European Journal of Orthodontics 16 (1994) 295-300 O 1994 European Orthodontic Society

Changes in cheek pressure following rapid maxillary

expansion
Demetrios J. Halazonetis, Elias Katsavrias, and Meropi N. Spyropoulos
Department of Orthodontics, Athens University, Greece

SUMMARY The purpose of the present investigation was to study the effects of rapid maxil-
lary expansion on the pressures exerted by the cheeks on the maxillary arch. The sample
consisted of 15 patients (five males, ten females) who received either a Hyrax or Haas type
expansion appliance for treatment of a bilateral maxillary constriction of more than 5 mm.
The median age of the sample was 12 years. Buccal pressures were measured at the upper
first molar on the left and right side, before and after active expansion, and also after an
average of 3-4 months of retention with the appliance in place.
Buccal pressures on the maxillary first molar averaged approximately 3 g/cm2 before
expansion and increased significantly to a value of approximately 9 g/cm2 after expansion.
Pressure change was approximately 0.6 g/cm2 for each millimetre of expansion. During the
3-4-month period of stabilization of the appliance, the pressures remained at the post-
expansion levels and no adaptation of the soft tissues was observed. These results lead to
the conclusion that cheek pressures on the maxillary arch may be implicated in the relapse
occurring after rapid expansion, even after the usual 3-month period of stabilization.

Introduction movements and resting positions (Gould

Rapid maxillary expansion is probably unique
in orthodontics for achieving such a large and
evident orthopaedic effect. The separation of
the maxillae is, however, followed by a large
tendency for relapse. Skeletal relapse is due to
the high stresses accumulated between the
articulations of the craniofacial complex and is
usually no longer present once the mid-palatal
suture remineralizes, during the third month
after expansion (Zimring and Isaacson, 1965,
Wertz, 1970; Ekstrom et al, 1977; Wertz and
Dreskin, 1977; Bishara and Staley, 1987).
Dental relapse may be attributed to such factors
as the tension produced in the palatal mucosal
and supracrestal fibres (Muguerza and Shapiro,
1980), the buccal axial inclination assumed by
the upper teeth, and the resulting imbalance
between the buccal and lingual pressures.
The teeth are thought to reside in a state of
equilibrium, balanced between the cheek and
tongue pressures. Experimental evidence, how-
ever, seems to suggest that such an equilibrium
of forces does not exist, tongue pressures being
significantly greater during almost all functional
and Picton, 1962, 1968; Weinstein et al, 1963;
Lear et al, 1965; Lear and Moorrees, 1969;
Luffingham, 1969; Promt, 1975, 1987a,b; Tinier
et al, 1985; Thtter and Ingervall, 1986; Kato
et al, 1989; Lindeman and Moore, 1990). This
imbalance remains a puzzle and various factors
have been implicated to explain it, including
forces resulting from the occlusion, from the
periodontal ligament and from the transverse
gingival fibres. Recently, studies of lingual pres-
sures using new instrumentation have reported
significantly lower values, indicating that per-
haps the observed imbalance of forces may be
attributed to limitations of the experimental
apparatus (Frohlich et al, 1991, 1992).
The purpose of the present investigation was
to study the effects of rapid maxillary expansion
on the pressures exerted by the cheeks on the
maxillary arch. These pressures may be implic-
ated in the dental relapse seen after expansion,
and it would, therefore, be interesting to observe
if there is an increase in pressure during the
expansion phase of treatment and if the pres-
sures return to pre-expansion levels during the
stabilization of the appliance.
296 D. J. HALAZONETIS ET AL.

Table 1 Distribution of sample by sex and age. instead of water. The diagram and photograph
of the device are shown in Figs 1 and 2. Air
Patient Sex Age was pumped into the tube assembly and escaped
1 male 11.3
through the hole in the mouthpiece. The mouth-
1 male 11.8 piece was held on the buccal aspect of the first
female 12.3 maxillary molar, so that the opening faced
4a female 11.8 towards the cheek. When the opening was
5 female 10.10 covered by the cheek, the air pressure in the
6 male 11.0
7 female 12.0
8 female 11.9
9 female 12.3
10 male 12.7
11 female 11.6
12 female 15.3
13 female 11.6
14 female 13.2
15 male 16.1

Median age: 11.9

Subjects and methods

Fifteen subjects (five male and ten female) parti-
cipated in the study. The age of the subjects
ranged from 10.10 to 16.1 years (Table 1). All
subjects were diagnosed as having a bilateral
maxillary constriction with posterior cross-bite
(bilateral or unilateral), requiring expansion of
at least 5 mm. A Haas or Hyrax type appliance
was used for correction of the maxillary con-
striction, as the first stage of the orthodontic
treatment. The appliance was then stabilized
and left in place for retention.
Instrumentation
The pressure measuring device was constructed
based on the same principle used by Thuer et al.
(1985) with modifications. The device was self- Figure 2 (a,b) The pressure measuring device with detail
contained and portable, and air was used of the mouthpiece.

