ORIGINAL ARTICLE

Immediate effects of rapid maxillary expansion

with Haas-type and hyrax-type expanders:
A randomized clinical trial
 Weissheimer,a Luciane Macedo de Menezes,b Mauricio Mezomo,a Daniela Marchiori Dias,a
Andre
Eduardo Martinelli Santayana de Lima,b and Susana Maria Deon Rizzattoc
Porto Alegre, Rio Grande do Sul, Brazil

Introduction: The purposes of this study were to evaluate and compare the immediate effects of rapid maxillary
expansion (RME) in the transverse plane with Haas-type and hyrax-type expanders by using cone-beam
computed tomography. Methods: A sample of 33 subjects (mean age, 10.7 years; range, 7.2-14.5 years)
with transverse maxillary deciency were randomly divided into 2 groups: Haas (n 5 18) and hyrax (n 5 15).
All patients had RME with an initial activation of 4 quarter turns followed by 2 quarter turns per day until the
expansion reached 8 mm. Cone-beam computed tomography scans were taken before expansion and at the
end of the RME phase. Maxillary transversal measurements were compared by using the mixed analysis of
variance (ANOVA) model and the Tukey-Kramer method. Results: RME increased all maxillary transverse
dimensions (P \0.0001). There was less expansion at skeletal than dental levels. The hyrax group had greater
statistically signicant orthopedic effects and less tipping tendency of the maxillary rst molars compared with
the Haas group. Conclusions: Both appliances were efcient in correcting a transverse maxillary deciency.
The pure skeletal expansion was greater than actual dental expansion. The hyrax-type expander produced
greater orthopedic effects than did the Haas-type expander, but this effect was less than 0.5 mm per side and
might not be clinically signicant. (Am J Orthod Dentofacial Orthop 2011;140:366-76)

apid maxillary expansion (RME) is an important

method used to correct a transverse maxillary deciency. It was rst described in the literature over
a century ago by Angell,1 and it has been disseminated
and made widely popular by Haas since 1961.2 In
RME, rigid and xed expanders are used to produce
heavy forces to obtain the maximum skeletal response
by opening the midpalatal suture, with minimum
orthodontic movement.2-5
Among the appliances used for RME, the toothtissueborne (Haas-type) and the tooth-borne (hyraxtype) expanders are the most recognized in the literature.
The main difference between them is the acrylic pad that
leans on the lateral walls of the palatal vault (Haas-type)

From the Department of Orthodontics, Pontical Catholic University of Rio

Grande Do Sul, Porto Alegre, Rio Grande do Sul, Brazil.
a
Postgraduate student (Ph.D.).
b
Professor.
c
Assistant professor.
The authors report no commercial, proprietary, or nancial interest in the products or companies described in this article.
Reprint requests to: Andre Weissheimer, Pontifcia Universidade Cat
olica do Rio
Grande do Sul, Faculdade de Odontologia, Predio 6, Avenida Ipiranga, 6681, sala
209, Porto Alegre, RS, Brazil, CEP 90619-900; e-mail, andre5051@hotmail.com.
Submitted, March 2010; revised and accepted, July 2010.
0889-5406/$36.00
Copyright 2011 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2010.07.025

366

to reinforce the anchorage for greater orthopedic

response and better force distribution during RME.2,4
In the hyrax-type expander, there is no acrylic pad;
therefore, it is more hygienic and prevents soft-tissue
irritation caused by food impaction under the acrylic
plate.6 Although a cephalometric investigation has not
demonstrated any differences between Haas-type and
hyrax-type expanders,7 there is no consensus in the literature regarding the differences in the immediate
RME effects produced by these appliances.
Several investigations have analyzed the effects of
RME through 2-dimensional cephalometric radiographs,
which do not allow accurate identication of dentoskeletal structures because of the superimposition of many
bones in the different planes of space.2,7-9 To overcome
these limitations, computed tomography (CT) for the
assessment of the transverse dimensions of the
maxilla was introduced by Timms et al10 in the
1980s. However, the use of conventional CT scans in
orthodontics has been limited because of cost and radiation concerns.11 Cone-beam CT (CBCT) has ushered
in a new era in dental diagnostics. This technology was
designed for imaging hard tissues of the maxillofacial
region with minimum distortion at a lower cost and
with lower radiation emissions compared with

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367

Fig 1. A, Haas-type expander and B, hyrax-type expander at the end of the active phase of RME.

