Palatal Expansion with the

Nitanium Palatal Expander (NPE)

Straight Wire Concepts: Diagnosis & Technique

NITANIUM PALATAL EXPANDER 2

ADVANTAGES
1.

Story and Ekstrom suggested that slow expansion procedures allow physiologic
adjustments and reconstitution of the sutural elements to occur in approximately
30days.
Findings show younger patients to separate the suture slightly. Suture separation occurs
at a rate which allows the maintenance of tissue integrity during adjustments to the maxillary
repositioning and remodeling, causing orthodontic and
orthopedic changes.
2.

Enlow - Growth along the mid-palatal suture is known to participate in the widening
of the palate. The natural tendency of cortical plates is to grow away from each
other, as shown in figure one diagram. This growth takes place at any age, if permitted.
Other treatment methods contract this natural growth.
3.
McAndrews - The application of light continuous forces along reversal lines in areas
allowing periosteal growth acts to develop normal arch dimensions at any age without tilting
teeth beyond desired levels.
4.
Bell - Increased activity of fibroblastic and fibroclastic and osteoblastic activity
occurs when maxilla is slowly widened. The slower expansion techniques have also been
associated with a more physiologic adjustment to the stability and less relapse potential than
in rapid expansion procedures. Often a neuromuscular adaptation of the mandible to the
maxilla, allowing normal vertical closure.
5.
Histologic findings show greater repairatory reaction and greater stability than the
R.P.E.
6.

Requires no adjustment by the patient.

7. Can program appliance to exact expansion

required and will stop at that point.
8.

No effect on speech or eating.

9.

Does not require frequent adjustments.

10. Rotates molars buccally and distally.

Figure

11. Can be used for anchorage.

12. Can be placed directly. Does not require costly lab procedures.
13. Reduced cost and time savings.
14. No real apparent suture splitting as seen in the R.P.E. or Quad helix.

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15. Light, gentle, continuous force.

16. No patient discomfort.
17. Total operator control.
18. Can widen the suture slightly for favorable fibroblastic, fibroclastic and osteoblastic
response.
19. Influence the direction of maxillary and mandibular growth.
20. Less retention time required usually 6-8 weeks.
21. Less tipping of abutment teeth thus less relapse.
22. Can be used with headgear, utility arches or continuous archwires.
23. With maxillary alteration, can get opening of the nasal cavity in younger patients.
24. Takes only 2 well fitted bands and is easy to insert.
25. Can influence the symmetrical repositioning of the TMJ.
26. Very hygienic.
27. Working with nature.
28. More physiological.
29. Allows patient to accept a mandibular comfort zone.
30. Can allow mandibular advancement.
31. Will cause orthodontic and orthopedic changes.
32. Greater stability.

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PALATAL EXPANDER COMPARISONS

