American Journal of ORTHODONTICS

Volume 57, Nzlmber 3, March, 1970

ORIGINAL ARTICLES

Palata,l expansion: Just the beginning

of dentofacial orthopedics
Andrew J. Haas, D.D.S., MS.
Ctiyahoga Falls, Ohio

A
dictability
mong the most remarkable aspects of palate expansion is the pre-
of occurrences during treat,ment and results following treatment.
If the suture opens, as it invariably will in patients who are under 16 or 17
years of age, certain expected phenomena occur :
1. Anteroposteriorly, the opening of the midpalatal suture is paral-
lel; inferosuperiorly, the opening is triangular with the apex being in
the nasal cavity.
2. The central incisors react as expected, considering that they are
linked by elastic transseptal fibers. As the suture opens, the crowns con-
verge while the roots diverge. When the crowns come into contact, the
continued pull of the fibers causes the roots to converge toward their
original axial inclinations. During this cycle, which usually takes about
4 months, the axial inclination of these teeth may vacillate as much as
50 degrees.
3. The alveolar processes bend and move laterally with the maxillae,
while the palatal processes swing inferiorly at their free margin. The
effect is a dental arch expansion and an increase in intranasal capacity.
4. When the midpalatal suture opens, the maxilla always moves
forward and downward. This is probably due to the disposition of the
maxillocranial sutures. Sicherl calls attention to the fact that these su-
tures are oriented in such a. manner that growth would produce a down-
ward and forward vector of maxillary movement. Since these hafting zone
sutures are disengaged by the palatal expansion procedure, an effect

Presented at the sixty-third annual meeting of the American Association of Ortho-

dontists, St. Louis, Missouri, April 26, 1967.

219
 Amer. J. Orthodont.
220 Haas ikfQrch1970

similar to immediate growth is manifested in a downward and forward

displacement of the maxilla.
5. The change in maxillary posture invariably causes a downward
and backward rotation of the mandible which decreases the effective
length of the mandible and increases the vertical dimension of the IOWW
face.
The downward and forward conduction of the maxilla improves the Class
III closed-bite skeletal pattern because of the obviously improved spat.ial re-
lationship of the maxilla, and, as a result of the accompanying downward and
backward rotation of the mandible, the effective length of the mandible is
reduced and lower facial height increases. The posterior cross-bite is cor-
rected by lat.eral and bending movements of the alveolar processes. The a.n-
terior cross-bite is partially or completely ameliorated by the forward shift
of the maxilla and the clockwise rotation of the mandible.
The transposition of the maxilla affects the Class III open-bite skeletal pat-
tern with both favor and disfavor. Its effect is favorable in that the maxilloman-
dibular dysplasia becomes less severe. Unfortunately, however, as the mandible
rotates, the skeletal and dental open-bite deteriorates.
The downward and forward maxillary displacement makes the Class II,
Division 1 skeletal pattern decidedly worse with regard to the maxillomandib-
ular relationship, since the maxilla is now farther forward and the mandible
is farther backward. Most deep-bite Class II skeletal patterns are not af-
fected too adversely if the mandible possesses good characteristics. Thus, if
the mandibular rotation can be held, it will aid in bite opening.
The open-bite case, regardless of classification, is always affected adversely
by maxillary expansion. However, this need only be temporary and should
not be considered a contraindication to t,he procedure if factors requiring
the treatment are present in the case.

Indications for the procedure

Rapid maxillary expansion by opening of the midpalatal suture is cx-

tremely advantageous in the treatment of (1) both surgical and nonsurgical
Class III cases, especially the nonsurgical ones, (2) cases of real and relative
maxillary deficiency, (3) cases of inadequate nasal capacity exhibiting chronic
nasal respiratory problems, (4) the mature cleft palate patient, and (5)
selected arch length problems to avoid the profile disturbances so frequent.ly
a,ssociated with removal of teeth. These are ordinarily cases with good morpho-
genetic patterns where just a slight amount of width in both arches would give
an excellent occlusion.
In 19612 a preliminary report was made on forty-five cases treated initially
by palate expansion. Thirty-two of these cases have been without any maxillary
retention for at least 5 years. To date, not one of them has shown lateral re-
lapse. In more than 300 cases treated by this technique, there has not been a
relapse of the posterior cross-bite correction ; however, many of these patients
are wearing palatal retainers. This gratifying success is due to viewing these
cases with an orthopedic concept rather than an orthodontic prejudice. When
Volume 57
Number 3 Palatal expansion 22 1

attempting to correct the dysplasia in width, the attempt must be made to cor-
relate the denture bases rather than the dental arches.8 This practice will al-
most always result in a marked overcorrection of the buccal tooth segments,
usually into a bilateral containment of the mandibular teeth, namely, a Brodie
syndrome.
When the midpalatal suture opens, the alveolar processes appear to bend
laterally while the palatal shelves drop inferiorly. This, along with PDM com-
pression, results in considerable change in axial inclination of the posterior
teeth. It is therefore important that the dental expansion be overdone in the
interest of improving the denture base relationship.
The posterior teeth are readily controlled in the treatment subsequent to
removal of the palate-expanding device. An acrylic plate is placed within 48
hours, and the acrylic is trimmed from those teeth which are to be permitted
to tip lingually. Thus, a unilateral dental overexpansion can be controlled
by trimming one side of the acrylic plate more than the other. The areas of the
plate which contact the teeth may be used as fulcrums about which the buccal
teeth may be torqued to establish more upright buccal tooth segments.
Correction of only the dental cross-bite is inconsistent with the primary ob-
jective of orthopedic treatment-the establishment of a more favorable denture
base relationship. When this occurs, the maxillary posterior teeth must almost
always be markedly overexpanded. The increment of dental arch width gained
by alveolar bending, periodontal membrane compression, and extrusive tooth
displacement is almost certain to be lost in the orthodontic and postorthodontic
periods.
Brodie4p 5 has observed that the tongue is usually carried low in a patient
with constricted maxillary dental arches. He has suggested the use of a loose-
fitting acrylic plate as a possible means of training the tongue to a more normal
posture. Thus, placement of the acrylic plate, following maxillary expansion
would seem to have a dual purpose during conventional orthodontic treatment.