Fig 2. Transverse maxillary posterior region evaluation: A and B, preexpansion; C and D, at the end of
the active phase of expansion.

conventional CT. The high resolution of CBCT images

is due to the isotropic voxel (equal in all 3 dimensions),
which produces submillimeter resolutions ranging from
0.4 mm to as low as 0.125 mm.11 Several investigations
have shown the high accuracy of CBCT images for
quantitative and qualitative analyses.12-15 Its use is
recommended in orthodontics for several purposes
such as evaluation of impacted teeth,16,17 evaluation

of bone grafts in cleft regions,18 analysis of alveolar

bone before placement of orthodontic temporary anchorage devices,19 and evaluation of RME effects on
nasomaxillary structures.20
The purposes of this study were to evaluate and compare the immediate effects of RME on the transverse
plane with Haas-type and hyrax-type expanders by
using high-resolution CBCT.

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Fig 3. Landmarks used in the evaluation of the maxillary posterior region.

MATERIAL AND METHODS

This study was approved by the ethical committee of

the Pontical Catholic University of Rio Grande do Sul in
Brazil. Informed consent was obtained from the parents
of all patients who agreed to participate in this study. The
sample was selected by examining subjects in need of orthodontic treatment at the Department of Orthodontics
of the School of Dentistry. The inclusion criteria for
this study were transverse maxillary deciency, mixed
dentition or early permanent dentition, and no surgical
or other treatment that might affect the RME effects
during the expansion period. Patients with congenital
malformations or periodontal diseases, or above 15 years
of age were excluded from the study sample.
In this prospective study, the sample comprised 33
healthy white children (11 boys, 22 girls) with a mean
chronologic age of 10.7 years (range, 7.2-14.5 years)
and a mean skeletal age of 10.9 years (range, 6.8-15
years). These patients were randomly divided into 2
groups: Haas (n 5 18) and hyrax (n 5 15). In the Haas
group, the Haas-type expander, with 4 bands (rst permanent molars and rst premolars or rst deciduous molars)
and buccal and lingual stainless steel bars of 1.0-mm
diameter was used (Fig 1, A). In the hyrax group, the
hyrax-type expander, with 4 bands, buccal and lingual
stainless steel bars of 1.0-mm diameter and a jackscrew

September 2011  Vol 140  Issue 3

with 1.4-mm stainless steel extensions soldered to the lingual surfaces of each pair of bands, was used (Fig 1, B).
Both appliances had expansion jackscrews with activations of a quarter turn equivalent to a 0.2-mm expansion. All patients in the Haas and hyrax groups had RME,
with initial activations of 4 quarter turns (0.8 mm)
followed by 2 quarter turns per day (0.4 mm) until the
expansion screw reached 8 mm.
The i-CAT (Imaging Sciences International, Hateld,
Pa) was used to obtain CBCT images before RME (T1)
and at the end of the active expansion phase (T2). The
CBCT scans were performed at 120 kV, 8 mA, scan
time of 40 seconds, and 0.3-mm voxel dimension. The
data for each patient were reconstructed with 0.3-mm
slice thickness, and the digital imaging and communications in medicine (DICOM) images were assessed by using the EFILM workstation software program (version
2.1.2, Merge Healthcare, Milwaukee, Wis). All linear
and angular measurements were made by a blinded examiner (M.M.), who had no access to the data or the clinical consultations of the patients in this sample.
For transverse maxillary posterior region evaluation,
the DICOM les with CBCT images at T1 and T2 were imported into EFILM and visualized as axial images
arranged side by side. To obtain standardized axial and
coronal slices and thus allow the comparisons between
T1 and T2, the following references were used. In the

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Table I. Landmarks for transverse maxillary evaluation

Skeletal
Line 1-2

Posterior baseline

Line 13-14

Anterior baseline

Distance 5-6

Posterior apical base width

Distance 11-12

Posterior midpalatal suture width

Distance 15-16

Anterior apical base width (inferior)

Distance 17-18

Anterior apical base width (superior)

