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Rapid palatal expansion is a preliminary treatment procedure that aims at enlarging the maxillary dental arch and the palate
(roof of the mouth) to re-establish balance between the width of the jaws. This procedure is also called maxillary expansion.
Expansion is indicated when the upper jaw is too narrow compared to the lower jaw. This often causes an abnormal dental
relationship and/or deviation of the lower jaw (see pictures).
A jaw that is too narrow can often limit the airway located above the palate (nasal cavity) and expansion may sometimes help
this condition. Palatal enlargement can facilitate the flow of air in the nasal cavity and allow the patient to breathe more easily
through the nose.
By widening the jaw, expansion may create more space to align crowded teeth.
This procedure can be done at an early age because jaw width problems are visible early and will not be fixed with time.
It is important to note that most of the time, a second phase of treatment will be necessary when all the permanent teeth have
erupted to complete the corrections of the malocclusion.
Expansion is not aimed at correcting dental malpositions but only harmonizing the width of the jaws instead. This can
sometimes improve the position of the teeth but, sometimes, the position of the upper incisors may seem to be not as good after
the expansion (to see examples). This will be fixed during a second phase of treatment.
Ideally, expansion using an expander is performed at an early age (mixed dentition).
(A) 6-year-old boy with a narrow upper maxilla. When the mouth closes, the mandible is aligned with the upper jaw (blue arrow). (B) At the e
between the right canines (circle) makes the mandible shift to the right in a crossbite. Rapid maxillary expansion will correct
(A) At the end of the expansion treatment, the maxillary arch is overcorrected; there is a lot more expansion than neces
segments are wider than the lower posterior teeth. The mandible now deviates to the left, which shows occlusal instability a
more obvious with an upper occlusal view (B, arrows). This excess in expansion will disappear once the expander is remov
removing the appliance, the excess in expansion starts to decrease. (D) After 5 months, the maxillary arch width is norm
corrected, the midlines are aligned and the mandible is centered.
(A and C) 7-year-old young patient with a posterior crossbite (arrow) caused by a narrow maxilla. This makes the
mandible deviate to the right. (B) This deviation is visible when looking at the face; the chin is shifted to the right.
After expansion, the posterior crossbite is corrected (arrow), the maxillary arch is wider and the chin has shifted toward
the middle, thus eliminating the asymmetry. Notice that there is still a significant space between the central incisors
(diastema). This space can close a little in the following months, but a diastema will remain because this boy already
had a significant space before expansion.
To see other examples of mandibular deviation corrections following rapid palatal expansion, follow this link.
What is an expander and how does it work?
The expander is a custom-made orthodontic appliance which is bonded (cemented) to the posterior upper teeth
and which allows enlargement of the palate.
It includes a screw placed in the middle that can be turned to activate the appliance and generate a force that
delicately separates the two palatal bones where the suture that unites them in the middle is located.
The patient (or the parent) must perform 1 or 2 screw activations per day, never more, until desired
enlargement is obtained.
The activation period can last from 2 to 3 weeks and will result in activating the screw between 40 and more
than 50 times.
The patient is seen regularly (every 7-15 days) during the activation period.
Once necessary expansion is obtained, activations of the screw are stopped and the appliance stays in place
3 months to allow the bone tissue to form in the middle of the palate, in the suture that has been enlarged.
Illustration: The palate is composed of several bones united in the middle by the medial palatal suture (red
line). The rapid expansion appliance acts on this suture to separate the bones by moving them laterally (blue
arrows) thus widening the palate. (adapted from Timms 1979)
During maxillary expansion, the opening of the suture is made progressively but rapidly:
(A) The first 3-4 turns of activation of the appliance will not produce visible changes, but still start to act on the suture.
(B) After a few turns, the suture starts to open. A diastema (space) that appears between the upper central incisors confirms
that the opening of the suture occurs normally. Activation is continued until the desired amount of expansion is obtained ( 3
weeks).
(C) At the end of the activation period, the suture is maintained open by keeping the appliance in the mouth approximately 3
months without turning the screw. This immobilization period is necessary to allow remineralization of the opening zone of the
suture. After this period, the expander can be removed. The space between the central incisors starts to close during
immobilization.
The opening of the suture is not visible in the mouth but it is visible on an X-ray. The X-rays below show a palate with an
expander in place while the palatal suture opens during the rapid maxillary expansion phase. When the suture opens normally, a
diastema (space) will appear between the upper central incisors.