Objectives and requirements

To reiterate, the prime objective of palate expansion is to coordinate the

maxillary and mandibular denture bases. The appliance should be designed to
enhance the orthopedic movement and to curtail orthodontic response. The
dental anchorage units must be made as strong as possible. It would be de-
sirable to band all posterior teeth, with bands joined by buccal and lingual
soldered bars. Rigid unit castings cemented to the teeth would offer even
greater anchorage. These methods of attaining anchorage are discouraged by
the fact that in most cases the path of insertion of the appliance would be
difficult, if not impossible, to establish. Therefore, weakening the anchorage by
omitting the buccal soldered bars invites more denture displacement and less
suture opening.
The elimination of the acrylic palatal button in favor of an all-wire frame-
work is equally hazardous. Under such circumstances, the brunt of the screw
force is borne by the thin buccal alveolar plate while, with the split acrylic
palatal appliance, the bulk of the orthopedic force is resisted by the vertically
 Amer. J. Orthodont.
222 Haas J!rarch19iO

inclined walls of the palatal vault, alveolar process, and teeth. Therefore, less
toot,h movement and more orthopedic movement will occur.
It is interesting to note that authors6’ 7 who use anchorage-deficient palate-
expansion appliances report only slight changes in nasal cavity width. The
magnitude of the alteration in nasal cavity and apical base width is an excel-
lent indication of the success of the orthopedic effort. The increased width 01
the dental arch obviously is the least dependable.
W7ertz” analyzed changes in nasal airflow in a, small sample of cases follow-
ing maxillary expansion. He concluded that “opening the midpalatal suture
for the sole purpose of increasing nasal permeability cannot be justified.” It
would be difficult to quarrel with his conclusion in the light of the limited
nasal changes that his therapy produced. It would be of great interest, how-
ever, to follow a similar study on a larger sample of patients treated with a
maximum anchorage appliance.
I recently sampled 100 consecutive alphabetically filed maxillary expansion
cases. Patients over 17 years of age were excluded. The increase in nasal cavity
width was measured on the anteroposterior head films taken before and after
expansion. The mean increase in width for the 100 cases was 4.1 mm., with a
range of 3 to 5.5 mm. All cases showed expansion of from 10 to 11.5 mm. Had
screws of greater capacity been used, certainly a greater range of expansion
could have been attained. The results in this range have been so gratifying that
additional expansion should be approached with caution, if at all.

Fixed appliance and resistance units

The tissue-borne fixed split acrylic maxillary palate-expansion appliance is

seen in Fig. 1.
To attain maximum anchorage, the buccal and lingual bars are placed as
close to the gingiva as possible and contoured for maximum contact with the
abutment bands and unbanded second premolars.
The solder joints arc massive to additionally strengthen the anchorage unit.
Ideally, the abutment bands should be free of solder only at the interproximal
areas to permit insertion of the appliance. As previously stated, it would be
desirable to band more teeth or use unit castings to gain additional anchorage.
Alas, the path of insertion would probably be impossible in many cases if these
modifications were attempted!
Occasionally, it has been beneficial to extend the buccal and lingual bars
(closely contoured) to the canines and/or second molars.
Note that the acrylic masses are confined to the rather ischemic tissue which
lies between the first premolars and the first molars. Care is taken to avoid
impingement on t,he tissues that possess a rich blood supply, namely, the rugae,
the gingival tissue, and the tissue overlying the posterior alveolar foramina.
Fig. 2 beautifully illustrates a typical response when a tissue-borne palatal
expansion appliance is utilized. In the case illustrated, that of a 13-year-old
boy, the screw was expanded 11 mm. in 20 days’ time.
It is obvious that the posterior dental segments have moved as units with
their respective bases and have enjoyed minimal, if any, tipping or displace-
-volume 57
Number 3 Palatal expansion 223

Fig. 1. The tissue-borne fixed split acrylic maxillary palatal expansion appliance.

Fig. 2. Typical response to use of a tissue-borne palatal expansion appliance.

ment. It is axiomatic that the smaller the dental anchorage displacement, the
greater the separation of the maxillae.
Even though the central incisor separation in this case is outstanding, it
is not an ideal barometer as to the amount of suture opening, since the incisors
are usually moving proximally at an astounding rate.
The appliance design advocated by Isaacson and Murphy,? and first de-
scribed in principle by Goddard8 in 1893, seems to meet the requirement of
having a strong dental anchorage. The over-all anchorage value of the ap-
pliance is questionable, particularly when used on older patients, since the
only units of resistance are the buccal teeth, the periodontal fibers, and the
thin buccal alveolar plate.
When a fixed acrylic palatal appliance with dental anchorage reinforced
on both the buccal and lingual sides is used, the optimum in anchorage units
is achieved. The resistance units are the inclined walls of the palatal vault,
the buccal alveolar process, the posterior teeth, and the periodontal fibers.
While the all-wire framework appliance might be relatively efficient in a
mixed-dentition case or in a young full-dentition case, it must still be con-
sidered inferior to an applia.nce which gains additional anchorage by action
on the base itself. The all-wire framework appliance is unquestionably inferior
 Amer. J. Orthodowt.
224 Ham MWCk1970

to the base-borne appliance in older patients because of the resistance these

patients may exhibit to midpalatal suture opening. Frequently, after the age
of 18 years, it is not possible to open the midpalatal suture. This may be due to
the bridging of bone spicules across the suture or to the increased rigidity of
the contiguous bones, especially the zygomaticofrontal buttress. In any event.
the failure of the suture to open could result in extreme dental pain and even
to teeth perforating the buccal alveolar plate if entirely tooth-supported an-
chorage is utilized.
With similar conditions, when a base-borne fixed split acrylic palatal ap-
pliance is used, the patient over 18 years of age is instructed to turn the screw
one quarter-turn daily (approximately 0.25 mm.). The patient is also instructed
to stop turning the screw if the circummaxillary pressure is not dissipated
within l/z hour and to call the office. The patient is then directed to turn back on
the screw until comfortable ; this is rarely more than one quarter-turn. He
is then told to “turn the screw at whatever rate is consistent with comfort.”
Overexpansion of the buccal denture segments is gained in approximately
2 to 3 months. Of course, the patient is observed periodically ; an interval of
2 weeks between visits seems suitable. It is recommended that the appliance
be retained in place for at least 3 months. This, of course, is not necessary t,o
allow for suture repair, as the midpalatal suture probably was altered little,
if at all. However, the acrylic masses exert very heavy force against the maxil-
lary base during activation and probably well into the retention phase, and
this seems to stimulate “high” alveolar and apical base expansion. This is in
contrast to “low” alveolar expansion incurred when teeth are expanded with
a conventional orthodontic appliance.
When examining plaster models of cases treated in the above manner it is
difficult to distinguish them from those in which suture opening occurred. Fig.
3 shows three anterior views of a case in which the midpalatal suture failed to
open. The third model was made 3 years after all retention devices had been
removed. Recent photographs made 6 years after discontinuation of all reten-
tion is shown in Fig. 4. The stability of these cases is excellent.

