous introduc-
expander, with or without prior orthodontic tion of rapid maxillary expansion as a routine
expansion with a removable lower Schwarz appli- clinical procedure,8,13 we began to explore the
ance. Further investigations led to the examina- possibility of orthodontic and orthopedic expan-
tion of spontaneous improvement of Class II sion in growing individuals, focusing on the
malocclusion during the post-expansion period short-term and long-term stability of expanded
when the patient was wearing a removable palatal dental arches.
plate to stabilize the treatment results achieved.
We also investigated whether the eruption of the
Etiology of dental crowding
second molar is affected using a lower lingual
arch, a lower Schwarz appliance, or both during Before initiating a discussion of the treatment
the transition to the permanent dentition. effects produced by expansion treatment, we
Overall, we estimate that at least 2500 patients asked a fundamental question as to the etiology of
have been treated in our Ann Arbor practice the underlying tooth-size/arch-size relationship.
using our mixed dentition protocol that involves Is crowding caused by teeth that are too big,
a lower Schwarz expander (40% of patients), a arches that are too small, or some combination of
bonded acrylic splint expander (100% of the two? One would assume that the last answer is
patients) and “temporary braces” on the maxil- correct, but surprisingly in most instances it is not.
lary incisors (65% of patients); these are real In one of the first clinical investigations by our
numbers based on a census of our patient popu- research group, Howe and co-workers14 com-
lation. We have collected records prospectively pared pretreatment dental casts of 50 patients
on all early-expansion patients treated in the with erupted permanent second molars and
Ann Arbor practice beginning in 1982. Thus, our severe crowding to the dental casts of 54
comments in this paper are based both on our untreated individuals from the University of Michi-
clinical studies and our hands-on experiences. gan Growth Study15 who were classified as having
ideal or near-ideal occlusions. The study evalu-
ated both the sizes of the teeth and the dimen-
Passive expansion with vestibular shields
sions of the bony bases.
Our first exposure to expansion during orthodon-
tic treatment other than that produced by fixed
Tooth size
appliances was the passive expansion of the dental
arches that occurs with Function Regulator (FR) In the first part of our study, individual tooth
therapy developed by Rolf Fr€ankel.9 The unique sizes were considered; the results were surprising.
vestibular shields of the FR appliance are con- In no instance was there a statistically significant
structed so that the shields are fabricated 3 mm difference between the size of any given tooth
away from the maxillary mucosa, allowing passive when the crowded and uncrowded dental arches
expansion of the dental arches as well as were compared. The mesiodistal sums of the
ARTICLE IN PRESS
teeth in both arches then were determined, as available in the crowded individuals in compari-
measured around the dental arches from the dis- son to the normal occlusion group.
tal of the first molar to its antimere. Even though The conclusion that can be drawn from the
there was a slight tendency (»1 mm) toward findings of this 1983 study14 is that a decreased
larger teeth in the crowded cases, there was no size of the bony bases, rather than large aggre-
statistical difference in aggregate tooth size in gate tooth size is the primary factor in dental
either arch between the two samples.14 Thus, crowding. Therefore, expansion of the dental
increased tooth size typically was not the cause of arches, particularly in the early mixed dentition,
the crowding, although there were some individ- may be indicated in individuals with tooth-size/
uals with larger than normal tooth size in the arch size discrepancies.
crowded group.
A relatively simple clinical guideline that we
Expansion in the late mixed/early
developed subsequently is based on the measure-
permanent dentition
ment of one permanent maxillary central incisor.
If the upper central is wider than 10 .0mm, then Before beginning a discussion of treatment
the teeth of the patient may be considered larger effects produced by expansion in the early mixed
than normal. The average mesiodistal diameter dentition, it is appropriate to present data from a
of the maxillary central incisors in Caucasian study published by our group in 2003 that
males and females is 8.9 § 0.6 mm and involved patients treated with a Haas-type
8.7 § 0.6 mm, respectively.15 A central incisor expander followed by comprehensive edgewise
width greater than 10 mm is two standard devia- orthodontics in patients in the late mixed or
tions larger than the norm; the possibility of early permanent dentition.16 This unique treated
tooth extraction should be considered in these group consisted of 112 subjects, all of whom were
patients. from the private practice of Drs. Robert and
Thomas Herberger of Elyria, Ohio, and who
were treated according to the RME protocol
developed by Dr. Andrew Haas.8 These records
Size of the bony bases
were compared to those of 41 untreated subjects
Significant differences were observed between from the University of Michigan Growth Study and
the arch dimension of the crowded and the University of Groningen Growth Study.