digital display

000.00 gr/cm4
electronic pressure
transducer mouthpiece

6mm
air pump

Figure 1 Diagram of the pressure measuring device with detail of the mouthpiece (measurements are in mm).
CHEEK PRESSURE AND RAPID EXPANSION
tube assembly increased, depending on the pres-
sure of the cheek on the mouthpiece. The
increase in air pressure was measured by an
electronic transducer (SCX05DNC, SenSym
Inc, 1255 Ream wood Ave, Sunnyvale,
CA 94089), converted to a digital signal by an
A/D converter (ICL7135 Intersil) and displayed
on the digital display of the device. The mouth-
piece had a size of 6 x 3.5 x 1 mm. The max-
imum pressure that could be recorded by the
device was approximately 150 g/cm2, as limited
by the air-pump capacity.
Calibration of the pressure measuring device
was carried out by immersing it at various
depths in distilled water. Calibration was
checked at various times during the experi-
mental period and no recalibration was found
necessary.
Measurements
The distance between the buccal surfaces of the
upper first molars was measured before, during,
and after active expansion, and also during the
retention period. Pre-expansion width was
measured without the appliance in place, and
assigned a value of zero. Increase of width
during expansion is reported based on this pre-
expansion width. The thickness of the molar
band and the palatal attachments was included
in the measurements, because the cheek and the
mouthpiece of the pressure measuring device
would be displaced additionally by this amount.
Some of the expansion values that are reported
are, for this reason, greater than the 10 or
11 mm that are usually produced by expansion
screws.
Pressure from the cheek was recorded oppos-
ite the first maxillary molar on the left and right
side. Measurements were taken with the patient
relaxed. The patient was positioned so that the
Frankfort plane was horizontal and the teeth
lightly in occlusion. At each measurement ses-
Table 2 Descriptive statistics of the variables measured.
Expansion (mm) Pressure right (g/cm2)
Pre- Post-
expansion expansion
Mean 10.78 3.43 8.94
Median 11.0 4.1 8.7
SD 2.43 2.75 3.59
Range 5.75-14.0 0-7.8 0-17.8
297
sion, three readings were taken and the average
of the three was used. To allow the patient to
become accustomed to the mouthpiece, a couple
of sham measurements were performed. Then
readings were taken alternatively from the two
sides of the arch, with a couple of minutes
between measurements. All measurements were
performed by the same investigator using the
same mouthpiece. The size of the mouthpiece
was similar to the attachment on the buccal
surface of the molar and this facilitated the
placement of the mouthpiece at approximately
the same position for each measurement.
Results
Descriptive statistics of the variables measured
at the three time points are shown in Table 2.
A two-factor analysis of variance of the pressure
measurements showed a statistically significant
difference between the pressure measurements
at the three time points, but no statistical differ-
ence between the right and left side mea-
surements.
The changes in pressure between the time
points were further investigated using the paired
Mest (Table 3). During the expansion phase,
the cheek pressure on the right side increased
from 3.43 to 8.94 g/cm2 (P<0.001) and on the
left side from 3.23 to 9.72 g/cm2 (P<0.001).
During retention, no statistically significant
change in pressure was observed (Fig. 3).
Pressure values for all the patients are shown
in the bar graph in Fig. 4.
Discussion
The purpose of this investigation was to study
the dynamics of the cheek pressure on the upper
molar during rapid expansion. The results could
provide a better understanding of the factors
that lead to relapse of the expansion, as well as
of the equilibrium of tooth position.
Pressure left g/cm2) Retention
(days)
Post- Pre- Post- Post-
retention expansion expansion retention
9.16 3.23 9.72 9.42 118.4
9.4 4.2 9.2 8.7 98.0
3.69 2.73 2.69 2.48 47.8
0-16.5 0-7.0 6.3-16.0 5.6-15.5 62-253
298 D. J. HALAZONETIS ET AL.

Table 3 Changes in cheek pressure during the expansion and retention phase.

Expansion phase, Expansion phase, Retention phase, Retention phase,

right side left side right side left side
Mean of difference 5.51 6.48 0.22 -0.29
t-Value (paired Mest) 6.28 8.43 0.73 -1.01
Probability (P) 0.000 0.OM 0.48* 0.33*

*NS, change not statistically significant.

Right Left

Right Left Right Lett Right Left

Initial Post-expansion Post-retention

Figure 3 Mean pressures at the three time points for the

right and left sites. Vertical lines represent one standard
deviation above and below the mean.