A B C

Fig. 3. A, Anterior view before palatal expansion, at the age of 19 years. B, Anterior
view at retention, age 21. C, Anterior view 2 years out of retention, age 26.
 Palatal expansion 225

The greatest disadvantage to the all-wire framework appliance must OCCUr

during the retention period, while the teeth are supported in their expanded
state by the appliance. Thormeg noted that cases retained less than 2 months
demonstrated considerable collapse. No retention resulted in complete relapse,
while cases held over 2 months manifested complete stability. Zimring and
Isaacson1o have demonstrated that forces tending to collapse the maxillary
expansion exist for approximately 6 weeks.
Let us consider now the fact that the teeth are maintained in their ex-
panded state by the tooth-borne appliance, while for a period of 6 to 8 weeks
forces are compressing the expanded maxillae. Considering the physiology
of tooth movement, such a system of forces and resistances can only result in
partial relapse of the attained nasal cavity and apical base width. The pres-
sures on the maxillae would be directed in part to the buccal surfaces of the
roots of the maxillary buccal teeth.
The result, of course, would be resorption of buccal alveolar bone with at-
tendant medial movement of the maxillae. Such a phenomenon cannot occur
when a base-borne appliance is used, for the acrylic masses support the base.
The base-borne appliance is universal in that it will treat all cases, in all age
groups, better than existing appliance mutations which weaken anchorage. A
modification that would enhance anchorage would be welcomed.
Some of the use advantages of the appliances are that (1) it results in
greater nasal cavity and apical base gains, and the former facilitates breathing
in cases of nasal stenosis, (2) it results in a more favorable relationship of the
denture bases in width and frequently in the anteroposterior plane as well,
and (3) it creates more mobility to the maxilla (instead of teeth) for continued
maxillary orthopedic influence.
Anchorage stands alone as the salient characteristic to be considered in
designing a palate-expansion appliance. All others are relatively unimportant
by comparison. It is only reasonable that, if the object is to move bones, un-
desirable displacement of dental anchorage must be avoided. It seems that an
inverse proportion exists, namely, the greater the displacement of the dental
anchorage unit, the less the displacement of the maxillae and accompanying

Fig. 4. Intraoral photographs of patient shown in Fig. 1, 6 years out of retention.

226 Ham Amer. J. Orthodmt.
March 1970

midpalatal suture cleavage. The result is an orthopedic failure and frequently

a limited orthodontic success. Conversely, if minimal dental anchorage displacc-
ment is achieved, both an orthopedic and an orthodontic success are more easily
attained.
The base-borne appliance has been criticized as being capable of producing
tissue irritation. If the appliance is properly designed,2, 3 this is far more fancy
than fact. In my practice it has not been necessary to remove an appliance
because of tissue irritation in more than 8 years. Care must be taken to confine
the acrylic masses to the rather ischemic tissue covering the vault and palatal
walls from the midline to within several millimeters of the free gingival margin
and anteroposteriorly from the mesial aspect of the first premolar to the distal
aspect of the first molar.
It is imprudent to impinge upon the palatal rugae, the pala.tal gingival
tissue, and the soft tissue superior and lingual to the second molar. No special
instructions regarding hygiene need to be given to candidates for maxillary
expansion, as the tongue unwittingly is a superb janitor. It is easy to visualize
the tongue searching out food particles about the appliance, much 51s it does
when food particles cling to and between the natural teeth or other fixed and
removable prostheses.
The only thing which could be regarded as nonhygienic is the thin leathery
film of congealed mucus which coats the surface of the appliance previously
in contact with palatal tissue. There is no greater incidence of halitosis during
palate-expansion treatment and retention than is noted in conventionally
treated cases. Further, there is no greater odor when such an appliance is
removed than when conventional appliances are removed.
To completely ignore even a sta.ble dental anchorage in the interest of
hygiene when designing and using an all-wire framework appliance is an
unpardonable orthopedic sin. The primary law of orthopedics is “thou shalt
utilitze maximum anchorage to gain your orthopedic objective.”
In the thirty-two cases previously mentioned, frontal head films were taken
before and after palate expansion and at least a year after removal of all maxil-
la.ry retention. These head films were scrutinized with regard to permanency
of attained apical base and nasal cavity width. Parallel vertical tangents were
constructed to the points of greatest convexity on the lateral walls of the aper-
ture and greatest concavity on the zygomatico-alveolar crest (Fig. 5). This
point on the crest represents the approximate union of the alveolar and basal
bone in the area of the first permanent molar. A linear measurement was taken
across each pair of tangents to record the nasal and apical base width at the
three stages to be studied. In all cases, the gained apical base and nasal cavity
width held. The maxillary expansion in all instances had been accomplished
at least 5 years preceding the final measurements. These cases were retained
with the stabilized expansion appliance for at least 90 days following mid-
palatal suture separation. On the basis of this overwhelming evidence it can
be expected that the expansion of the maxilla, excluding the alveolar processes
is absolutely permanent if the prescribed technique21 s is followed. The incre-
ment of dental arch width gained by alveolar bending, periodontal membrane
compression, and tooth movement is liable to relapse.
Volume
Number
57
3
Palatal expansion 227

Fig. 5. Segmental tracing of a frontal head film showing tangents constructed to the
greatest curvature of the lateral nasal walls and the greatest concavity on the zygomatico-
alveolar crests, for purposes of measuring nasal cavity and apical base width.

Another impressive finding in the study was that measurements taken on

postexpansion and postretention records for each case were completely com-
parable within a fraction of a millimeter, even when some images were ob-
viously foreshortened or elongated by tipping of the head. This suggests strong
validity to the use of measurements in the horizontal plane on frontal head
films, particularly near the midline.