uncrowded subjects. The crowded group had
smaller dental arch dimension, especially in
Dental changes
transpalatal widths and arch perimeter. For
example, transpalatal width measured between Serial dental casts were available at three differ-
the maxillary first molars was 37.4 mm in males ent intervals: pre-treatment (T1), after expansion
and 36.2 mm in females in the uncrowded sam- and fixed appliance therapy (T2), and at long-
ple.14 In contrast, the same measurement in the term observation (T3). The mean duration of
crowded group was 31.3 mm in males and the T1T2 and T2T3 periods for the treatment
30.8 mm in females. Thus, the differences group was 3 years 2 months, and 6 years 1 month,
between the two groups was on average 56 mm respectively, with the last observation interval at
in the transverse dimension, indicating that 20 years of age.
decreased transpalatal width was a characteristic Treatment by means of a Haas-type expander
of dental crowding. followed by fixed appliances produced signifi-
Significant differences were found in arch cantly favorable long-term changes in almost all
perimeter measurements as well. In the non- the maxillary and mandibular arch measure-
crowded group, the average mandibular arch ments. In comparison to controls, a net gain of
perimeter was 88.1 mm in males and 84.6 mm in 6.0 mm was achieved in the maxillary arch perim-
females.14 In contrast, in the crowded group, the eter, whereas a net gain of 4.5 mm was found for
same measurement in males was 83.7 mm in the mandibular arch perimeter of treated sub-
males and 79.6 mm in females, indication not jects in the long term (about 20 years of age).
only the presence of sexual dimorphism but also The net gain was determined by taking the
that there was at least 4.5 mm less arch perimeter increase in each arch dimension of the RME
ARTICLE IN PRESS
4 McNamara et al
group and subtracting the gain or loss of the without detrimental effects on the vertical skele-
untreated group.16 Thus, at least in the samples tal relationships. Thus, an increased mandibular
studied, clinically meaningful increases in arch plane angle is not a contraindication to RME
width and perimeter were observed in the therapy.
treated group in comparison to what occurred in
the untreated sample.
Expansion in the early mixed dentition
Skeletal changes Early treatment protocol
A companion lateral cephalometric study of the Since 1982, we have used the following protocol
long-term cephalometric effects of a subgroup of in the management of early mixed dentition
patients treated with the same protocol17 revealed patients with crossbites and tooth-size/arch-size
that RME therapy used in the treatment of Class I discrepancies. The essential appliance is the
and Class II patients does not have a significant bonded acrylic splint expander2 (Fig. 1) that is
long-term effect on either the vertical or the ante- made from 3 mm Splint BiocrylTM , softened and
roposterior skeletal dimensions of the face when pressed on a stainless-steel wire framework using
compared to a matched group of patients treated a thermal-forming machine (BiostarTM ; Great
with fixed appliances alone or to untreated con- Lakes Orthodontic Products, Tonawanda NY).
trols. For example, there was no opening of the Substituting cold-cure acrylic for Splint BiocrylTM
mandibular plane angle and no forward or back- is not recommended because the former type of
ward movement of Point A over the long term. acrylic is too rigid, making bonded expander
Further, a related posteroanterior cephalometric removal difficult.