Distance 21-22

Anterior mid-palatal suture width

Alveolar
Distance 3-4
Distance 19-20

Dental
Distance 7-8

Posterior width at the alveolar crest level

Anterior width at midalveolar level

Intermolar width at occlusal surface

Distance 9-10

Intermolar width at palatal root apices

Angle 1MD

Right rst molar angulation

Angle 1ME

Left rst molar angulation

axial slices, the images that displayed the root canal in

the most apical region of the palatal root of maxillary
rst permanent molars were selected. By using the MultiPlanar Reformation tool, the MultiPlanar Reformation
line was positioned at the root canal in the most apical
region of the palatal root of the maxillary rst permanent molars on the right and left sides. From these references, standardized coronal images were produced,
and the measurements were made (Fig 2). The landmarks
used for evaluation of the maxillary posterior region are
shown in Figure 3 and described in Table I.
The analyses of the transversal changes in the maxillary anterior region were performed in a similar way to
those of the posterior region. In the axial slices, images
at T1 and T2 were selected with the root canals in the
most apical region of the roots of the maxillary permanent canines visualized. After that, the MultiPlanar

Line formed by the 2 lower points at the inferior inner contour of the
posterior nasal cavity on the right and left sides, respectively.
Line formed by the 2 lower points at the inferior inner contour of the anterior
nasal cavity on the right and left sides, respectively.
Distance between points 5 and 6 (points formed by the intersection of the
line 1-2 with buccal contour of maxilla on the right and left sides,
respectively).
Distance between points 11 and 12 (lower points at medial limits of maxillary
palatine processes, on the right and left sides, respectively), representing
the midpalatal suture.
Distance between points 15 and 16 (points formed by the intersection of line
13-14 with buccal contour of maxilla on the right and left sides,
respectively).
Distance between points 17 and 18 (intersection of the straight line, which is
parallel and 5 mm superior to line 13-14, with buccal contour of maxilla
on the right and left sides, respectively).
Distance between points 21 and 22 (lower points at medial limits of maxillary
palatine processes, on the right and left sides, respectively), representing
the midpalatal suture in the anterior region.
Distance between points 3 and 4 (coronal-most points of the maxillary
buccal alveolar processes, on the right and left sides, respectively).
Distance between points 19 and 20 (intersection of the straight line, which is
parallel and 5 mm inferior to line 13-14, with buccal contour of maxilla on
the right and left sides, respectively).
Distance between points 7 and 8 (points formed by the intersection of
a straight line, that superimpose the long axis of the root canal of rst
permanent molar palatine root, with the occlusal surface on the right and
left sides, respectively).
Distance between points 9 and 10 (apices of palatine root of permanent rst
molars, on the right and left sides, respectively).
Angle formed by the straight line from point 7 and that superimposes the
long axis of the root canal of permanent rst molar palatine root, on the
right side, with line 1-2.
Angle formed by the straight line from point 8 and that superimposes the
long axis of the root canal of permanent rst molar palatine root, on the
left side, with the line 1-2.

Reformation line was positioned at the root canal in

the most apical region of the maxillary permanent
canine root on the right and left sides. From theses references, standardized coronal images were produced,
and the measurements were made (Fig 4). The landmarks
used to evaluate the RME effects in the anterior region of
maxilla are shown in Figure 5 and described in Table I.
Statistical analysis

Intraexaminer reliability of the measurements was

determined by intraclass correlation coefcients. Double
assessments of each parameter at T1 and T2 (10 days
apart) of 15 randomly selected patients from both
groups were compared (Table II). The data obtained
from all measurements were processed with SAS software (version 9.0.2, SAS, Cary, NC). Means and standard
errors for each parameter were calculated, and data at T1

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Fig 4. Transverse maxillary anterior region evaluation: A and B, preexpansion; C and D, at the end of
the active phase of expansion.

and T2 were compared by using the mixed analysis of

variance (ANOVA) model and the Tukey-Kramer method
at a signicance level of 5%.

linear measure (distance 9-10), which indicated greater

inclination of these teeth in the Haas group than in the
hyrax group (Table VI).