Orthodontic force versus orthopedic force

Historically, the implication has been made that forces directed toward the
oral cavity with the ultimate purpose of altering the relationship of the teeth
are orthodontic forces. The cephalometric studyI by the Department of Ortho-
dontics at the University of Illinois in 1938 certainly proved that this was the
case to that time. The contention that orthodontic treatment affects only the
alveolar process is still unchallenged. However, there is no longer any question
in my mind that forces of a high magnitude which greatly exceed the minimal
forces required for tooth movement do expand and inhibit the growth potential.
These forces must be considered orthopedic.
The nature of the orthopedic force precludes the possibility of much tooth
movement until the force has deteriorated. Therefore, the teeth may be used
as anchorage units in directing these forces to intermaxillary and maxillo-
cranial sutures. Orthodontic and orthopedic forces often differ as to objectives,
application, intensity, time and timing, and type.

Objectives and application

The objective of orthodontic force is to move teeth individually or in units,

using other teeth, both supported and unsupported, for anchorage. When an
orthopedic force is used, the object is to realize maximum influence on the den-
ture bases and jaws. If the teeth are used as anchor units, it is desired to prevent
their movement as much as possible.
Orthodontic forces are always applied directly to the teeth, the kineses
228 Haas Amer. J. Orthodont.
March 1970

being supplied by arch wires, intermaxillary elastic, intramaxillary elastics,

light extraoral force, bite plates, and other auxiliaries. It is intended that cer-
tain teeth move while others, hopefully, remain stationary.
Orthopedic forces a,re exerted both extraorally and intraorally. The intra-
oral application requires dental anchorage units of maximum resistance to
minimize their displacement and to maximize the effect of the force on sutures
and other growth sites.
Intensity of force

It is generally conceded that optimum tooth movement occurs with rela-

tively mild forces, whether they are continuous or intermittent. They are usu-
ally directed toward a small area, such as the periodontal membrane of a tooth
or teeth.
At its source an orthopedic force must be great because it is dissipated over
a wide area, be it a single maxillary suture, a complex of maxillary sutures,
or the entire mandible. At its focus of activity, the force is relatively light and
physiologic in character.
Orthodontic forces are ideally measured in grams and ounces, while ortho-
pedic forces must be calculated in pounds.

Time and timing

Orthodontic forces may be administered at any time during the life of a,

person and will be effective in changing tooth relationships. These forces are
ordinarily applied over a shortened period of time, as it usually takes less time
to modify a dental relationship than a skeletal relationship.
Orthopedic forces are ideally utilized in the early growth experience of
the individual, whether it is desired to promote or retard the growth potential.
The latter is possible only in the growing person. Except for palate expansion,
orthopedic forces are necessarily applied over a longer period of time because
of the relatively slow unfolding of the growth process.
Type of force

Orthodontic forces may be intermittent or continuous. Orthopedic forces are

usually intermittent, at least at this stage in their use. Should anyone doubt
the potential of heavy forces applied to facial sutures, attention is directed to
Fig. 6, which dramatically demonstrates the orthopedic effect of the Milwaukee
brace on a child treated for scoliosis. Note that the effect goes far beyond the
mere depression of teeth or inhibition of alveolar growth. The teeth, with their
ability to resist depression, probably were strong factors in mediating the
heavy orthopedic force to the sutures of the hafting zone, other craniofacial
sutures, the mandibular condyle, and the alveolar processes.
Contrary to popular belief among orthodontists, the Milwaukee brace does
not exert an active force against the mandible.12The brace does exert pressure
against the areas of the spine to be modified. To try to avoid these pressures, the
patient is expected to “get up off the brace” into a more normal posture. There
is no active pressure from the brace to the mandible. The mandible receives a
Volume 57 Palatd expansion 229
Number 3

Fig. 6. Before- and after-treatment tracings of a patient treated for scoliosis with the Mil-
waukee brace. The broken-line after-treatment tracing was constructed from a film made
438 days following the initial film and tracing. The patient was 12 years 3 months old at
the start of treatment. Note the almost unbelievable loss in vertical dimension and splay-
ing of anterior teeth. [Courtesy of Albert P. Westfall.)

downward pressure from the weight of the head when the patient is not up off
the brace. This pressure is equivalent to the weight of the head, about 8 to 10
pounds in a one-hundred pound child. If a force of this magnitude can produce
deformity, why would it not be feasible with a force of lesser intensity, but
nevertheless a heavy force, to produce a negative mandibular rotation in an
open-bite skeletal pattern?
The negative rotation of the mandible would depend on depression of
supraerupted posterior teeth, inhibition of posterior alveolar growth, preven-
tion of the descent of the maxilla, or perhaps even influencing mandibular
morphology. Sassouni and Nanda13 offer a noteworthy description of the musculo-
skeletal relationships in the deep-bite and open-bite skeletal patterns. They vis-
ualize the deep-bite person as having the vertical chain of mast&tory muscles
well forward of the molar resistance, where it serves to keep buccal teeth de-
pressed. In the open-bite skeletal type, these muscles exert an oblique force pos-
terior to the molar resistance. This arrangement of the musculature not only dis-
courages bite closure but contributes to continual divergence of the jaws with
subsequent growth.
If the orthodontist could mechanically simulate a more anteriorly disposed
musculature, then conceivably the open-bite skeletal pattern could be favorably
influenced by depression of molars, inhibition of posterior alveolar growth,
prevention of the descent of the maxilla, and even a change in the mandibular
230 Haas Amer. J. Orthodont.
March 1970

Fig. 7. Application of the vertical-pull chin cup to produce both skeletal and dental bite
closure.

form. The end result would be a counterclockwise forward and upward rotation
of the mandible, with an attendant decrease in anterior facial height and in-
creased mandibular prominence.
Fig. 7 depicts a vertical-pull chin cup, one method of applying a vertical
force anterior to the molar resistance. The vertical-pull chin cup is very effec-
tive in countering the undesirable downward and backward rotation of the
mandible which accompanies palate expansion and which is particularly un-
desirable in the open-bite skeletal pattern, regardless of classification.
Fig. 8 demonstrates the superimposed tracing of a Class III open-bite
skeletal tendency prior to and subsequent to treatment. This patient was
subjected to a vertical-pull chin cup through 26 months of treatment and 9
months of retention. Note the bite-closing effect by the chin cup in spite of
adverse genetic growth tendencies, palate expansion mechanics, and the use of
Class III intermaxillary elastics, all of which contribute to a deterioration of
the original pattern.
The Y axis closed, the mandibular plane angle decreased, and the occlusal
plane flattened dramatically. It would seem, therefore, that the vertical force
from the chin cup triumphed over the bite-opening forces.
The Class III case responds ideally to maxillary expansion. The buccal
cross-bite is ordinarily corrected within 3 weeks. The anterior cross-bite may
or may not be resolved by the downward and forward displacement of the
maxilla and negative mandibular rotation.
The accompanying negative rotation of the mandible causes a favorable
change in the deep-bite skeletal pattern by diminishing the effective length of
the mandible and lengthening lower face height. The A-P relationship of the
Volume 57 Palatab expansion 23 1
Number 3