study on the same patient sample18 demonstrated Surprisingly, our protocol has not changed
the long-term stability of the skeletal correction in much over the years, except for the addition of
the transverse dimension, when the expanded the lower Schwarz appliance in 1986. We still use
patients were »20 years of age. ExcelTM adhesive (Reliance Orthodontic Prod-
A much larger cephalometric study on a ucts, Itasca, IL), a material specifically designed
larger Herberger sample by Lineberger et al.19 to bond large acrylic appliances with adequate
was performed to evaluate the skeletal and den- working time. The bonded expander is activated
tal changes in the short and long-term in hyper- once-per-day for 28 days; then the number of
divergent patients treated with rapid maxillary turns remaining is determined by the orthodon-
expansion (RME) and fixed appliances. The tist. After the completion of expansion, the appli-
sample consisted of 143 patients who underwent ance is left in place for 5 additional months to
RME with a Haas-type expander followed by
edgewise therapy. Two groups were established:
a normal vertical dimension group (mandibular
plane angle [MPA] greater than 20° and smaller
than 27°; N = 52) and a hyperdivergent group
(MPA equal to or greater than 27°, N = 91). Lat-
eral cephalograms were taken before treatment
(T1, average age 11.5 years in both groups) and
after fixed appliance therapy (T2, average age
14.3 years for the two groups).
No significant differences in treatment effects
(T2T1) were found in any of the sagittal or ver-
tical dentoskeletal variables examined. The long-
term evaluation of the patients at five or more
years post-treatment (T3T2) showed no signifi-
cant skeletal changes. The results of this retro-
Figure 1. Bonded acrylic splint expander that is made
spective study indicate that rapid maxillary from 3 mm thick Splint Biocryl. Brackets also have been
expansion can be carried out successfully in placed on the maxillary incisors for alignment. Copy-
patients with increased vertical dimension right Needham Press, used with permission.
ARTICLE IN PRESS
6 McNamara et al
patients were compared with those of 41 Treatment by way of an acrylic splint RME
untreated controls at three different intervals: alone and in combination with a lower Schwarz
pre-treatment (T1), after expansion and fixed appliance followed by fixed appliances produced
appliance therapy (T2), and at long-term obser- significant long-term increases in maxillary arch
vation (T3). The mean ages for treatment group widths over controls. The use of the lower
were 8 years 10 months at T1, 13 years 10 months Schwarz expander prior to RME led to signifi-
at T2, and 19 years 9 months at T3. cantly more favorable results when compared to
Treatment by means of an acrylic splint the RME-only protocol: Significantly greater
expander followed by a second phase with full increase in the transverse width of the lower arch
fixed appliances produced significantly favorable and in mandibular arch perimeter occurred as
long-term changes in almost all the maxillary and did an uprighting of the lower posterior teeth
mandibular arch measurements.22 The amount buccally, thus allowing for an amount of maxil-
of change in both maxillary and mandibular inter- lary expansion that was effective clinically for cor-
molar and intercanine widths fully corrected the recting tooth-size/arch-size discrepancies of a
initial discrepancies. Approximately 4 mm of moderate amount.
long-term relative increase in maxillary arch During the overall observation interval, the
perimeter, and 2.5 mm additional maintenance significant increases in maxillary and mandibular
of mandibular arch perimeter were observed in arch perimeters in the RME-Sz group were
patients when compared to untreated subjects respectively 3.8 mm and 3.7 mm when compared
(Note: It should be remembered that these with the matched control group.18 The RME-
patients were judged not to need active expansion only protocol produced modest long-term
of the lower dental arch at the beginning of treat- increases in maxillary arch perimeter (2.6 mm);
ment). These results suggest that this treatment the average long-term increase in mandibular
protocol is effective and stable for the manage- arch perimeter (2.0 mm) in the RME-only group
ment of constricted maxillary arches, while it can was not statistically significant.
relieve modest deficiencies in arch perimeter.
Spontaneous improvement of Class II
Schwarz/RME combination relationships
In about 40% of patients undergoing early ortho- The major focus of the discussion thus far has
pedic expansion, we choose to expand the lower been the resolution of tooth-size/arch-size dis-
arch orthodontically prior to RME because of crepancy problems. There is another phenome-
anterior crowding and/or lingually-inclined non, however, that has been a serendipitous
lower posterior teeth (RME-Sz group). The lower finding, that being the so-called “spontaneous
Schwarz appliance is activated once per week in improvement” of Class II malocclusions in
an effort to create a modest amount of arch patients with maxillary constriction, perhaps as a
length anteriorly and upright the lower posterior manifestation of “maxillary deficiency syn-
dentition prior to RME.1 drome.”24 A most interesting (and somewhat sur-
O’Grady and co-workers23 considered two prising) observation following our initial efforts to
groups of patients, one treated with RME alone expand Class II patients in the early mixed denti-
and one with the Schwarz/RME sequence. Both tion was the occurrence of a spontaneous
groups were matched longitudinally to untreated improvement of the Class II malocclusion during
controls. The dental casts of 27 RME-only patients the retention period. Such patients either had an
were compared with those of 23 RME-Schwarz end-to-end or full cusp Class II molar relationship
patients and with those of 16 untreated controls at the start of treatment. Generally, these patients
with constricted maxillary arches at four different did not have severe skeletal imbalances, but typi-
intervals: pre-treatment (T1), after expansion/ cally were characterized clinically as having either
before fixed appliance therapy (T2), after fixed mild-to-moderate mandibular skeletal retrusion
appliance therapy (T3), and at long-term observa- or an orthognathic facial profile.