Transverse expansion of the palate has been used by clinicians for over 100 years to
produce additional room in the maxillary arch. Today there are numerous removable
appliances such as the Schwarz plate, Jackson, Crozat, Saggital, etc., which incorporate
either jackscrew or coffin-type adjustments. All of these appliances depend upon a high
amount of patient cooperation, and most of these appliances are lost (by the patient)
during the first month of treatment resulting in disappointment to the parent, patient and
doctor.
There are also fixed/removable appliances, such as the transpalatal bar, W-arch, quad
helix, Potter arch, Wilson multi-action palatal, Cetlin-type rotators, etc. Some of these
appliances can also be easily dislodged. Most of these devices must be removed and
adjusted by the doctor every 3 to 4 weeks and have intermittent forces (up to 2 pounds)
which are often unpredictable.
Most rapid palatal expanders (RPE) are fixed appliances that utilize a jack screw and
(sometimes) acrylic assemblies. These devices require: two upper bicuspid bands and
two molar bands soldered to a jack screw (often referred to as a Hyrax); an impression; a
working cast; cleanup; lab services and cementation. These devices are activated by the
patient, rely upon a high amount of patient cooperation, and tend to generate excessive
pressure on the mid-palatal suture. Additionally, the relapse rate for these devices can
approximate 45%, depending upon the amount of sutural opening. Many RPE appliances can cost $100.00 or more.
Other appliances such as the Pendulum Appliance is a fixed appliance which incorporates
an expansion screw and a nickel titanium wire to distalize molars. Again, this appliance
is highly dependent upon patient adjustments. This appliance has limited applications,
and if used as directed, can be very expensive.
Ortho Organizers Nitanium Palatal Expander (NPE) is a fixed/removable nickel titanium
appliance. The Nitanium Palatal Expander incorporates an innovative lingual attachment
with adjustable ortholoy arms and a horizontal lingual sheath that is spot-welded to
maxillary molar bands. A locking indent fastens the expander securely to the maxillary
molar band and, thereby, enhances the safety of the system. To prevent removal, the
applaince may also be secured by chain elastic or stainless steel ligatures.
The continuous low force exerted by the NPE appliance on the maxillary teeth and midpalatal suture approximates the physiologic ideal postulated by prominent researchers.
Bell says, Histologic findings reported in conjunction with slow expansion procedures
suggests that sutural separation occurs at a rate which allows for the maintenance of
tissue integrity during adjustment to maxillary repositioning and remodeling. The NPE
is capable of delivering a uniform low continuous force to the mid-palatal suture.
The physical changes produced by the appliance on the palate are a consequence of
harnessing nickel titaniums shape memory and transition temperature. Nickel titanium
can be processed to a set shape which it constantly returns to after being deformed. This
is called shape memory. Nickel titanium can also be alloyed to produce a metal with
specific thermal transition temperature. Ortho Organizers transition temperature is 94o
F. At temperatures above the transition temperature, the inter-atomic forces bind the
atoms tighter, producing a stiffer metal. At temperatures below transition temperatures,
the inter-atomic forces weaken, producing a very flexible metal.
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Clinically, when you take the NPE (with a transition temperature of 94o F) and chill it, the appliance
becomes flexible and is easy to bend to facilitate placement. As the mouth begins to warm the
appliance (and subsequently reaches 98o F), the device becomes stiffer as the shape memory is
restored and the expander exerts a continuous low force on the teeth and mid-palatal suture to produce the expansion. As the expansion begins to take place, the stiffness in the appliance may cause
slight pressure which can be relieved by the patient sipping a cold fluid. This feature makes the
appliance very patient friendly because the patient can mitigate the pressure response.
Ortho Organizers Nitanium Palatal Expander (NPE) has the capacity to rotate, upright, expand and
distalize the maxillary molars while simultaneously expanding the bicuspid segment. From the time
of insertion, until completed expansion, the appliance can be adjusted by the clinician if desired.
In summary, the device is self-activated by body temperature, automatically expands to its predetermined shape, requires no manipulation by the patient or practitioner, permits the patient to mitigate
the pressure response, produces a low constant pressure on teeth and mid-palatal suture, and has a
built-in safety system.

HOW TO MEASURE FOR THE NPE

1. Research has indicated that approximately 90% of cases that are in need of palatal
expansion require a minimum of 4 mm increase (expansion) of the upper first molars
(2 mm per side).
2. To determine the millimeters of expansion required for an individual case; three methods can
be used:
A. Schwarz Index
B. Arch Measurement
1. Measure the width of the distal buccal cusp tips of the mandibular first molars.
2. Measure the width of the central pits of the maxillary first molars. This will give you the
desired width. Subtract the mandibular measurement to determine the difference in mm.
This is the mm amount of expansion you will need.
3. Measure lingual to lingual of the maxillary first molars where the lingual sheaths will be
placed. Add to this, the mm difference you need to expand. This will give you the
appliance size in mm.
4. The widest portion of the dental arch is the mesial buccal cusp of the maxillary and
mandibular first molars.
C. The third method is very simple. Measure from the lingual of the maxillary first molars,
where the lingual sheaths will be placed, and add 4 mm to this measurement. This will
be the size NPE required.
3. An additional 2-3 mm can also be gained by adjusting the wire of the NPE by placing a
bend in the center of the nitanium loop of the appliance using plier # 200-450.
4. If 6 mm or more of expansion is needed, two separate expanders (used in sequence) may
be required.

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SEATING THE NITANIUM PALATAL EXPANDER

The Nitanium Palatal Expander is designed to work in
conjunction with a standard horizontal lingual sheath
welded on a band. Once the doctor has established the
need for expansion of the maxilla, the appliance
can be inserted much the same way as a
standard Goshgarian palatal bar or a stainless
steel lingual transpalatal arch is inserted.
1.

Place separators mesial and distal on

upper first molars.

2.

Fit bands that have both buccal tubes

and lingual sheaths attached.