Fig. 8. Class III case which benefited materially from the application of the vertical-pull
chin cup. No vertical elastics were used in treatment of this case.

denture bases is correspondingly improved. Conversely, the open-bite skeletal

pattern becomes more severe with the negative mandibular rotation.
The entire maxilla appears to be made mobile by the palate-expansion pro-
cedure. At least, this could be hypothesized from the reaction of the bone to
subsequent manipulation. For example, in the deep-bite skeletal pattern if the
anterior cross-bite is not corrected by displacement of the maxilla, vigorous
Class III elastics are applied directly to the stabilized palatal appliance. Since
the appliance literally binds the maxilla into a unit, the pull of the Class III
elastics off a full mandibular strap-up, in essence, pulls against the entire
maxilla.
The maxilla responds to the vector of the force by moving forward and
tipping down in the back. The molars are also extruded. These events contribute
to increased posterior vertical dimension which, as expected, influences man-
dibular posture in a downward and backward rotation.
It is this synergistic negative mandibular rotation and positive maxillary
movement which orthopedically correct the anterior dental cross-bite and im-
prove the denture base relationship, namely, point A and point B.
Fig. 9 illustrates the case of a lo-year-old boy with a 17-day interval be-
tween compared tracings. The maxilla moved forward in a counterclockwise
rotation, tipping down in the back with ANS serving as a pivot. The com-
pensatory rotation of the mandible was downward and backward. The very
stable pterygoid root plane, as suggested by Ricketts,14 was used to measure
changes in the profile. While point A and the maxilla came forward only 1 mm.,
232 Haas

Fig. 9. Class III deep-bite skeletal pattern which shows slight maxillary displacement but
marked mandibular rotation in response to maxillary expansion.

pogonion event backward 5.5 mm. and downward 8 mm. This spectacular
mandibular movement was not in part translator>-, as might be suspected from
its magnitude. It was a simple rotational movement and resulted in a dramatic
change in the profile, which Fig. 30 substantiates. Remember that this OCCW~~
in 17 days. Note t.he change in the Downs profile arc from a concave arc to a
straight line. The arc is a curve scribed through nasion, point A, and pogonion.
Cephalometrically, the patient tended to the deep-bite skeletal pattern; thus,
heavy Class III elastics were applied to the maxilla through the stabilized
palatal appliance.
Fig. 11 establishes what happened in the 2 months that these elastics WPW
used. The maxilla was tippect down further in back and moved forward 2 mm.
at point A. A corresponding downward and backward rotation of the mandible
was not seen because nlncl~ of the bitt opening ohscrv-cd in the initial tracing
was due t,o a severely disturbed buccal occlusion. The behavior of the mandible
in this tracing reflects the bitt closing due to improved buccal occlusion.
The over-all efYect of orthopedic management for 4 months is made evident
in Fig. 12. Observe that the maxilla moved forward 3 mm. and tipped down in
the back while pogonion moved back 3 mm. with the rotation of the mandible.
The general effect was an improved skeletal pattern due to a more favorable
denture base relationship, increased lower face height, and decreased effective
mandibular length.
The question of whether skeletal bite opcnin g due to maxillary displacement
will be permanent is still unanswered. Clinical observations to date indicate
 Palatal expansion 233

Fig. 10. Roentgenograms showing amazing change in profile in a mere 17 days’ time.

Fig. 11 Fig. 12

Fig. 11. Tracings showing the effect of the use of vigorous Class III elastics to protract the
maxilla made mobile by the palate-expansion procedure.

Fig. 12. Tracings showing the combined action of palate expansion and the use of heavy
Class III elastics on the skeletal and dental pattern.
 234 Haas Amer. J. Orthodont.
March. 1970

Fig. 13. A profile change wrought by 18 days of palate expansion. Note the change in
the arc and the increase in lower face height.

Fig. 14. Tracings showing why the profile change in Fig. 11 was so dramatic. There was
a net change of 7 mm. in overjet, since point A came forward 3.5 mm. and point B re-
treated 3.5 mm.

that much of it is. Bite
not as stable as that due
A second deep-bite
mechanics is illustrated
place in 18 days. The
straight line.
opening due to supraerupted posterior teeth is probably
to maxillary displacement.
Class III case showing excellent response to orthopedic
in Fig. 13, which shows the profile change that took
profile arc changed from a concave arc to a relatively
 Palatal expansion 235

Fig. 15. Roentgenograms demonstrating the unquestionable forward displacement of the

maxilla since the PTM gap widened to the extent that the apex of the fissure is now patent.

In the previous case, the maxilla. moved slightly in response to palate ex-
pansion but a great deal in response to strong Class III elastic force. In this
case, measuring from the pterygoid root plane to point A and pogonion on the
profile, it is obvious that the maxilla has undergone tremendous change. It
moved forward 3.5 mm. and downward 2.5 mm. Pogonion went back 3.5 mm. and
down 5 mm. (Fig. 14). There was a net change of 7 mm. in overjet and 5 mm.
in vertical dimension ; hence the profound profile change.
Another exciting alteration occurred at PTM. Fig. 15 clearly shows an in-
crease in the size of the PTM gap as a result of the forward displacement of the
anterior root. Note the opening of the pterygomaxillary fissure at the apex of
the gap.
To continue the protraction of the maxilla, this patient wore a chin cup
designed primarily to use the mandible for anchorage. Elastics were worn from
the distal aspect of the stabilized palate-expansion appliance to the vertical
spines extending from the chin cup (Fig. 16, A and B). This gave a forward
vector of pull on the maxilla for 12 hours, while heavy intraoral Class III
elastics were maintained on a 24-hour schedule to displace the maxilla forward
while tipping it down in the back (Fig. 16, C). As a corollary, the mandible
rotated downward and backward, improving the facial pattern by decreasing
effective mandibular length and increasing lower face height.
In the open-bite Class III skeletal pattern, these mechanics would definitely
be contraindicated because of the obvious disastrous consequence of additional
skeletal or dental bite opening. Such a patient is subjected to a vertical-pull
chin cup to counter the bite opening caused during palate expansion. A pair
of protraction spines are added to the chin cup, as shown in Fig. 17. Elastics
are worn from the distal aspect of the stabilized palatal appliance to the spines
off the chin cup. The direction of force is in a horizontal plane. This mechanical
assembly will orthopedically influence the mandible in a forward and upward
236 Haas Amer. J. Orthodont.
March 1970

Fig. 16. The protraction chin cup (A) shows the chin being used as a source of anchorage
to protract the loosened maxilla horizontally with the use of heavy elastics. B, The elastics
run horizontally from the protracting spines on the chin cup to the first molar buccal hooks
on the palatal expansion appliance. C, Vigorous Class III elastics are also worn to tip the
maxilla down in back to permit skeletal bite opening.

