ORIGINAL ARTICLE

Spontaneous mandibular arch response after

rapid palatal expansion: A long-term study on
Class I malocclusion
Anna Carolina Lima, DDS, MS,a Anna Letcia Lima, DDS, MS Roberto M. A. Lima Filho, DDS, MS,b and
Ordean J. Oyen, PhDc
So Jos do Rio Preto, So Paulo, Brazil, and Milwaukee, Wis
The purpose of this study was to investigate the spontaneous mandibular arch response to rapid palatal
expansion as the sole orthodontic intervention. Particular attention was paid to clinically significant effects and
long-term (mean age, 11.3 years) posttreatment stability in 30 Class I malocclusion patients treated during the
early and mid mixed dentition. Measurements were made directly on 120 dental casts obtained at 4 assessment
stages: pre-expansion (A1), short-term follow-up (A2), progress (A3), and long-term follow up (A4). Comparisons
between A1 and A2 showed statistically significant (P .001) increases for intermolar widths (lingual and occlusal
values). During the transition to the permanent dentition, a significant (P .001) decrease occurred in arch length
and arch perimeter. There was a 25% intermolar width (occlusal value) decrease from the initial net gain, whereas
the lingual values remained unchanged. Comparisons between A2 and A4 showed an intermolar width (occlusal
value) net gain of 50% and a significant (P .001) decrease for the arch length and arch perimeter. There was
remarkable stability in intermolar width (lingual value) and intercanine width (occlusal value), indicating that the
increase in the mandibular arch width dimension was in response to the orthopedic effects of rapid palatal
expansion in the early and mid-mixed dentition and that the stability was maintained until adulthood. (Am J Orthod
Dentofacial Orthop 2004;126:576-82)

n recent publications, investigators have speculated

that the position of the mandibular dentition might be
influenced more by maxillary skeletal morphology
than by the size and shape of the mandible.1 What seems
to be overlooked in these publications is that Haas2
noticed the same thing as early as 1961. Haas3 recently
restated what he had observed in his first clinical study 40
years ago: When the maxillae are separated 12-14 mm,
noticeable spontaneous expansion will occur in the lower
dental arch, due to altered muscle balance between the
tongue and buccinator muscles as they affect the lower
dental arch. That is, a permanent increase in maxillary
apical base which leads to a spontaneous, permanent and
significant increase in mandibular arch width.
In contrast to the maxilla, problems associated with
the position of the teeth in the mandible are more difficult
to deal with clinically. It is more difficult to induce
a

Private practice, So Jos do Rio Preto, So Paulo, Brazil.

Diplomate of the American Board of Orthodontics, private practice, So Jos
do Rio Preto, So Paolo, Brazil.
c
Adjuntant professor of dental education, Marquette University School of
Dentistry, Milwaukee.
Deceased.
Reprint requests to: Anna Carolina Lima, Avenida Alberto Andal, 4025, So
Jos do Rio Preto, SP 15015-000, Brazil; e-mail, aclimabr@yahoo.com.br.
Submitted, July 2003; revised and accepted, June 2004.
0889-5406/$30.00
Copyright 2004 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2004.06.011
b

576

changes in the highly resistant body of the mandible when

orthodontic and orthopedic forces are applied. Tooth
movements, except for tooth displacement into extraction
sites, are mostly limited to tipping or rotational changes
and are influenced by differences in the bony structure
between the alveolar process and the mandibular apical
base.
Rapid palatal expansion (RPE) has been used for
more than a century as a treatment for maxillary
constriction. Although there are many reports on this
topic, most pertain to reactions in the maxillary complex.4,5 Very little has been written about the changes
in the mandibular dentition under the influence of
maxillary expansion or the long-term stability of the
mandible itself.
This present study involved a longitudinal investigation of the spontaneous mandibular arch dimension
changes in patients with Class I malocclusion and
transverse maxillary/mandibular skeletal discrepancies.
Unlike most published studies, all subjects had been
treated with only RPE during the early and mid mixed
dentition, with no subsequent orthodontic intervention.
MATERIAL AND METHODS