RESULTS

DISCUSSION

The overall immediate effects of RME on the transverse plane are shown in Table III. There were signicant increases in maxillary width at the skeletal,
alveolar, and dental levels for both the Haas (Table
IV) and the hyrax (Table V) groups in all parameters
(P \0.05). There was less expansion at the skeletal
than at the dental level, just as the increase in the maxillary apical base was smaller in the posterior region
(distances 5-6 and 11-12) compared with the anterior
(distances 15-16, 21-22) (Tables III-V). The hyrax
group had greater statistically signicant increases in
the maxillary transverse dimensions at the skeletal
level than did the Haas group in both posterior
(distances 5-6 and 11-12) and anterior (distance 2122) regions (Table VI). There was no signicant difference between the groups for the buccal inclination of
the maxillary rst permanent molars, except for the

After Broadbent21 introduced the cephalostat in

1931, several investigations have analyzed the effects
of RME through cephalometry in 2-dimensional radiographs.3,8,22 The major problem associated with
cephalometry is projection errors, which have an effect
on linear and angular measurements, caused by
magnication and distortion and are compounded by
incorrect patient positioning.23,24 To overcome these
limitations, we evaluated and compared, using highresolution CBCT, the immediate effects of RME on the
transverse planes with Haas-type and hyrax-type expanders. CBCT was used because it is a suitable examination for imaging craniofacial areas, with minimum
distortion, at a lower cost and with lower radiation dosages than conventional CT.11,25,26 In addition, CBCT is
an accurate and reliable method for assessing changes
associated with RME on nasomaxillary structures.20

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Fig 5. Landmarks used in the evaluation of the maxillary anterior region.

Table II. Intraclass correlation coefcients of the mea-

surements
Measurement
Distance 5-6
Distance 11-12
Distance 15-16
Distance 17-18
Distance 21-22
Distance 3-4
Distance 19-20
Distance 7-8
Distance 9-10
Angle 1MD
Angle 1ME

ICC
0.98
0.94
0.96
0.95
0.61
0.98
0.96
0.95
0.97
0.93
0.74

Regarding previous reports that used CT images to

evaluate RME, our study had an adequate sample size
(33 subjects).10,20,27-33 Furthermore, this study design
had some important features: (1) it was a prospective
study; (2) the patients were randomly divided between
the groups; (3) the methodology was highly
standardized in terms of appliance fabrication, and rate
and amount of expansion; and (4) it used highresolution CBCT. In this study, since the active expansion
phase lasted only 19 days, there was no need to use
a control group without treatment since normal growth
was not an inuencing factor in this short time. In this

study, the overall effects of RME produced a signicant

skeletal increase in the transverse maxillary dimension,
conrming previous reports.2-5,20,28,30,34,35 The skeletal
expansion amounts were greater in the anterior
region2.82 mm (distance 17-18), 3.48 mm (distance
15-16), and 4 mm (distance 21-22)compared with
the posterior2.64 mm (distance 5-6) and 2.88 mm
(distance 11-12) (Table III). In agreement with previous
authors, the expansion pattern was triangular with
a wider base at the anterior portion of maxilla.20,29,35
The greater expansion in the anterior region could be
explained by the resistance of the medial and lateral
pterygoid plates of the sphenoid bone to the maxillary
tip movement during the RME.35 Another feasible explanation would be through maxillary expansion biomechanics: ie, the direction of the expansion force
produced by the expanders would be located anterior
to the center of resistance of each maxillary half.36
The hyrax-type expander produced greater skeletal
expansion3.14 mm (distance 11-12) and 4.37 mm
(distance 21-22)than did the Haas-type expander
2.62 mm (distance 11-12) and 3.63 mm (distance
21-22) (Table VI). The skeletal gain in the hyrax group
accounted for 38.5% to 39.2% (posterior region) and
37.5% to 54.7% (anterior region) of the total expansion
(8 mm). In the Haas group, the increases were smaller,
ranging from 27.2% to 32.7% in the posterior region

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Table III. Immediate changes in the maxillary transverse plane with RME
T1
Variable
Skeletal
Distance 5-6 (mm)
Posterior apical base width
Distance 11-12 (mm)
Posterior midpalatal suture width
Distance 15-16 (mm)
Anterior apical base width (inferior)
Distance 17-18 (mm)
Anterior apical base width (superior)
Distance 21-22 (mm)
Anterior midpalatal suture width
Alveolar
Distance 3-4 (mm)
Posterior width at alveolar crest level
Distance 19-20 (mm)
Anterior width at midalveolar level
Dental
Distance 7-8 (mm)
Intermolar width at occlusal surface
Distance 9-10 (mm)
Intermolar width at palatal root apices
Angle 1MD ( )
Right rst molar angulation
Angle 1ME ( )
Left rst molar angulation