tion (T4). The mean ages for the treated groups As per our protocol, these patients inten-
were approximately 9 years at T1, 12 years at T2, tionally were overexpanded slightly (with a ten-
14 years at T3, and 20 years of age at T4. dency toward a buccal crossbite) relative to the
ARTICLE IN PRESS
8 McNamara et al
lower arch, with only the lingual cusps of the Phase II treatment cephalogram (T2) taken
upper posterior teeth contacting the buccal 3.7 years later. The control sample, derived
cusps of the lower posterior teeth. Following from the records of three longitudinal growth
expander removal, a maxillary maintenance studies mentioned earlier, consisted of the
plate (Fig. 5) was used for stabilization. Six to 12 cephalometric records of fifty Class II individu-
months later, the tendency toward a buccal cross- als (28 males; 22 females). The mean age of ini-
bite often disappeared, and some of the patients tial observation for the control group was
now had a solid Class I occlusal relationship. It 8.9 years, and the mean interval of observation
should be noted that the shift in molar relation- was 3.9 years. All subjects in both groups were
ship in these patients typically occurred before pre-pubertal at T1 and showed comparable prev-
the transition from the lower second deciduous alence rates for pre-pubertal or post-pubertal
molars to the lower second premolars, the point stages at T2.
at which an improvement in Angle classification The treatment group demonstrated slight but
sometimes occurs in untreated subjects due to statistically significant increases in mandibular
the forward movement of the permanent lower length and a slight advancement of pogonion rel-
first molars into the leeway space. ative to the nasion perpendicular. The acrylic
We addressed the concept of the spontaneous splint RME had significant effects on the antero-
improvement of Class II malocclusion by conduct- posterior relationship of the maxilla and mandi-
ing two related investigations.5,25 From an initial ble, as shown by the improvements toward Class
sample of 1137 consecutively-treated patients I in the maxillomandibular differential value, the
from our private practice, McNamara and col- Wits appraisal value, and the ANB angle.
leagues assembled the cephalometric records of Patients treated with the bonded RME showed
500 patients who had undergone acrylic splint the greatest effects of therapy at the occlusal level,
RME therapy during the early mixed dentition.25 demonstrating highly significant improvement of
Cephalometric films were available at the begin- Class II molar relationship and a decrease in over-
ning of treatment (T1) and at the beginning of jet (Fig. 6). The change in sagittal molar relation-
Phase II (T2). For comparison, we used records ship between Time 1 (initial) and Time 2 (pre-
from 188 untreated subjects from the Michigan, Phase II) as observed cephalometrically was com-
Bolton-Brush, and Denver Child Growth Studies, pared to the same measurement in the untreated
on whom longitudinal cephalometric films were Class II sample. During the 4-year treatment/
available at the same time points. This study observation interval, the average change in the
included both Class I and Class II patients. Due to untreated group was 0.0 § 0.8 mm. In contrast,
the length of the above article, results of this study the average movement toward Class I was
will be not discussed here. 1.8 § 1.0 mm in the expander group.
From the above data base, we narrowed the Looking at the comparison between the two
focus of a second study,5 which was a prospective groups in more detail (Fig. 6), 18% of the con-
clinical investigation conducted by Guest and co- trols had a negative change toward Class II, while
workers that focused only on patients who had none of the Class II treated worsened (¡1 mm or
Class II malocclusion. These patients were com- more negative). The molar relationship of 62%
pared to a matched untreated Class II control of the control sample did not change, while only
group. 8% of the treated sample remained unchanged.