The red arrows indicate the opening zone of the palatal suture.
The immobilization period ( 3 months) after the activation of the screw allows this area to undergo recalcification and form
bone in the opening zone of the suture.
It is possible to radiologically confirm that a maxillary suture is opening properly as shown on the examples below. Having to take
such radiographs is however uncommon.
(A) Before activation of the appliance; the expansion screw and the suture are closed. (B)
Toward the end of expansion, the screw is open (blue arrows) and the suture is open by
several millimetres. The red arrows indicate the dark zone which represents the opening of
the suture. (C) Another case showing a very wide opening during maxillary expansion. The
expansion screw was open by 14 mm and the dark zone of the suture is well visible.
Front (anteroposterior) view, a radiograph clearly shows the opening of the palatal suture indicated by yellow arrows. A, B and C represe
radiograph. The expansion screw, which reached its maximum opening, is also visible. The red arrow in (C) indicates the opening between
Occlusal radiograph where the opening of the suture is clearly visible. The darker areas on the radiographs are where the maxillary bo
Note: Several variations in the design of expanders exist and each orthodontist has his own preferences. Certain appliances
have more or less acrylic that covers the palate, they can have molar bands, acrylic that covers the posterior teeth, springs or
extensions behind the anterior teeth, etc. Regardless of the kind of appliance used, they all have a screw in the middle that must
be turned or activated and they are fixated permanently to the posterior teeth (until the end of the treatment) and the activation
principles and the instructions below apply. Every type of fixed appliances can be efficient if they are used properly with known
protocols.
The activation is performed by inserting the special key that we have given you into the screw located in the middle of the
expander and by turning the screw backward (toward the throat). Do not be afraid to insert the key all the way through the hole of
the screw, the key has a stopper that will prevent it from being inserted too deeply.
It is normal to see the child produce an exaggerated amount of saliva in the few hours following the insertion of the appliance.
The mouth thinks that the appliance is food! This will disappear rapidly.
The activation should not be painful to the patient. In fact, turning the screw is often more traumatic psychologically for the
parent who does it than for the child!
This must generally be done twice per day; once in the morning and another time in the evening, unless we tell you otherwise.
Never perform more than 2 turns per day. If you have to skip a turn for some reason, do not try to make up for lost time by
doing more turns the following days. The total number of turns is more important than the rate (turns/day) at which they are
made.
We will see the patients two weeks after the expander is installed to verify that everything goes as planned, that the
expansion progresses normally, etc. Afterward, and depending on the amount of expansion required, we will see the patients
every two weeks until the total desired expansion is obtained.
Once the expansion is obtained, we will stop turning the screw and will immobilize the appliance for a period of approximately
three months (immobilization period) before removing it.
It is preferable to make the turns before eating to minimize the discomfort sensation that can follow activation.
Avoid activating the appliance right before going to bed.
Ensure that you see the screw well. For the parents: when you activate the appliance, make the patient sit on a chair and make
him/her tilt his/her head backward to get a better view. Good lighting is also essential. If you activate your own appliance, do so
in front of a mirror.
Ensure that you wrap the string of the key around your finger or wrist. This important precaution will prevent you from
swallowing the key accidently.
Insert the key in the hole in front of the screw. Then push the key delicately, but continuously, from the front to the back of the
mouth. Remove the key at the end of the turn (toward the back of the mouth). A new hole will automatically appear in front of the
screw when you push the key backward as far as possible. The screw is now ready for the next activation. The screw contains 4
different holes and each activation is equal to one-quarter turn.
The upper jaw is generally wide enough in 15 or 20 days. However, the appliance must stay in the mouth for an immobilization
period of 3 months to allow the formation of bone to fill up the space created by expansion. The appliance will thus remain in
the mouth for a total of 4 months.
Installing a fixed expander bonded to the teeth only takes a few minutes. To see how this appliance is installed, follow the
The screw of an expander can be open by more than 1 cm to enlarge the palate.
8-year-old young girl with a posterior crossbite treated using rapid expansion. (A) The narrow upper jaw causes interferences between the te
when the mouth closes (arrows), which make the lower jaw deviate to the right. The midlines (middle of the dental arches, in blue) are no
aligned. (B) At the end of the expansion phase with the appliance in the mouth. (C) Once the appliance is removed, the width of the maxilla
arch is adequate and the mandible repositioned itself in the middle (aligned blue lines). Deviation of the jaw is no longer present.