Fig. 17. The use of the vertical-pull chin cup to counter skeletal and dental bite opening
where such a phenomenon is undesirable. Simultaneously, the maxilla may be protracted
in the maxillary deficiency cases by use of the intra-extraoral protraction elastics.
Volume 57 Palatal expansion 237
Number 3

Fig. 18 Fig. 19

Fig. 18. Obvious degeneration of the skeletal pattern. Point A came forward 2.5 mm. while,
with negative mandibular rotation, pogonion receded 2 mm. Thus, there was a 4.5 mm.
deterioration in skeletal overjet.
Fig. 19. Tracings verifying the tendency for the maxilla and mandible to return toward
their former posture.

rotation while pulling the entire maxilla forward. The anterior cross-bite is
corrected orthopedically; of course, further fine adjustment of the A-P rela-
tionship is usually necessary during the orthodontic phase of treatment.
Class III cases treated by palate expansion with subsequent orthopedic
influence of the maxilla and mandible have an improved facial balance over
cases treated by conventional orthodontic methods. This is to a large extent due
to the posture of the incisors and denture bases in the treated cases. Conven-
tionally treated Class III cases bear the stigma of labially tipped upper incisors
a.nchored to a retruded base and lingually inclined lower incisors anchored to a
protruded base. In the orthopedically treated cases, the incisors are upright
and the bases are in an improved A-P relationship.
In 1961 I reported that during palate expansion the downward and forward
displacement of the maxilla, coupled with the clockwise rotation of the man-
dible, made the Class II, Division 1 skeletal pattern decidedly worse2 (Fig.
18). Concern was expressed as to whether or not this result was too much of a
price to pay for gained maxillary apical base width and improved nasal ven-
tilation. The question was partially answered, since it was found that the
maxilla and the mandible tended to return to their former posture (Fig. 19).
In Fig. 20 the models of that patient, a boy 8 years 4 months of age, may
be seen. On the left is the model made at the start of treatment; on the right is
the model made at stabilization of the palatal appliance. Consider that the
 Amer. J. Orthodonf.
238 Ham March 1970

Fig. 20. Comparison of starting models with models made after maxillary expansion. A,
anterior view; 6, right view; C, left view.

condition now appears to be more Class II than Class II, that is, the denture
displacement is more than a premolar width on both sides.
Fig. 21 depicts the profile changes during the two phases of treatment. On
the left is the typical Class II profile. In the center is the more severe profile
caused by the forward movement of the maxilla and the counter movement of
the mandible. This change occurred in 17 days. The profile on the right is at
completion of active treatment.
A cervical gear was placed 6 months after maxillary expansion, along with
Class III elastics to a light ligated lower arch, for 26 months. Then the upper
and lower incisors and canines were banded. No other teeth except a rotated
lower premolar were banded in the course of treatment. This strap-up remained
operative for 16 months. The force on the cervical gear was continually in-
creased until it was approximately 4 pounds. The models at stabilization are
contrasted to the retention models in Fig. 22.
Volume
Number
57
3
Palatal expansion 239

Fig. 21. Degeneration of the Class II skeletal pattern. The left profile is suggestive of a
dental Class II, while the center profile resembles that of a skeletal Class II case. The right
profile reflects the condition at completion of active orthodontic treatment. Note the change
in the profile arc between the center and right films.

The tracings will convey some very interesting findings. From the first
(Fig. 18)) it is obvious the skeletal pattern degenerated. Point A came forward
2.5 mm. and pogonion went back 2 mm., for a net change of 4.5 mm. added over-
jet. In Fig. 19 there was improvement in the pattern during a 4-month resting
phase. This patient was very slow in tooth eruption, and it was deemed advis-
able to wait 6 months before commencing guiding treatment. As it turned out,
a greater delay might have resulted in a shorter over-all treatment time.
The results of treatment on point A, ANS, nasion, and pogonion were as-
sessed by measuring from the pterygoid root plane. Fig. 23 shows a chart of
these measurements, recorded in millimeters. During midpalatal suture separa-
tion, the maxilla moved forward 2.5 mm. and pogonion went backward 2 mm.,
for a net change of 4.5 mm. of added overjet to the denture and profile. During
active treatment, point A was reduced 3.5 mm. from its value at the start of
treatment and 6 mm. from its position at stabilization. ANS, which was very
clear in all headfilms of the series, was reduced 4 mm. from the start of treat-
ment. Thus, 4 years later, there was less mass to the maxilla in depth than at
the start of treatment. Growth was not only inhibited in this maxilla ; it was
subtracted from it!
Brodie,15 Lande,16 and others have shown that nasion, ANS, and point A
come forward at similar rates in the untreated person. In the course of treat-
ment nasion came forward 2 mm.; thus, there was a net reduction in ANS of
240 Haas Atuer. J. Orthodont.
March1970

Fig. 22. Comparison of post expansion models with models made at the time active ortho-
dontic appliances were removed. A, anterior view; 8, right view; C, left view.

4 mm. and in point A of 6 mm. Considering the change from the time of stabili-
zation, ANS was reduced a net of 6 mm. and point A by 8 mm.
In an indifferent skeletal pattern such as this, how could this be anything
but inhibition of the growth potential? Such changes could never be demon-
strated by treatment with simple orthodontic force, as the 1938 cephalometric
evaluation so well established.‘l
Fig. 24 further demonstrates the marked maxillomandibular changes that
occurred in this case between stabilization of the expansion appliance and
 Palatal expansion 241

Fig. 23. Comparison of lineal measurements from pterygoid root plane with profile land-
marks-nasion, point A, ANS, and pogonion. It seems incredible that 4 years after the
start of treatment there was less depth to the maxilla than at the start.