The treatment sample consisted of fifty Molar relationship improved slightly (maximum
patients with Class II malocclusion (19 males, 31 1.5 mm) in 20% of the controls, whereas the
females) treated with the rapid maxillary expan- molar relationship improved in 92% of the
sion (RME) protocol described earlier. Some treated Class II sample. Further, a change in
patients had a removable lower Schwarz appli- molar relationship toward Class I of 2 mm or
ance and/or maxillary incisor bracketing as greater was not observed in the controls, while
part of their treatment protocol. Post-expan- 48% of the treated group had at least 2 mm
sion, the patients were stabilized with a remov- (maximum 4 mm). Treatment with the acrylic
able maintenance plate and/or a transpalatal splint RME had no sustainable effects on the skel-
arch. The mean age at the start of treatment of etal vertical dimension, maxillary skeletal posi-
the RME group was 8.8 years (T1), with a pre- tion, or maxillary dentoalveolar dimensions.
ARTICLE IN PRESS
10 McNamara et al
compared to a control sample of 20 untreated conventional RME approach would have less
subjects from the University of Michigan Growth resistant forces and probably more skeletal
Study.29 Posteroanterior cephalograms were avail- effects than at stage C when there are many ini-
able for both treated patients and control subjects tial ossification areas along the midpalatal suture.
before treatment and at a long-term observation. Patients in stages D and E might be better treated
Treated and control samples were divided into 2 by surgically assisted RME because fusion of the
groups according to individual skeletal matura- midpalatal suture already has occurred partially
tion. or totally, hampering the RME forces from open-
The early-treated and early-control groups ing the suture. Interestingly, adults (older than
had not reached the pubertal peak at T1 (cervi- 18 years) showed great variability in sutural matu-
cal stage, CS 1 to 3), whereas the late-treated and ration. We found that 53% of the adults were in
late-control groups were during or slightly after stage E, 31% were in stage D, 13% were in stage
the peak at T1 (CS 4 to 6).27 In the long-term, C, and 1 subject (3%) was in stage B. Therefore,
maxillary skeletal width, maxillary intermolar 16% of the adult subjects showing more imma-
width, lateral nasal width, and lateral orbital ture stages, potentially could be treated with con-
width were significantly greater in the early- ventional RME procedures.
treated group. The late-treated group exhibited In another study31 that correlated the stages
significant increases in lateral nasal width and in of maturation of the midpalatal suture with the
maxillary and mandibular intermolar widths. CVM method, we found that the most immature
Patients treated before puberty exhibit signifi- stages A and B are typical of the prepubertal
cant and more effective long-term changes at the phases of development (CS 1 and CS 2 in CVM)
skeletal level in both maxillary and circummaxil- while stage C occurs at the pubertal peak (CS 3
lary structures. When RME treatment is per- in CVM). The stages D and E describing partial
formed after the pubertal growth spurt, or total fusion of the midpalatal suture, respec-
maxillary adaptations to expansion therapy shift tively, are associated with a post-pubertal stage of
from the skeletal level to the dentoalveolar level. development (CS 5). However, for postpubertal
In 2013, Angelieri et al.30 proposed a novel patients (CS4 and CS5), an individual assessment
classification method for the individual assess- of the midpalatal suture with CBCT can be indi-
ment of midpalatal suture morphology (Fig. 7) cated, since 14% of patients at CS5 show a stage
using cone-beam computed tomography C in midpalatal suture maturation and, presum-
(CBCT) images that can be helpful when making ably, could be treated with conventional RME.