The sample consisted of 120 dental casts obtained

at 4 assessment stagespre-expansion (A1), short-term

Lima et al 577

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follow-up (A2), progress (A3), and long-term follow-up (A4)from 30 patients (12 boys and 18 girls;
mean ages, 8.2 years at A1, 9.4 years at A2, 13.2 years
at A3, and 20.7 years at A4) treated only with RPE.
The patients were treated at the Lima Ortodontia
Clinic in So Jos do Rio Preto, State of So Paulo,
Brazil, between 1975 and 1991 and were selected
according to the following criteria: (1) all patients were
treated nonextraction during early or mid mixed dentition stage, (2) all patients had Class I malocclusions
with transverse maxillary/mandibular skeletal discrepancies, (3) no subsequent comprehensive orthodontic
treatment was implemented in either the maxilla or the
mandible, and (4) all mandibular dental arches showed
mild or no crowding.
On the initial dental casts, the crossbite status was
noted and the following distribution observed: 21
patients had unilateral, 7 bilateral, and 8 were associated with some anterior crossbite; only 2 patients had
no initial crossbite, having posterior teeth with buccal
inclination and edge-to-edge occlusion. Except for 3
patients, the entire sample had midline deviations
associated with various mandibular shifts.
All palatal expanders were manufactured, cemented, and activated by the same orthodontist, according to the following protocol: at initial activation, the
appliances received 2 quarter turns (0.5 mm). Thereafter, the appliance was activated 1 quarter turn in the
morning and 1 quarter turn in the evening. The subjects
were seen at weekly intervals for approximately 3
weeks. When the desired overcorrection for each patient was achieved (screw being opened 8-11 mm), the
appliance was stabilized. The expander was in situ
during the expansion and stabilization period for a
mean time of 5 months (range, 3-7 months). After
removal of the expander, a loose, removable acrylic
plate was placed within 48 hours. Generally, each
patient wore the acrylic plate for a variable amount of
time, usually for 1 year or until short-term follow-up
impressions were taken.
Measurements were made directly on mandibular
dental casts by the principal investigator (A.C.L.) with
an electronic digital caliper (Fred V. Fowler, Newton,
Mass), recorded accurate to 0.01 mm, and WinWedge
version 1.2 software (Tal Technologies, Philadelphia,
Pa) allowed the data to be directly digitized in the
computer with a spreadsheet program. If cusp tips were
worn, the centers of the resulting facets were used as
landmarks. When either the deciduous teeth were missing or the permanent teeth were not fully erupted, the
measurement for that antimere was eliminated. Dental
arch width, arch length, and arch perimeter were
measured at the 4 assessment stages.

Lingual measurements for mandibular intermolar

width were made at the point of the intersection of the
lingual groove with the cervical gingival margin and for
intercanine width at the cervical margins of the tooth
from the point of greatest convexity bilaterally, according to McDougall et al.6 The occlusal intermolar width
was measured as the distance between mesiobuccal
cusps tips of the first permanent molars bilaterally7 and
the intercanine width as the distance between cusp tips
bilaterally.8 Additional maxillary intermolar arch width
data from the same patients and measured the same way
were obtained from Lima5 for comparison.
Arch length was defined as a summed linear measurement taken from a central incisor contact point to
the mesial contact points of the first permanent molars.7
Arch perimeter was measured by finding the linear sum
of the lengths of segments connecting the mesial
contact points of first molars and first deciduous molars
or premolars, the mesial contact points of the first
deciduous molars or premolars, and the mesial contact
point of the lateral incisors, and from the mesial contact
points of the lateral incisor for both sides of the arch.7
Patient records (n 30) were obtained as follows:
the mean age at A1 was 8.2 years (range, 7.9-9.10
years), and within 4 months a maxillary expander was
cemented; mean age was 9.4 years (range, 7.9-10.10
years) at A2, and records were taken after removal of
the palatal expander and after the use of a removable
plate, as described by Haas9; mean ages were 13.2
years (range, 10.8-14.11 years) at A3 and 20.7 years
(range, 18-23.9 years) at A4.
Statistical analysis

Because there were no statistically significant sex

differences, the sexes were grouped for subsequent
descriptive and inferential analyses of the variables at
each assessment stage. The Pearson correlation coefficient (r) was used to determine associations between
changes in mandibular intermolar widths (occlusal
versus lingual) and intercanine widths (occlusal versus
lingual).
Method error

Sequential mandibular dental casts were measured

with a digital caliper calibrated to 0.01 mm. To standardize measurements, all data were collected by 1 investigator (A.C.L.). Measurements were repeated on 10 randomly selected casts to determine error of the method
between first and second measures. Standard deviations
were found to be in the range of 0.07 to 0.18 mm for all
measurements (average variation, 0.1 mm). Clinically, 0.1
mm is not considered significant. Also, because the error
of 0.1 mm is less than the average variation, the amount of

578 Lima et al

American Journal of Orthodontics and Dentofacial Orthopedics

November 2004

Table I.