Fig. 24 Fig. 25
Fig. 24. When viewing this tracing one can only ask: “How could this change be anything
but orthopedic?” Point A was retracted a net of 8 mm. without removal of teeth or ques-
tionable superpositioning of head film tracings.
Fig. 25. Tracings demonstrating that when a Class II face is changed to a Class I face it
grows like a Class I face. Class II skeletal patterns corrected orthopedically by maxillary
reduction cannot relapse skeletally.

retention. The mandible was free to grow downward and forward, which it did
nicely. The maxilla did not enjoy this freedom; forward growth was not only
eliminated, but it would seem that the maxilla was driven posteriorly. I have
been aware of the fact that many of my orthopedically treated cases show more
than an expected increment of vertical growth. Perhaps it is not possible to
inhibit the growth potential after all. It may well be that the growth subtracted
 Amer. J. Orthodod.
242 Haas March 1970

from the horizontal vector is added to the vertical vector. As is so frequently

suggested in papers of this type, more study of the phenomenon is indicated.
Fig. 25 demonstrates the superimposed tracings of head films made at
setention, when the patient was 12 years 10 months of age, and the second
made a year later. The maxilla and the mandible are now continuing to grow
downward and forward at essentially the same rate as described by Broad-
bent,17 Brodie,‘“, I8 Lande,‘” and others. This is to be expected, as the maxilla
is no longer being restrained by an extended application of heavy cervical
force.
It is not considered expedient to wait for the maxilla to make a spontaneous
recovery following degeneration of the Class II pattern in response to palate
expansion. It is recommended that heavy force be applied with a Kloehn cervi-
cal gear directly to the maxilla, through the palatal appliance, immediately
after stabilization.
While some are trying to shorten retention time,‘” it is advantageous to
exploit the full orthopedic potential of the palatal appliance by leaving it in
place even longer than 3 months. Orthopedic forces thereby may be applied to
the maxillary complex as a unit, rather than orthodontic forces applied just

Fig. 26. Three Downs’ profile strips made at initiation of maxillary expansion, at its com-
pletion, and after 9 months of heavy cervical gear. While the center strip does show a
worsening of the pattern, it is only a fraction of the actual distortion since the patient
positioned the mandible forward (see tracing in Fig. 27). On the right a definite improve-
ment in the profile is obvious. Had it not been for the mandibular positioning, it would
seem as miraculous as it did clinically.
 Volume 57 Palatab expansion 243
Number 3

to the teeth after the appliance is removed. These forces may be directed
toward expansion, as in the Class III case, or toward inhibition, as in the Class
II case. The better the attained denture base relationships, the less tooth
movement will be required in the orthodontic phase of treatment.
The following Class II case is that of a girl, 11 years 10 months old, who
demonstrated appreciable deterioration of the skeletal pattern due to mid-
pal&al suture opening. Fig. 26 shows three Downs profile strips made at the

Cfl
lb 1 68
IO a2 6s -A---

Fig. 27 Fig. 28

Fig. 27. Significant 3.5 mm. forward translation of the maxilla in response to maxillary
expansion. Unfortunately, some of the impact is lost because the mandible was positioned
forward by the patient probably some 8 mm. at pogonion. This assumption is reasonable,
since the disturbed buccal occlusion and maxillary displacement following expansion
always result in considerable negative mandibular rotation. Further, in Fig. 28 it can be
seen that the mandible was held in its habitual position and, as such, was moved POS-
teriorly 7 mm. at pogonion.
Fig. 28. Marked retraction of the entire maxilla, by orthopedic force from the cervical gear
to the maxilla as a unit, through the stabilized palatal expansion appliance. In the 9
months that the appliance was left in place to permit orthopedic force to effect the maxil-
lary complex, point A and, of course, the entire maxilla were retracted beyond their posi-
tion at the start of treatment. Since nasion grew forward 2 mm., the retraction of point
A was a net of 6.5 mm. postexpansion and a net of 3 mm. from the start of treatment.
Of course, there were no bands on anterior teeth; thus, point A was in no way affected
by tooth movement. Further note how much the mandible had been positioned forward
in the postexpansion records. This is relatively unimportant to the purpose at hand, which
was demonstrateto the maxillary changes due to palatal expansion and the continued
orthopedic influence to inhibit the maxillary growth potential in the A-P plane.
244 Haas A ,,ze~‘. J. Orthodmt.
Mnmh 19io

start of treatment, at appliance stabilization, and after 9 months of hcav>

cervical force delivered to the m;lsilla nhich was bonnd into a unit, 1)~ the fiscal
expansion appliance. \Vhilc the pattern sonrcd temporarily, there was rapid
recovery and then striking impro\.cmcnt in I) months time. It is anfortunat (’
that the pat,icnt was guilty of mandibular positionin g in the profile at stabili-
zat.ion and even more unfortunate tllilt the ;Issist;rtjt who took the llt>ad film was
oblivious to t.1iitt fad.
The tracings of lateral llrlad films taken ilt the start of t~spansion ant1 at
stabilization (E’ig. 27) verify that the maxilla moved downward slightly ant1
forward 3.5 mm. The anterior root of PTM mo~cd forward almost a like amount,
creating a correspondingly wider gap. The mandible was positioned forward
at least 4 mm. ijt pogonion. In realit!-, howcvcl~, thcro was a downward and back-
ward rotation.
li’ig. 28 compares stabilization with 9 months of heavy ccr\-ical gear. 11; is
impressive that tlio maxilla was ;Ipparcntly movc~l posteriorly beyond its
original posture into a more retrutl(4 position. It \lvias t ranslattd do\~~n\~ard ;IS
well in a bodily fashion, su ggesting that it might have been bctt(lr to apply the
extraoral ortl~opedic forc~e from a lic~~tl ca]) rathctr than from tht> ecrvical
anchorage which was applied. The J’TM gap narrowed. The distance from point
A to pterygoid root, dccreascd 4.5 mm. Sincr no bands mere I,lactd on the nn-
terior teeth, point A was not affcrtctl 1,~ tooth mo\-rment but, in this cnsc, r(‘-
fl&cd the posterior movement of the clltirc maxilla.
The mandible, as cspccted, translated botlily in a posterior direction bc-
cause of the positioning dcscribcd ;I~OW. It also underwent nrgatirc rotation
due to the inferior displacement of the maxilla and the disturbed buccal ocelu-
sion.
The use of extraoral t,raction following stabilization is recommended in the
tr’eat,ment of virtually all Class II cases ant1 lll:UlS L%ss I cases.
If vertical dirnension of the face is ideal, a straight posterior thrust from the
cervical gear is favored in thca (‘lass T ease to rcstorc the maxilla to its formc>l
or new ideal position (Fig. 29). Tn the Class It caasc, the cervical traction is
coritinued to retract thcl maxilla beyond its original position by alteration at
the maxillocranial sutures.
It is speculated that width of the 1’TN gap is maintained by resorption
primarily on the posterior surface of the maxilla to prevent compression of the
vessels, nerves, and tissues coursing the fissure. Histologically, the connective
tissue covering and lying between bones has the potential to differentiate into
ostroclastic and osteoblastic cells in response to pressure and tension.
In the skeletal deep-bite type, the outer bows of the cervical gear should be
bent at a high level to tip the maxilla down in the back (Fig. 30). This action
conceivably could result ii1 permanent bitt opening b,~ generating a downward
and backward rotation of the mandible. In the Class II case, the maxilla is also
retracted, preferably beyond the starting posture.
A high-pull or vertical-pull extraoral forcae (Fig. 31) is indicated in the
open-bite skeletal type. IIere the primary ob,jclcti\-c is interference with the
descent of the maxilla as required in a skeletal Class I open-bite case.
 Pcrlatal expansio?l 245