T2

Change

Mean

SE

Mean

SE

Mean

SE

60.29

0.64

62.93

0.64

2.64

0.11

\0.0001*

00.00

0.08

02.86

0.08

2.88

0.09

\0.0001*

38.37

0.61

41.85

0.61

3.48

0.23

\0.0001*

38.96

0.83

41.78

0.83

2.82

0.23

\0.0001*

00.00

0.10

04.00

0.11

4.00

0.13

\0.0001*

51.65

0.51

57.28

0.51

5.63

0.16

\0.0001*

40.06

0.58

44.46

0.58

4.40

0.22

\0.0001*

43.51

0.44

51.31

0.44

7.80

0.15

\0.0001*

29.90

0.52

32.55

0.52

2.65

0.14

\0.0001*

110.6

1.4

118.1

1.4

7.53

0.74

\0.0001*

117.7

1.2

123.8

1.2

6.17

0.68

\0.0001*

*Statistically signicant (P \0.05).

and 32.7% to 45.2% in the anterior region. These

comparison results between the appliances differ from
previous reports.7,28,37 Siqueira et al7 compared the
Haas-type and hyrax-type expanders through frontal
cephalometric radiographs and found no differences
between them. Garib et al28 also found no differences
between these 2 expanders using spiral CT. This phenomenon could be explained by the small study sample
(n 5 8), which reduced the power of the t test to show
statistically signicant differences. When signicant
differences are demonstrated in such situations, they
clearly exist and most likely have clinical importance.
However, the absence of signicant differences does
not necessarily indicate that they do not exist. In addition, the RME changes were analyzed 3 months after
the active expansion phase, unlike our study, with the
immediate effects of RME on 33 patients evaluated. In
disagreement with the present study, Oliveira et al37
found that the Haas-type expander achieved expansion
with a greater component of orthopedic movement
than the hyrax-type expander. However, the comparison
between the 2 kinds of expanders was performed on
study models and anteroposterior cephalograms.
The main difference between Haas-type and hyraxtype expanders is the acrylic pad close to the palate in

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the Haas-type appliance. According to Haas,4 a purpose

of the acrylic pad is to reinforce the anchorage for
greater orthopedic response during RME. However,
the results of our study did not support this theory,
at least regarding the immediate effects of expansion.
Better results in the immediate skeletal response were
obtained by the hyrax-type expander vs the Haastype. This fact can be explained by differences in appliance design: more specically, in the connection mechanism of the jackscrew to the bands of the anchorage
teeth. In the hyrax-type appliance design, the jackscrew
was directly connected to the bands by a rigid stainless
steel framework (1.4 mm), unlike the Haas-type appliance design, where the acrylic was responsible for connecting the stainless steel framework (1.0 mm) to the
jackscrew. According to a previous study about the biomechanics of RME, appliance designs that use an
acrylic interface with the teeth are far less stiff than
those constructed solely of soldered stainless steel
wire, as in the case of the hyrax-type expander.36 However, the acrylic pad against the palate would be important, especially during the retention period, when it
would prevent the bone from moving through the
teeth, thus averting an orthopedic relapse of the expanded maxilla.4,5,20

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Table IV. Immediate changes in the maxillary transverse plane with RME in the Haas group
T1
Variable
Skeletal
Distance 5-6
Posterior apical base width
Distance 11-12
Posterior midpalatal suture width
Distance 15-16
Anterior apical base width (inferior)
Distance 17-18
Anterior apical base width (superior)
Distance 21-22
Anterior midpalatal suture width
Alveolar
Distance 3-4
Posterior width at alveolar crest level
Distance 19-20
Anterior width at midalveolar level
Dental
Distance 7-8
Intermolar width at occlusal surface
Distance 9-10
Intermolar width at palatal root apices

T2

Change

Mean (mm)

SE (mm)

Mean (mm)

SE (mm)

Mean (mm)

SE (mm)

61.10

0.87

63.29

0.87

2.19

0.15

\0.0001*

00.00

0.11

02.61

0.11

2.62

0.12

\0.0001*

38.98

0.82

42.28

0.82

3.29

0.30

\0.0001*

39.70

1.12

42.33

1.12

2.62

0.31

\0.0001*

00.00

0.15

03.63

0.15

3.63

0.17

\0.0001*

51.96

0.69

57.41

0.69

5.44

0.25

\0.0001*

40.56

0.79

44.59

0.79

4.03

0.30

\0.0001*

43.42

0.59

51.12

0.59

7.70

0.20

\0.0001*

30.57

0.71

32.72

0.71

2.15

0.18

\0.0001*

*Statistically signicant (P \0.05).