The sample was not divided according to sex
or type of malocclusion, mainly because of its
limited size, but also because the purpose was
to study changes in pressure for the individual
and not differences in pressure between indi-
viduals. It was, therefore, assumed that all
subjects would respond in a similar manner to
the treatment performed. Moreover, Thtier and
Ingervall (1986) did not find any correlation
between cheek pressure and sex. Differences in
the design of the expansion appliance (Haas
versus Hyrax) are not thought to have influ-
enced the results, as these differences are mainly
located in the palatal aspect of the appliance.
The expansion protocol was similar in all cases.
The measuring device was a simplified version
of the device used by Thiier et al. (1985) and
others (Thiier and Ingervall, 1986; Frohlich
et al, 1991, 1992). The use of air instead of
water reduced the time response of the device,
but this was not a consideration in this study,
as mean rest pressures were recorded and not
pressures during swallowing or other functional
activities. The device was capable of measuring
20 15 10 5 0 0 5
^Pressure (gr/cm 2 )
| o Mitel • Post-expansion •Post-retention |
Figure 4 Bar graph of the pressure values of the 15 patients
for the three time points measured. Missing bars signify a
value of zero.
negative pressures, but no negative readings
were obtained, in contrast to other studies
(Thiier and Ingervall, 1986; Frohlich et al,
1991, 1992). The negative pressures reported in
these studies are possibly due to a negative
atmospheric pressure that arises in the oral
cavity during breathing or swallowing. This
negative pressure, which probably affects the
teeth from both the buccal and lingual side,
would not be present without a complete lip
seal. Therefore, the fact that no negative pres-
sures were observed may be attributed to two
factors. First, the lips were slightly apart in the
area of insertion of the mouthpiece. This pre-
vented any negative atmospheric pressure from
accumulating in the oral cavity, and recordings
CHEEK PRESSURE AND RAPID EXPANSION
of zero pressure were observed when the cheek
was not in contact with the upper molar.
Secondly, the use of air instead of water elimin-
ated the need to swallow, which could be
responsible for the build up of negative pres-
sures in the above mentioned studies.
Pre-expansion pressures were lower than the
pressures reported by Luffingham (1969) and
Proffit (1975), who found a mean value of 7.2
and 8.7 g/cm2, respectively. This is to be
expected according to the results of Gould and
Picton (1968) and Proffit (1975, 1978a,b), who
conclude that the cheek pressures are adaptive
in nature and, therefore, lower pressures would
be expected in subjects with constricted arches.
Seven subjects in the present study had a pre-
expansion pressure of zero in at least one side
of the dental arch, due to the lingual position
of the upper molar, which precluded the cheek
from coming into contact with it.
During expansion, pressure increased signi-
ficantly in all subjects, except for patients 11
and 15 on the right side. Pressure increase was
of the order of 0.6 g/cm2 for each mm of expan-
sion. Post-expansion pressures were slightly
higher than those reported by Luffingham
(1969) and Proffit (1975), probably due to the
over-expansion of the maxillary arch and the
buccal position of the mouthpiece, because of
the presence of the molar attachments of the
expansion appliance.
The appliance was stabilized for the usual
period of 3 months, although in some patients
it was retained longer. During the stabilization
period there was no significant decrease in the
cheek pressures measured. McNulty et al.
(1968) reported on a sample of five patients
who had their upper incisor denture teeth posi-
tioned labially. Two of the subjects showed a
gradual adaptation of the soft tissues and return
of the labial pressures to initial levels. The rest
of the sample showed inconsistent responses.
Soo and Moore (1991) placed a lip bumper
appliance, and studied the labial pressures at
the incisor and canine areas. After an expected
initial rise in pressure, they reported a gradual
decrease in pressure at the incisor area, as the
lips adapted to the lip bumper appliance during
a period of 1-2 months. No such change was
observed for the canine region, where the place-
ment of the appliance resulted in an initial drop
in pressure, which continued during the period
of the experiment. This result could not be
explained by the investigators.
299
The results of the present study seem to
suggest that the constriction of the maxillary
arch in these patients was not caused by a
hyperactive buccal musculature, pushing the
teeth towards the tongue. Rather, the con-
stricted position of the teeth (caused by other
factors) resulted in low buccal pressures, as the
cheeks were left hanging passively without sup-
port, other than the mandibular arch. After
expansion, the maxillary teeth, now closer to
their normal position, could provide this sup-
port and would bear increased buccal pressures.
This probably relieves the lower arch of some
of the buccal pressures that were exerted on it
previously and this can be an explanation of
the automatic expansion that is observed in the
lower arch during rapid maxillary expansion.
During expansion, the cheek pressures at the
upper molar increase, and remain high for at
least the usual period of stabilization and reten-
tion of the expansion. This does not, however,
necessarily mean that these high pressures are
responsible for the dental relapse that almost
always follows the removal of the palatal expan-
sion appliance, even though they are of a magni-
tude capable of producing tooth movements
(Weinstein, 1967). The skeletal and dental
changes that accompany rapid maxillary expan-
sion alter the tongue position as well and,
therefore, the whole dental equilibrium.
Furthermore, the cheek pressures after expan-
sion, although higher than the pre-expansion
pressures, were close to the normal range of
pressures reported for patients with dental
arches of normal width. Thus, the changes
observed in this study may signify a normaliza-
tion in dental equilibrium. Further study is
needed to better resolve these issues.
Simultaneous measurement of cheek and lingual
pressures during rapid expansion would be
interesting, but is hampered by the inevitable
bulkiness of the expansion appliances, which
does not allow a normal tongue position.
Address for correspondence
D. Halazonetis,
19 Likavittou Street,
Athens 106 72
Greece
Acknowledgements
We would like to express our thanks to Drs E.
Anastasopoulou, D. Kardara, M. Nasika,
300
N. Souleles and A. Sotiriadou for kindly provid-
ing us with material for this study.
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