These temporary upper canines present a crossbite (tilted inward) but this is a dental problem rather than a skeletal one.
Correcting this does not necessitate rapid palatal expansion.
(A) When a space (diastema) is already present before the beginning of rapid maxillary expansion, the opening of the space between t
significant. Right posterior crossbite (arrows). (B) The initial space of 2.5 mm increased to 10 mm when the expander was immobilized. (C
close completely on its own, but it is possible to close it using fixed appliances. This correction can be performed while the expander is
activation turns are finished. (D) Result after the closing of the diastema, the removal of the appliances and the posterior relapse of t
(A) Before expansion, the upper central incisors are straight. (B) At the end of expansion, a significant space will appear
between the central incisors which are still straight (arrows). (The hygiene problem and dental plaque accumulation are to
be noted.) (C) After a few months, the central incisors have relapsed mesially, but they also titled mesially, which may occur
sometimes. This will be corrected during a subsequent step.
Although such variation in the position of teeth may cause a small esthetic damage in some rare cases, this usually does not
cause any functional problems. Lets also remember that expansion being only a first phase of treatment, other corrections will
be necessary later anyway to finalize and optimize the position of incisors and all the irregularities will thus be corrected.
Moreover, it is possible that these teeth will move again when the permanent canines erupt.
(A) 9-year-old young girl showing a bilateral posterior crossbite (arrows) caused by a significant constriction of the upper m
(C and E) At the end of the expansion phase with the expander still in the mouth. (D) After the relapse of the overcorrection of expansion, th
a normal relationship (in width), but the upper central incisors have a different inclination. (F) Immediately following the removal of the exp
redness and inflammation that will quickly disappear with a good oral hygiene. The yellow line has the same dimension as on image (B) and
the increase in the palatal width obtained.
(A) Bilateral posterior crossbite (arrows) caused by a maxillary constriction in an 11.9-year-old girl. The upper central incisors are relatively
(B) After 4 weeks of activation of the rapid expansion appliance, the central incisors are not at the same level and are starting to tilt toward t
later, when the expander is immobilized, the central incisors seem to upright slightly. (D) 2 years after the expansion, the permanent teeth
central incisors are still tilted even if they came closer together a few weeks after the expansion ended. A second step of treatment will
malpositions.
(A and B) Right posterior crossbite in a patient with mixed dentition (arrows). There is no space between the upper central incisors before
expansion. (C) Maxillary constriction causing the crossbite. (D and G) Expansion created a 8-mm diastema between the upper central incis
during immobilization of the expander. (G) This upper occlusal view shows the amount of overcorrection obtained. (E) After 3 months of imm
removal of the appliance, the space has closed completely (black arrow). (F) Maxillary expansion is maintained when the permanent prem
erupt.
(A) Another example of a significant dental space present before the treatment. OPTICAL ILLUSION; These pictures show that it is hard
(B) After expansion, the diastema almost reaches 10 mm and will close partially of expansion obtained by only using pictures. (A) A fron
afterwards. show a significant posterior expansion, but still, the scr
mm! (B) An upper occlusal view makes it possible to
posterior segments go past 100% the lower posterior t
90% to the left (arrows), which confirms that a lot of ex
Remember that optical phenomenon by looking a
The following image illustrates a transverse cut of the palate where a crossbite is present on the right side.
(A) Unilateral posterior crossbite (blue circle on the patients right side). The opposite side can be normal (no crossbite) or could
also present a crossbite (bilateral crossbite).
(B) As expansion progresses, teeth are moved outward. Interference between the tips of the teeth may occur on the side where
the crossbite was; the teeth will then momentarily fit in a tip-to-tip relationship (red circle). On the opposite side, teeth may separate
vertically (absence of contact). The patient may then be under the impression that teeth only touch on one side. The interference
may sometimes be adjusted by polishing the tips of the teeth if this causes discomfort to the patient.
(C) At the end of expansion, overcorrection that makes the upper teeth go over the lower teeth is seen on each side (more on
the side where there was no crossbite to begin with). This is normal and desirable.
(D) Normally, after the relapse following the removal of the appliance, the overcorrection disappears and teeth touch normally after
having returned partially toward the middle.
The red line represents the initial palatal width and serves as a comparison to appreciate the enlargement of the palate.