Ungrouped descriptive statistics: measurements (in millimeters) at pre-expansion (A1), short-term follow-up
(A2), progress (A3), and long-term follow-up (A4) in 30 patients
Variable
IM(a)
IM(b)
IC(a)*
IC(b)*
AL
AP

A1

A2*

A3

A4

33.95 1.81
45.13 1.98
21.37 1.59
26.36 1.90
64.96 2.90
69.23 3.24

34.92 2.03
46.61 2.18
21.63 1.45
26.13 1.49
64.98 2.75
69.23 3.07

35.00 1.84
46.26 2.09
20.68 1.69
26.55 1.84
62.10 3.17
65.90 3.28

34.87 2.03
45.86 1.96
20.37 1.51
26.12 1.84
60.65 3.41
64.38 3.10

Data are presented as mean SD. IM(a), IC(a), lingual points: intermolar and intercanine widths at tooth/gingival intersection; IM(b), IC(b),
occlusal points: intermolar at mesiobuccal cusp tips and intercanine widths at cusp tips; AL, arch length; AP, arch perimeter.
*In 2 subjects, canines were not present at stage A2, and these were not included in intercanine samples.

error is not adequate to offset or confuse prediction based

on average variations observed in this study.
RESULTS

Descriptive analyses of the 6 variables (4 arch-width

measurements, arch length, and arch perimeter) at 4
assessment stages for all 30 subjects are shown in Table I
and Figure 1. For the lingual values, the mean initial
mandibular intermolar width was 33.95 1.81 mm, as

opposed to the maxillary width of 32.47 2.25 mm. The

mean initial mandibular occlusal intermolar width was
45.13 1.98 mm, whereas intercanine widths (lingual
and occlusal values) were 21.37 1.59 mm and 26.36
1.90 mm, respectively. The mean initial arch length and
arch perimeter were 64.96 2.90 mm and 69.23 3.24
mm, respectively.
The paired Student t-test results are shown in Table II.
From pre-expansion (A1) to short-term follow-up (A2), a

Fig 1. Box-plots of variables measured at pre-expansion (A1), short-term follow-up (A2), progress
(A3), and long-term follow-up (A4). IM(a) intermolar width (lingual points); IM(b), intermolar width
(occlusal points); IC(a), intercanine width (lingual points); IC(b), intercanine width (occlusal points);
AL, arch length; AP, arch perimeter.

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American Journal of Orthodontics and Dentofacial Orthopedics

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Table II.

Paired Student t-test results for significance of

average difference values (in millimeters) for each
variable at pre-expansion (A1), short-term follow-up
(A2), progress (A3), and long-term follow-up (A4) in
30 patients
Comparison
A2A1

A3A1

A4A1

A3A2

A4A2

A4A3

Variable

Mean

SD

P value

IM(a)
IM(b)
IC(a)
IM(a)
IM(b)
IC(a)
AL
AP
IM(a)
IM(b)
IC(a)
AL
AP
IC(a)
AL
AP
IM(b)
IC(a)
AL
AP
IM(b)
IC(b)
AL
AP

0.97
1.47
0.39
1.05
1.13
0.68
2.85
3.33
0.93
0.72
0.99
4.30
4.85
1.14
2.87
3.33
0.75
1.37
4.32
4.85
0.40
0.43
1.45
1.52

0.88
1.32
0.81
1.41
1.63
1.14
1.88
2.66
1.77
1.66
1.22
1.71
1.83
1.02
1.43
2.26
1.19
1.11
1.77
1.82
0.94
0.78
1.92
2.05

.0000**
.0000**
.019*
.0003**
.0007**
.0027*
.0000**
.0000**
.0076*
.024*
.0001**
.000**
.0000**
.0000**
.0000**
.0000**
.0018*
.0000**
.0000**
.0000**
.027*
.0055*
.0003**
.0003**

*P .05;
**P .001.

In 2 subjects canines were not present at stage A2 and these were not
included in intercanine samples.