a clinical decision between conventional and sur-
gically assisted RME especially for adolescent
and young adult patients. CBCT images from
Non-extraction vs extraction decision
140 subjects (ages ranged from 6 to 58 years)
were examined to define the radiographic stages Rapid maxillary expansion been shown to be a
of midpalatal suture maturation. predictable way of widening the transverse
Five stages of maturation of the midpalatal dimension in patients in the early mixed, later
suture were identified and defined (Fig 7): stage mixed and early permanent dentition. It is
A, straight high-density sutural line, with no or lit- much more than an appliance used in the cor-
tle interdigitation; stage B, scalloped appearance rection of unilateral and bilateral posterior
of the high-density sutural line; stage C, 2 paral- crossbites. Our long-term research indicates
lel, scalloped, high-density lines that were close that patients with mild to moderate crowding
to each other, separated in some areas by small can be managed effectively with RME, especially
low-density spaces; stage D, fusion completed in in those patients whose lower posterior teeth
the palatine bone, with no evidence of a suture, initially are tipped lingually. In such patients,
while in the maxillary portion of the suture still the removable lower Schwarz appliance is effec-
can be visualized as 2 high-density lines separated tive in uprighting lingually tipped posterior
by small low-density spaces; and stage E, fusion in teeth as well as creating a modest amount of the
the maxilla. arch length anteriorly. More severe crowding,
Based on our proposed staging methodology, however, must be managed through the
we speculated that at stages A and B, a removal of permanent teeth.
ARTICLE IN PRESS
Figure 7. Stages of maturation of the midpalatal suture as observed with CBCT images. Stage A is seen in this
patient as a relatively straight high-density line at the midline. Stage B is observed as one scalloped, high density
line at the midline. Stage C is visualized as two parallel, scalloped, high density lines that are close to each other
and separated in some areas by small low-density spaces. Stage D is visualized as two scalloped, high-density lines at
the midline on the maxillary portion of the palate, while the midpalatal suture cannot be visualized in palatine
bone. At stage E, sutural fusion has occurred in the maxilla. From Angelieri et al., 2013.25
It should be noted that when the outcomes of crossbites (in conjunction with a facial mask)
520 consecutively treated patients from our prac- and improving tooth size/arch size discrepan-
tice who underwent RME in the early mixed denti- cies. When applied in the appropriate patient,
tion were analyzed, 52 patients ultimately RME alone or in combination with a removable
underwent the removal of permanent teeth, not lower Schwarz appliance has been shown to pro-
considering the third molars.32 The teeth removed vide clinically significant increases in available
typically were maxillary first premolars or four pre- arch width in comparison to matched untreated
molars, leading to a 10% extraction rate in this controls. Other benefits of orthopedic expansion
prospective treatment sample. The need for extrac- include improvement in smile esthetics, the crea-
tion was based primarily on profile considerations tion of space to aid in the eruption of impacted
that were evident at the beginning of Phase II. canines or incisors, and enlarging the nasal air-
way, subjects not covered in this discussion.
An additional treatment effect of early interven-
Final remarks
tion in the transverse dimension is that it may lead
Expansion of the transverse dimension has many to a spontaneous improvement in molar relation-
indications. As this article has described previ- ship in some Class II patients during the transition
ously, orthopedic expansion with RME is indi- to the permanent dentition. The bonded RME had
cated in patients with constricted maxillae, as its greatest effects at the occlusal level, specifically
manifested by a narrow transpalatal width, as producing highly significant improvement of Class
measured from the closest point on the lingual II molar relationship and a decrease in overjet. The
surface of the maxillary permanent first molar to Class II molar relationship remained virtually
its antimere. Orthopedic expansion is beneficial unchanged in the control group, while the RME
in eliminating posterior crossbites, anterior group showed an improved molar relationship of
ARTICLE IN PRESS
12 McNamara et al
over 1 mm in 92% of the expansion patients, and 3. Sigler LM, Baccetti T, McNamara Jr JA. Effect of RME/
over 2 mm in almost 50% of them. TPA treatment associated with deciduous canine extrac-
Yet even with well-timed early intervention, tion on the eruption of palatally-displaced canines: A two-
center prospective study. Am J Orthod Dentofacial Orthop.
individual responsiveness to treatment must be 2011;139e(3):235–244.
expected, and in some cases, definitive sagittal 4. Pavoni C, Franchi L, Laganà G, Baccetti T, Cozza P. Man-
correction techniques (e.g., functional jaw ortho- agement of impacted incisors following surgery to remove
pedics) or an extraction protocol may by indi- obstacles to eruption: a prospective clinical trial. Pediatr
Dent. 2013;35:364–368.
cated as a part of the second phase treatment.