3.

Assemble the expander with the bands

as one unit and secure with ligature wire
or chain elastic.

4.

If needed, a trial fitting can be done prior to cementation.

Connect the spary straw to nozzle of ice spray can, then
spray the entire surface of the nitanium wire and place
appliance on first molars.

5.

For best results, we recommend use

of a glass ionomer cement, such as
Fascinate or Ketak. Mix cement and
place in bands, spray entire surface of
nitanium wire with ice spray which will
make the appliance dead soft for easy
placement.

6.

While the nitanium wire is passive, seat one band

completely, then seat the other band. When bands
are completely seated, immediately remove any
excess cement.
NOTE: An alternative method
for seating is to cement both
molar bands in place and seat
the appliance once the molar
bands have set. Also, if ice spray
is not available the appliance can
be placed in a cup of ice water
or the freezer for a few minutes
prior to delivery.

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NPE2
QUESTIONS & ANSWERS
1. Does it split the palate?
No, it does not split the palate in the early adult or adult dentition. Clinical research has shown, however, that
the suture widens in the primary and early mixed dentition and radiographic findings have shown a repair in
approximately 30 days (plus or minus a week). It appears that as the palate expands, regeneration matches the
rate of expansion.
2. Does it cause tipping of molars?
Molars and bicuspids will tip (like most expansion appliances) but over treatment will allow for normal settling.
Tipping can also be corrected with brackets and archwires as part of continuing treatment.
3. Why a shorter retention time?
This is a physiological movement that does not split the palate. Tissue regenerates while it is expanding.
4. How do you determine size to use?
One way is use the Schwarz analysis. Another option: When lower permanent first molars are in a normal
position, measure (in millimeters) the tip of the distal buccal cusp across the arch. (this millimeter measurement
= A) Next measure the central pit of the upper permanent first molars. (this millimeter measurement = B)
Subtract the central pit measurement of the upper first permanent molars (B) from the buccal tip measurement
of the lower first permanent molars.(A) This will yield the number millimeters of expansion required.
Next measure the lingual surface of upper permanent first molars where the lingual sheath will be placed (this
millimeter measurement = C) and add this measurement to the measurement of required expansion.
(A2
B+C = NPE size needed) This final number will give you the size of expander required. (The NPE allows for
the prescribed expansion plus 1.5mm to 2mm of over-correction due to the combined width of band material
and thickness of the lingual sheaths. Thus, a built in over correction of 1.5mm to 2mm)
5. Can you reuse the appliance?
It is not recommended. This appliance is for single use only. Reuse loses the initial effectiveness of the wire.
If an appliance is reused, the manufacturer will not be liable. Reuse may also violate OSHA standards.
6. Does it cause orthodontic or orthopedic changes?
It does both initially. At first, movement will be orthodontic, but after expansion is achieved you will also see
orthopedic changes in the maxilla and often lower jaw repositioning as well.
7. Why not complete in 1-to-2 weeks?
Some rapid palatal appliances can complete expansion in 3 to 5 weeks, however, repair takes 6 months and
retention can be as long as 2 to 6 years. With the NPE2 appliance movement is more physiological: expansion
is slow with continuous low force. Expansion is usually complete in 2 to 4 months and retention is usually 2
to 3 months.

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8. Will it cause root resorption?

It is difficult to say if expansion will cause root resorption -as any orthodontic movement can
cause root resorption. With the NPE2 resorption is not likely. To date there has been no root
resorption according to radiographic findings.
9. Can you control and adjust torque?
Yes. However, this should not be done until the appliance has spent itself. One can adjust the
portion of the NPE2 wire that goes into the sheath by adding buccal root torque into the wire with
a plier.
10. How much expansion per expander?
Up to 6mm of expansion can be obtained from an initial appliance. Additional expansion of 2 to
3mm can be obtained by adjusting the anterior motor wire for bicuspid expansion and adjusting
the distal wire for additional molar expansion.
11. How much should you over-correct?
2 to 3 mm of over correction is recommended.
12. What is total treatment time?
Primary dentition:
1 to 2 months or less. 2 months retention.
Mixed dentition:
2 to 3 months depending on severity. 2 months retention.
Young adults:
Usually 3 months. 2 months retention.
Adults:
Depends on age:
Up to 5+ months. 3 months retention.
13. What are some of the other functions of the NPE2?
a.
Expander
b.
Rotator
c.
Retainer
d.
Fixed saggital with utility archwire
e.
Anchorage in extraction cases
f.
Retract canines while distally rotating and expanding
g.
Unilateral correction
h.
Cross bite correction
i.
Expansion in cleft palate patients
j.
Expansion in surgical cases
k.
Assists in expanding lower arch because of tongue
l.
Creates buccal root torque
m.
Unilateral or bilateral molar contraction
n.
Habit corrections
o.
Assists in advancing anterior incisors
p.
Assists in stabilizing retraction of incisors
q.
Useful in T.M.J. cases with posterior displacement-in combination with utility archwires