significant increase (lingual values) in mandibular intermolar width of 0.97 mm was seen (P .001), whereas
maxillary intermolar width showed a net gain of 5.59 mm,
approximately 6 times greater than the mandibular intermolar width change. There was a significant increase of
1.47 mm in mandibular intermolar width (occlusal) (P
.001). The increase in intercanine width (lingual) of 0.26
mm was also significant (P .05). There were no
statistically significant changes for occlusal intercanine
width (occlusal), arch length, and arch perimeter. The
maxillary intercanine width (occlusal) increased significantly, by 4.51 mm.
From short-term follow-up (A2) to long-term follow-up (A4), a period marked by the transition from
mixed to permanent dentition, no significant changes
(lingual values) were found for mandibular intermolar
width, but, for maxillary intermolar width, there was a
decrease of 1.3 mm. Mandibular intermolar width (occlusal) and intercanine width (lingual) showed significant
decreases of 0.75 mm (P .05) and 1.2 mm (P .001),

respectively. No statistically significant changes for maxillary and mandibular intercanine widths (occlusal) were
seen. Arch length and arch perimeter showed significant
decreases of 4.32 and 4.85 mm, respectively (P .001).
The overall changes from pre-expansion (A1) to
long-term follow-up (A4) were a significant mandibular
intermolar width increase of 0.93 mm (lingual) and 0.72
mm (occlusal) (P .05 for both). The intercanine width
(lingual) decreased significantly, 0.99 mm (P .001).
There were no statistically significant changes for mandibular intercanine width (occlusal). Arch length and arch
perimeter showed significant decreases of 4.30 and 4.85
mm, respectively (P .001).
The association verified by the Pearson correlation
coefficient test between mandibular intermolar width (occlusal versus lingual values) changes was highly correlated (r 0.80) for all 4 assessment stages studied (Fig 2).
Similarly, mandibular intercanine width (occlusal versus
lingual values) changes were highly correlated (r 0.90
at A1 and A3; r 0.80 at A2 and A4) (Fig 3).
DISCUSSION

Spontaneous mandibular response after palatal expansion has been reported ever since RPE was reintroduced in the United States.2,10-12 Even though investigators have suggested that some mandibular arch
expansion is possible, very few published studies support this clinically significant fact. In this study, we
assessed the short-term and long-term spontaneous
mandibular response after RPE in patients with Class I
malocclusions and transverse maxillary/mandibular
skeletal discrepancies.
There are some important points to keep in mind when
considering the results of this study. Because the mandibular intercanine width (lingual value) cannot be obtained
from the time the deciduous teeth are shed until the
permanent successors have fully erupted, this measurement was not considered during the transitional dentition
period. All the mandibular dental casts measured represented mandibular dental arches with mild or no crowding. Results were compared with other RPE studies and
with longitudinal studies of untreated patients and did not
involve comparison with populations whose treatment
was restricted to orthodontic appliances.
Intermolar width

Intermolar width has been the most frequent measure of posterior arch dimension. In this study, after
RPE, from pre-expansion (A1) to short-term follow-up
(A2), there was a significant increase (P .001) of
0.97 mm for intermolar width (lingual value). This
increase was greater than some of the mandibular
intermolar widths (occlusal) previously reported. There

580 Lima et al

American Journal of Orthodontics and Dentofacial Orthopedics

November 2004

Fig 2. Scatter plots and Pearson correlation coefficients (r) of mandibular intermolar width changes
(occlusal versus lingual values) measured at tooth/gingival intersection (a) and at mesiobuccal cusp
tips (b) at pre-expansion (A1), short-term follow-up (A2), progress (A3), and long-term follow-up (A4).

Fig 3. Scatter plots and Pearson correlation coefficients (r) of mandibular intercanine width changes
(occlusal versus lingual values) measured at cervical margins of tooth from point of greatest
convexity (a) and intercanine width changes measured at cusp tips (b) at pre-expansion (A1),
short-term follow-up (A2), progress (A3), and long-term follow-up (A4).

Lima et al 581

American Journal of Orthodontics and Dentofacial Orthopedics

Volume 126, Number 5

was a significant increase (P .001) of 1.47 mm for

the occlusal value. From A1 to A2, both increases
mentioned above suggest a slight uprighting. To determine how much of the changes observed between A1
and A2 might be associated with changes through
normal growth, each patients occlusal width measurements were subtracted from Moorrees mean width
changes for each antimere and for each childs age and
sex.8 As a result, 0.08 mm of mandibular intermolar
width increase (occlusal) might be attributable to
changes through normal growth, and 1.39 mm (of 1.47
mm) to RPE.
Wertz10 reported an intermolar width increase of
1.5 mm for only 2 of 48 subjects, similar to the results
of the present study. Wertz left buccal bars off his
expansion appliance and rarely opened the expansion
screw beyond 7 mm; thus, he reported relatively little
change for mandibular intermolar width. Ulrich13 reported on patients who were treated with a bonded
rapid palatal expander and observed a 0.99-mm intermolar width increase, which is less than in the present
study.
Two long-term studies7,14 showed larger increases
in intermolar width2.3 and 2.8 mm, respectively. On
the other hand, longitudinal studies of untreated patients have shown either slight increases or decreases in
this dimension with increasing age. Sinclair and Little15
found no significant increases in intermolar width for
male patients, whereas female patients showed a statistically significant loss of 0.88 mm.