5. Guest SS, McNamara Jr JA, Baccetti T, Franchi L. Improv-
Ideal timing for RME is during the prepuber- ing Class II malocclusion as a side-effect of rapid maxillary
tal phases of development. In the postpubertal expansion: A prospective clinical study. Am J Orthod Dento-
period, however, an assessment of the midpalatal facial Orthop. 2010;138:582–591.
suture maturation using CBCT images may be 6. Moore T, Southard K, Casko J, Qian F, Southard T. Buc-
indicated in deciding between conventional cal corridors and smile esthetics. Am J Orthod Dentofacial
Orthop. 2005;127:208–213.
rapid maxillary expansion and surgically-assisted 7. Di Carlo G, Saccucci M, Ierardo G, Luzzi V, Occasi F,
rapid maxillary expansion. Zicari AM, Duse M, Polimeni A. Rapid Maxillary Expan-
sion and Upper Airway Morphology: A Systematic Review
on the Role of Cone Beam Computed Tomography.
Acknowledgments Biomed Res Int. 2017;2017 5460429.
8. Haas AJ. Rapid expansion of the maxillary dental arch
We acknowledge the contributions of many peo- and nasal cavity by opening the mid-palatal suture. Angle
ple in this overall research effort. First, we must Orthod. 1961;31:73–90.
mention our good friend Tiziano Baccetti who 9. Fränkel R. Decrowding during eruption under the
screening influence of vestibular shields. Am J Orthod.
worked on numerous research projects from
1974;65:372–406.
1994 to 2011, when he died tragically from a fall. 10 McNamara Jr JA, Unpublished data. 1975.
His presence is everywhere; we miss him greatly. 11. McNamara Jr JA, Bookstein FL, Shaughnessy TG. Skeletal
We also must acknowledge the many Univer- and dental changes following functional regulator ther-
sity of Michigan orthodontic residents who apy on Class II patients. Am J Orthod. 1985;88:91–110.
12. McDougall PD, McNamara Jr JA, Dierkes JM. Arch width
worked on projects related to the transverse
development in Class II patients treated with the Fränkel
dimension as part of their Master’s thesis. These appliance. Am J Orthod. 1982;82:10–22.
include Larry Spillane, Eric Brust, Joyce Chang, 13. Haas AJ. Palatal expansion: just the beginning of dentofa-
Chris Cameron, Susie Guest, Renee Geran, Paul cial orthopedics. Am J Orthod. 1970;57:219–255.
O’Grady, Matt Lineberger, Rebecca Lash Rubin, 14. Howe RP, McNamara Jr JA, O'Connor KA. An examina-
tion of dental crowding and its relationship to tooth size
and Lainie Shapiro as well as Paul McDougall
and arch dimension. Am J Orthod. 1983;83:363–373.
from the University of Detroit. Dental students 15. Moyers RE, van der Linden FPGM, Riolo ML, McNamara
who were major contributors include Lauren Jr JA. Standards of human occlusal development. Ann Arbor:
Sigler Busch, Heidi Novak, and Jared Little. Monograph 5, Craniofacial Growth Series, Center for
We thank Fernanda Angelieri from Guarulhos Human Growth and Development, The University of
Michigan; 1976.
University in Brazil and Lucia Cevidanes from
16. McNamara Jr JA, Baccetti T, Franchi L, Herberger TA.
The University of Michigan. Both researchers Rapid maxillary expansion followed by fixed appliances:
have helped expand our horizons into CBCT A long-term evaluation of changes in arch dimensions.
imaging. Finally, we thank Bob and Tom Her- Angle Orthod. 2003;73:344–353.
berger, the father-and-son orthodontic team who 17. Chang JY, McNamara Jr JA, Herberger TA. A longitudinal
study of skeletal side-effects induced by rapid maxillary
systematically gathered long-term records on
expansion. Am J Orthod Dentofac Orthop. 1997;112:330–337.
their expansion patients. Their contributions to 18. Cameron CA, Franchi L, Baccetti T, McNamara Jr JA.
our work are obvious. Long-term effects of rapid maxillary expansion: A poster-
oanterior cephalometric study. Am J Orthod Dentofac
Orthop. 2002;121:129–135.
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