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14. Are there any university studies of this appliance?

Yes, several universities are presently evaluating the appliance. In addition, many private clinical studies
have been completed, including: Appliance affect on the suture, airway and lamina dura; orthodontic
and orthopedic changes; and expansion and distalizing affects of the first and second molars. Other
studies concerning jaw and facial change are currently under way.
15. Can this appliance be used with cleft palates?
Yes. Two U.S. cleft palate clinics are presently using the appliance.
16. Why is the cost so high?
Cost is minimal considering what the appliance does. After expansion and a slight modification, the
appliance can be used as a retainer, saving additional cost. Plus, there are savings in lab fees and
valuable chair time.
17. How do you stop the appliance?
Since the appliance is preprogrammed, it will only go as far as clinician has selected. However, with
slight adjustments, one can constrict the appliance or add further expansion at will.
18. What kind of adjustments can be made to the appliance?
You can adjust the male portion of the appliance for torque. Also, you can adjust the stainless steel
portions for additional unilateral or bilateral expansion. Adjust the motor wire for additional bicuspid
expansion and molar rotation.
19. How long should the appliance be left in?
After expansion is complete, leave the appliance in an additional 1 to 2 months as a retainer.
20. Can you distalize molars without the anteriors going back?
By placing a utility archwire to advance the anterior incisors. Many times incisors lingualize 1 to 2mm.
21. What percent of patients need expansion?
Approximately 25 to 30% of all patients can benefit from expansion. In Class II cases, 95% can benefit
from molar rotation and expansion.
22. What age groups are most likely to need expansion?
The age groups most likely to need expansion are mixed or early adult dentition. These groups are where
the most rapid orthodontic and orthopedic changes can be seen. The appliance can be used for Primary,
Mixed or Adult dentition. The 20 to 40 year-old patient will take longer to physiologically expand due to

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23. How much working time is involved?

This depends on the experience of the clinician. The very first appliance always takes a little longer to place.
Generally, it only requires the time to fit 2 molar bands, place the appliance into lingual sheaths and cement
the bands.
24. Can I weld the sheaths to the molar bands?
Yes, you can weld the sheaths to the bands, but it is best to have the manufacturer do this to prevent the
possibility of a sheath coming loose from a band.
25. Can I fit and cement bands first and place appliance?
Yes, but it is not advisable. If the molar bands are not cemented ideally or symmetrically to the appliance,
the appliance will not fit properly. It is best to cement the appliance as one assembled unit.
26. What if the molars are rotated?
If molars are too severely rotated to place expander, use a Nitanium Molar Rotator prior to the NPE2 .
Upon initial placement the expander will distally rotate and expand the molars, then later will expand the
bicuspid areas. The Ortholoy arms will not touch the bicuspids initially, but in approximately 2 to 4 weeks,
they will touch the lingual surface of the bicuspids.
27. Any problems with oral hygiene?
This a very hygienic appliance because there is no acrylic touching the palate. The NPE2 is very light and
low profile, not bulky like many other expansion appliances.
28. Does the appliance interfere with speech?
No. However, some patients will initially experience minor difficulty in speaking the first few hours.
29. Is there any patient discomfort with this appliance?
No. Patients may initially feel a slight pressure in the palate, but to date, there have been no compliants of
discomfort. In fact many patients say there is no discomfort at all.
30. Can this be used with the Cetlin Technique?
Yes. Using the NPE2 is not as traumatic and is much easier to adjust then the use of a stiff steel
transpalatal bar.
31. How much force does the appliance produce?
The force is 350 grams at 3mm increments. However, if a 6mm expansion appliance is initially placed, the
force will be higher. After 3mm of expansion has occurred, the force will return to 350 grams.