Table V. Immediate changes in the maxillary transverse plane with RME in the hyrax group
T1
Variable
Skeletal
Distance 5-6
Posterior apical base width
Distance 11-12
Posterior midpalatal suture width
Distance 15-16
Anterior apical base width (inferior)
Distance 17-18
Anterior apical base width (superior)
Distance 21-22
Anterior midpalatal suture width
Alveolar
Distance 3-4
Posterior width at alveolar crest level
Distance 19-20
Anterior width at midalveolar level
Dental
Distance 7-8
Intermolar width at occlusal surface
Distance 9-10
Intermolar width at palatal root apices

T2

Change

Mean (mm)

SE (mm)

Mean (mm)

SE (mm)

Mean (mm)

SE (mm)

59.48

0.92

62.58

0.92

3.10

0.17

\0.0001*

00.00

0.12

03.14

0.12

3.14

0.14

\0.0001*

37.75

0.87

41.42

0.87

3.66

0.34

\0.0001*

38.22

1.19

41.22

1.19

3.00

0.35

\0.0001*

00.00

0.16

04.37

0.16

4.37

0.20

\0.0001*

51.34

0.73

57.15

0.73

5.80

0.28

\0.0001*

39.58

0.83

44.34

0.83

4.76

0.34

\0.0001*

43.60

0.62

51.50

0.62

7.90

0.23

\0.0001*

29.24

0.75

32.38

0.75

3.14

0.21

\0.0001*

*Statistically signicant (P \0.05).

In the hyrax group, the transverse expansion at the

suture gradually decreased from the anterior, by 4.37
mm (distance 21-22), to the posterior, by 3.14 mm

(distance 11-12) (Table V). This sutural orthopedic separation accounted for 54.7% and 39.2% of the total
expansion (8 mm) at distances 21-22 and 11-12,

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Table VI. Comparison between the changes in the maxillary transverse planes in the groups

Variable
Skeletal
Distance 5-6 (mm)
Posterior apical base width
Distance 11-12 (mm)
Posterior midpalatal suture width
Distance 15-16 (mm)
Anterior apical base width (inferior)
Distance 17-18 (mm)
Anterior apical base width (superior)
Distance 21-22 (mm)
Anterior midpalatal suture width
Alveolar
Distance 3-4 (mm)
Posterior width at alveolar crest level
Distance 19-20 (mm)
Anterior width at midalveolar level
Dental
Distance 7-8 (mm)
Intermolar width at occlusal surface
Distance 9-10 (mm)
Intermolar width at palatal root apices
Angle 1MD ( )
Right rst molar angulation
Angle 1ME ( )
Left rst molar angulation

Haas group

Hyrax group

T2-T1

T2-T1

Mean

SE

Mean

SE

2.19

0.15

3.10

0.17

0.0002*

2.62

0.12

3.14

0.14

0.010*

3.29

0.30

3.66

0.34

0.427

2.62

0.31

3.00

0.35

0.438

3.63

0.17

4.37

0.20

0.007*

5.44

0.25

5.80

0.28

0.342

4.03

0.30

4.76

0.34

0.119

7.70

0.20

7.90

0.23

0.526

2.15

0.18

3.14

0.21

0.0008*

8.25

0.98

6.80

1.11

0.334

6.14

0.90

6.19

1.02

0.975

*Statistically signicant difference (P \0.05).

respectively. These ndings endorse a previous report in

which, of the total expansion achieved, the hyrax-type
expander produced 55% of the suture expansion in the
anterior and 38% in the posterior regions.20 However,
the RME changes were analyzed 3 months after the
active expansion phase, unlike our study, where the
immediate effects of RME were evaluated.
This investigation showed a more signicant skeletal response compared with other studies.29,30 In
a study by Lione et al,29 the RME was performed
with a modied hyrax-type expander (bands on the
rst permanent molars only), and less sutural expansion was obtained in both the anterior (2.17 mm)
and the posterior (1.15 mm) regions. This small orthopedic effect could be explained by (1) the use of a modied hyrax-type expander, which had less anchorage;
(2) less total expansion (7 mm); and (3) the sutural expansion evaluated in a more posterior region (posterior
nasal spine) than in our study (in the rst molar region). In our investigation, the amounts of sutural
expansion (2.88 mm in the posterior and 4 mm in
the anterior regions) were greater than the amounts