The blue line shows that the mandibular arch width is relatively stable compared to the maxillary arch. In fact, however, a little bit of
expansion may occur in the mandibular arch that tends to follow the upper one.
A special activation key that allows for a better grip on the rod that must be inserted in the hole of the expansion screw exists.
This may be useful for patients who have a more limited opening of the mouth or if you have a hard time with a standard key. We
will provide you with this key if necessary.
(A) Activation key with a plastic handle (blue). (B) When the tip of the rod is inserted in the hole of the expansion screw and (C) during acti
handle backward to complete the one-quarter turn.
Example showing that crossbites do not auto-correct with time, years and growth. See below for more details on this c
(A) At 5 years of age, this boy showed a narrow upper maxilla. When he closes his mouth, an interference is present between
the temporary right canines (blue circle). In this incomplete closing position, the midlines of both jaws are aligned (blue dotted
lines).
(B) When he closes his mouth completely, which is necessary to get the posterior teeth to touch and chew, the interference
forces the mandible to shift to the right (white arrow), thus creating a right posterior crossbite (blue arrows) and a significant
deviation of the midlines (blue lines). We refer to this type of crossbite as being functional because, even if the cause of the
problem is a maxilla that is too narrow, the crossbite is visible when the function (closing) is used (functional crossbite).
(C and D) 6 years later, that is at 11 years of age, the permanent teeth have started to erupt and, despite growth, the same
maxillary constriction is still present with the posterior crossbite and the deviation of the midlines. This condition does not get
fixed without orthodontic intervention.
(A) Malocclusion with a left posterior crossbite (arrows) caused by maxillary constriction. (B) At the end of expansion, with the appliance in
was created during expansion and will progressively close. (C) After more than one year and once the eruption of the permanent teeth is co
functional and esthetically acceptable. No other corrections were performed. (D) Open mouth showing an alignment that is relatively acc
irregularities.
It may sometimes occur that a preliminary intervention, such as palatal expansion, be sufficient to obtain a functional and esthetic
occlusion that does not require any other interventions when the patient is a teenager. This is what happened in the following
example where a 9.4-year-old young boy had a right posterior crossbite accompanied by a mandibular shift on the same side.
Maxillary expansion and a short treatment to align the incisors resulted in an acceptable occlusion.
(A) 9.4-year-old boy Posterior crossbite (yellow arrows) and mandibular shift to the right when the mouth closes. This is obvious by comp
dotted lines). (C) Immobilization of the rapid maxillary expansion appliance at 9.5 years of age. (D) The use of a few orthodontic brackets
anterior crossbite and align the upper incisors. (E) These corrections only lasted for a few months. (F) 11.3 years of age The correction of
and we are waiting for the other permanent teeth to erupt. (B) When the permanent teeth have all erupted (13.5 years of age), the occlus
functionally acceptable and does not necessitate any other corrections. The midlines remain aligned. Lets also note the improvement of the
left lower incisor is located and which was slightly receding (blue arrows). Correcting the crossbite by these simple preliminary interventio
gingival loss with the years to come.
(A) Narrow maxilla in a 9-year-old boy who suffers from chronic snoring. (B) View of the upper jaw that is too narrow compared to the mandi
no guarantees, maxillary expansion often decreases snoring problems in children.
(A, B) Interference between the temporary canines that makes the mandible deviate to the right in a crossbite when it closes (B) in a 5-yea
any orthodontic intervention, the same condition remains 5 years later at 11 years of age. Growth is insufficient to correct such a problem.
still tipped inward (arrows in B, D, E and F). (G, H) The maxillary expansion will have made it possible to re-establish the balance between
correct the mandibular deviation.
This 18-year-old young man, who will start an orthodontic treatment to correct his malocclusion, shows a V-shaped maxillary arch that is
bilateral posterior crossbite. (A, B, C) Even if his gums are generally of good quality (width and thickness of tissues), even before the begin
teeth (indicated by the arrows) have different degrees of recession. The maxillary arch having to be enlarged, the level of gingiva will have
during the orthodontic treatment. If it diminishes significantly, gingival grafts or similar procedures may be necessary. The patient will have to
his oral hygiene and his brushing technique during the treatment to avoid contributing even more to gingival loss.
To learn about the steps and see videos illustrating how a rapid expansion appliance is installed and removed, follow this link.
Steps of the installation of a rapid maxillary expansion appliance. To learn more and see a video, follow the link ab