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CLINICAL TREATMENT MECHANICS FOR IMPACTED CUSPIDS

Impacted cuspids, palatal or labial, present complications in our routine treatment sequence.
The exact treatment mechanics vary significantly with each individual case. This case history
will present one version of treatment mechanics for management of a palatally impacted cuspid. Unfortunately, impacted canines most always increase our active treatment time. Their
movement is unpredictable resulting in indeterminable time sequencing. Therefore, it is difficult to say how long each individual step will take, but the basic mechanics for alignment will
remain consistent until the cuspids are in the arch.
Each individual case presents with many different considerations prior to determining a treatment sequence. Is the tooth labial or palatal? Is the impacted tooth rotated? Is referral surgery
required to expose the tooth? After exposure, what attachment can be placed on the exposed
tooth? Is there sufficient space in the arch for the tooth? Your answers to these questions will
help to determine the treatment sequencing.
Prior to exposing the tooth/teeth for bond placement, you will need to make space in the arch.
There is no need to apply florce to bring teeth into the arch unless you have made space to
accommodate them. If the posterior teeth are interdigitated properly, an archwire sequence
with open coil spring is ideal for creating and maintaining space for the cuspids. You will need
to determine if you can afford the anterior movement of the incisors. Anytime open coil spring
is used in the anterior, you will get some forward movement of the incisors. If the posterior
teeth are not interdigitated correctly, it will be necessary to establish the posterior segments by
making the antero-posterior correction prior to making space for the impacted teeth.
Once the posterior teeth are correctly positioned and you have sufficient space for the cuspids,
it will be necessary to expose the cuspid for bonding. For impacted cuspids that are in labial
version, I personally prefer to expose the labial surface of the tooth and place a small direct
bond bracket. Quite often, I will use a lower incisor bracket because of the size. Depending on
the severity of the impaction and the amount of tissue and bone removed, it may be necessary
to place a periodontal pack post surgery to allow for bracket placement at a later date. For
palatally impacted cuspids, I like to expose the cuspid and place a small direct bond bracket on
the lingual surface of the tooth. Placing the bracket on the lingual surface seems to allow
sufficient forces to move the tooth into position without rotating the crown of the tooth.
Treatment mechanics for aligning the cuspid should begin by placing an .016 x .022 stainless
steel archwire upper and lower. This wire is rigid enough to prevent any undesired movement
of the adjacent teeth. Place a short powerchain (5 units) from the lateral to the cuspid and then
to the first premolar. This is most often a unit of 5 links. The lateral and first premolar must be
steel ligated over the chain to prevent rotation. Because of the position of the cuspid, you will
likely need to have a free unit of chain adjacent to the cuspid. As the cuspid moves into
alignment, the chain can be decreased to a unit of three directly from the lateral to the cuspid
and to the first premolar.
As the tooth is repositioned, there can be some tissue bundling. During the alignment mechanics,
it may be necessary to periodically remove any bundling up of the tissue using an electrosurg
or laser. Clinically, the removal of this tissue has proven to expedite movement of the tooth.
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CASE REPORT:
A female patient, age 14.10 presented with a palatally impacted maxillary left cuspid. In addition
to the impacted cuspid, there was a significant tooth size discrepancy in the maxillary incisors
requiring bonding/veneers upon completion of the orthodontic treatment. Her dental classification
was Class I requiring no anteroposterior correction. After banding all first and second molars and
placing direct bond brackets second bicuspid to second bicuspid upper and lower, a routine
archwire sequence was initiated. At this time, the retained deciduos cuspid was extracted.
Approximately five months was spent progressing to the .016 x .022 stainless steel archwire upper
and lower, then the impacted cuspid was exposed. After ten days healing, a direct bond bracket
was placed on the lingual surface of the cuspid. A unit of five elastic powerchain was placed to
begin alignment of the cuspid. The chain was changed every two weeks for two months. At that
time, the tooth was properly bracketed and a unit of three powerchain was placed for further
alignment. After the tooth is moved into position labially, a .0175 twisted archwire was placed for
final alignment. This twisted wire was changed every three weeks, increasing the amount of
bracket engagement, for three months. This was followed by routine archwire sequence including
rectangular wires for final tip and torque of the cuspid. For a period of two months, using the .016
x .022 and .019 x .025 braided archwire, individual root torque was placed in the maxillary cuspid.
Total treatment time for this patient was 20 months.

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