decrease of 1.1 mm postretention, with a mean net gain

of 0.7 mm.
In contrast to studies of untreated subjects, in this
investigation, the intercanine width (occlusal value)
remained stable. According to some investigators,17,18
the intercanine width continues to decrease (0.5-1.5
mm) during the maturation of the permanent dentition.
Sinclair and Little15 showed intercanine width to be a
stable dimension in male patients, with minor decreases
(0.73 mm) noted in female patients aged 13 to 20 years.
Arch length

In the present study, mandibular arch length did not

show any changes that were attributable to RPE,
remaining unchanged from pre-expansion (A1) to
short-term follow-up (A2). At long-term follow-up
(A4), however, there was a 4.32-mm decrease, which
was less than, but resembled, the 4.83-mm decrease in
arch length reported by Sinclair and Little.15
On the other hand, Moussa et al7 verified a net gain
in arch length of 0.6 mm from pretreatment to postretention. Differences in results might be attributed to
their samples large age range (8.4-19.3 years) at
pretreatment.7
Arch perimeter

In this study, arch perimeter remained unchanged

after RPE and decreased 4.85 mm by long-term followup. Moussa et al7 reported a 0.6-mm arch perimeter net
decrease in the mandible 14.3 years after retention.

Intercanine width

Mandibular arch

For intercanine width (occlusal value), we found no

change after RPE. Haas2 reported no change for intercanine width in 5 of 10 subjects analyzed; however, the
age range was 9 to 18 years, rather than 7 to 9.10 years
in the present study. All short-term and long-term
studies reviewed showed larger intercanine width increases than the present one, ranging from 0.5 to 5 mm,
which might be attributed to differences in sample
selection criteria. Ulrich13 showed an increase in intercanine width of 0.69 mm.
Investigating the long-term stability of intercanine
width changes in the mandibular arch, Haas16 found
stable increases up to 4 or 5 mm. According to Moussa
et al,7 regardless of the direction of change induced by
the treatment, often a decrease occurred after retention.
Consequently, this evidence suggests that arches expanded into a broader arch form during treatment
undergo subsequent relapse of certain areas. Moussa et
al7 reported a mean intercanine width (occlusal value)
increase at posttreatment of 1.8 mm, followed by a

Review of the outcomes of other short-term and

long-term studies shows that, overall, the mandibular
response to RPE was quite variable. This might be
attributed to the lack of standardization for measurements of arch dimensions; differences in types of
malocclusions, age ranges at the beginning of treatment, sample distributions and sizes, follow-ups, types
of appliances used, and factors related to appliance
construction and application. All these variations make
evaluation of treatment outcomes very difficult to apply
in clinical practice.
The results of the present study are consistent with
what Haas2 has said since 1961, that a permanent
increase in the maxillary apical base leads to a spontaneous, permanent, and significant increase in mandibular arch width. According to findings of the present
study, the position of the mandibular dentition might be
influenced more by maxillary skeletal morphology than
by the size and shape of the mandible. Moreover, the
mandibular arch dimensions indicated that the position

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American Journal of Orthodontics and Dentofacial Orthopedics

November 2004

of the mandibular dentition after maxillary expansion

is, from a clinical perspective, stable.
Even though there was no orthodontic intervention
in this study, mandibular arch width was maintained or
increased, even through the transition from the mixed
to the permanent dentition. Considering the decrease
expected in changes through normal growth, this was a
remarkable finding. As expected, arch length and arch
perimeter decreased through the transitional dentition.
CONCLUSIONS

Mandibular intermolar arch width increased significantly after RPE with a Haas-type expansion appliance. This increase was followed by a slight decrease of
the occlusal value, whereas the lingual value was
maintained. Intercanine width (occlusal value) remained stable throughout all assessment stages. Arch
length and arch perimeter decreased during the transition from the mixed dentition to the permanent dentition. No meaningful adverse effects were observed in
the mandibular dentition after RPE, and the effects on
the mandibular dentition associated with this form of
maxillary intervention were favorable. The long-term
outcomes in spontaneous mandibular arch response to
RPE showed a remarkable and positive clinical stability
in mandibular arch-width dimensions in Class I malocclusion patients treated only with RPE.
We thank Dr Andrew J. Haas for his critical review
and constructive suggestions.

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