September 2011  Vol 140  Issue 3

reported by Podesser et al30 (1.6 mm in the posterior

and 1.5 mm in the anterior regions). This difference
could be explained by less total expansion (7 mm)
and the relapse that might have occurred because of
appliance removal and replacement at the end of the
active phase of RME for CT scan acquisition in their
study. In our investigations, there was no need to remove the appliances before the CBCT examination at
T2 because of the lower level of metal artifacts produced by CBCT compared with conventional CT.11,38
The greater amounts of expansion at the alveolar
level (distances 3-4 and 19-20) than the sutural expansion (distances 11-12 and 21-22) (Table III) show the
bending of the alveolar processes of the maxilla; this result agrees with previous reports.20,28,30 The expansion
at the alveolar level (distance 3-4) accounted for 70%
of the total expansion, 36% of which represents
sutural expansion and 34% is purely alveolar bending
toward the buccal aspect.
The great changes in maxillary transverse dimensions
occurred at the dental level, where the expansion accounted for 97% (distance 7-8) of the total expansion

American Journal of Orthodontics and Dentofacial Orthopedics

Weissheimer et al

(8 mm) (Table III). This greater expansion at the dental

level compared with the skeletal level agrees with previous reports.3,4,20,28,30,34,37 However, the actual dental
expansion can be found by subtracting the total
expansion at the dental level (distance 7-8) from the
suture and alveolar expansions (distance 3-4). Thus,
from 97% (7.8 mm) of the total expansion at the
dental level (distance 7-8), only 27% (2.17 mm)
represents actual dental expansion, which was smaller
compared with 36% (2.88 mm) of pure skeletal
expansion (distance 11-12) and with 34% (2.75 mm)
of pure alveolar bending. RME produced signicant
buccal tipping of the rst permanent molars,
accounting for 7.53 (angle 1MD) on the right side
and 6.17 (angle 1ME) on the left side (Table III). There
were no statistically signicant differences between the
2 groups in angular measurements. The amounts of buccal tipping of the rst permanent molars for the Haas
group were 8.25 on the right side (angle 1MD) and
6.14 on the left side (angle 1ME), whereas, in the hyrax
group, the tipping amounts were 6.80 on the right and
6.19 on the left sides. However, there was a statistically
signicant difference between the Haas and hyrax
groups in the linear measurement (distance 9-10), which
represents the distance between the apices of the palatal
roots of the rst permanent molars. The higher values for
distance 9-10 (nearly 8 mm of expansion) reected
a small buccal tipping of the rst molars. In the hyrax
group, distance 9-10 increased by 3.14 mm, whereas,
in the Haas group, there was an increase of 2.15 mm,
showing greater tipping of the rst permanent molars
with that expander (Table VI). Similar results were reported in other investigations.28-37 In the study of
Garib et al,28 the Haas-type expander produced greater
buccal tipping of the rst permanent molars (3.5 )
than did the hyrax-type expander (1.6 ). Oliveira
et al37 found that the Haas-type expander produced
greater buccal tipping of the rst permanent molars
(7.12 right side, 6.64 left side) compared with the
Hyrax-type expander (6.94 right side, 1.21 left side).
However, these differences were not considered statistically signicant in either study.
We assessed the immediate effects of RME; therefore,
long-term evaluation is necessary for a better understanding of the differences between Haas-type and
hyrax-type expanders, especially during the retention
and postretention phases of RME.
CONCLUSIONS

Based on this clinical trial with CBCT to assess the

immediate effects of RME on the transverse plane with
2 kinds of palatal expanders, the following conclusions
can be drawn:

375

1.

2.

3.

RME produced signicant increases in all maxillary transverse dimensions. The expansion pattern
was triangular, with smaller effects at the skeletal
level than at the dental level. However, the pure
skeletal expansion was greater than actual dental
expansion. The sutural expansion showed a wedge
shape with the wide base in the anterior maxilla.
The opening of the midpalatal suture accounted
for 50% of the total expansion (8 mm) in the
anterior region and 36% in the posterior region
(there was a decrease from anterior to posterior).
The hyrax-type expander produced greater orthopedic effects in 3 of the 5 skeletal points measured
compared with the Haas-type expander. However,
the effects were less than 0.5 mm per side and might
not be clinically signicant.

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