Fig. 29 :ig. 30

Fig. 29. Cervical gear for continued orthopedic influence in a Class I or Class II case with
good vertical dimension.
Fig. 30. Cervical gear for continued orthopedic influence in a skeletal deep-bite Cl ass I
or Class II case.

Fig. 31. Application of the modified face-bow head gear for continued influence in a
skeletal open-bite Class I case.

Fig. 32, A and B illustrates the application of a modified face-bow and

high-pull headgears to produce simultaneous retraction and depression of the
maxilla as required in a skeletal Class II open-bite case.
In a severe vertical dysplasia, regardless of classification, the vertical-pull
chin cnp may be incorporated into the assembly (Fig. 33). You might note the
obvious tension on the elastic straps.
All these extraoral devices are applied directly to the stabilized palatal
246 Huus

A B

Fig. 32. Application of the modified face-bow head gear for continued influence in cases
involving a high ANB angle and a high mandibular plane angle. In A a vertical-pull chin
cup may be added if the mandibular plane angle and/or open-bite are excessive.

Fig. 33. Application of a vertical-pull chin cup and modified face-bow head gear in a
severe Class I vertical dysplasia case.

expansion appliance immediately after stabilization. It is reasoned that the

maxilla is being acted upon as a unit to expand and inhibit its growth
potential.
I have been completely captivated by the response of the maxilla to ortho-
pedic expansive and inhibitive forces, as you might well have inferred by this
presentation. The palate-expansion technique is required in a relatively small
percentage of cases. The majority of my patients fall into the mixed-dentition
Class II, Division 1 category.
Volume 57
Number 3 Palatal expansio~a 247

Fig. 34. The relationship between the maxillary palatal expansion appliance and the
maxillary orthopedic crib. It is not necessary to add a screw to the maxillary orthopedic
crib to accommodate the buccal occlusion as the maxilla goes back and the mandible
grows forward. The forces of the occlusion seem to make the necessary adjustment.

Several years ago, the success of the stabilized palate-expansion appliance

in inhibiting the maxillary growth potential suggested a modification of the
appliance and a transfer of principles to the treatment of mixed-dentition
skeletal Class II cases.
I would like to introduce at this time, for want of a more imaginative name,
the maxillary orthopedic crib (Fig. 34), which is merely the skeleton of the
palate-expansion appliance with anterior and posterior transpalatal bars. The
anchor teeth are the first permanent molars and the first deciduous molars or
first premolars. By the use of the crib, the maxilla is essentially bound into a
unit, and orthopedic forces designed to inhibit or subtract maxillary growth
can be applied indirectly to the entire maxilla. In becoming resistance units,
the teeth now permit the heavy force to spill over into the hafting area sutures
so that growth retardation and resorption at the sutures may occur.
The orthopedic force is usually delivered by the cervical gear in a manner
similar to that previously described in the treatment of the Class II case, where
the palatal expansion appliance mediates the force. If the vertical dimension
is good, then a straight distal thrust from the face-bow is applied through a
doubled 3/-inch elastic neck strap delivering a force of approximately 3 to 5
pounds (Fig. 29).
In the deep-bite skeletal type the outer bows of the cervical gear are bent
high to torque the maxilla down in the back and, with the concomitant distal
thrust, provide a downward and backward vector of movement of the maxilla
and maxillary dental arch (Fig. 30). Thus, as molar height is increased,
whether by tooth movement or by movement of the entire maxilla, the mandible
rotates downward and backward. This results in the desired bite opening in
conjunction with the A-P correction.
The open-bite Class II skeletal pattern is treated with heavy force applied
through a high-pull headcap (Fig. 32) having the outer cervical bow bent to
a high level in the area of the first molar teeth. Hopefully, the
maxilla can be prevented from making its downward and forward descent. In
the more severe open-bite problems, a vertical-pull chin cup can also be used, as
these two extraoral devices complement each other (Fig. 33). Both tend to
depress teeth, and both would apply growth-inhibiting forces to the maxillary
growth centers.
 Anw~. J. Orthodmat.
240 Haas Mcwch 19il)

Clinically, the application of the vertical-pull chin cup is characterized by

a depression of posterior teeth. Tt would follow, then, that this chin cup force>
interferes with posterior alveolar growth. Thcorctically, it is not difficult tlj
caonceive of the force preventing the tl(>sccnt of the maxilla. For that matter, if
011~’considers the changes wrought by a misused Milwaukee b~*ace (Fig. 6), it
can be accepted that the r&ical-pull chin cup may even fo~c thf> eritirc>
maxilla superiorly and further cause’ sllbt lc change in mandibular morphology-.
WliatcYer is occurring, the \-crtical cliniclnsion in the molar area is reduced
and the dental and skeletal opcln-bitt call IW scw to inlprovc significantly.
The masillar;- ort,hopcdie crib finds its grcatcst application in the Class II
skrlctal pattern in the> mi(l(tlc to Iate niiscd dcntition ant1 wills- pcrnlancnt
dcntition. Various (aritcri;r may 1~ used to ;ISSWSsuch a pnttc~rn. I consider il
case belonging in this category wlicn thca mr3 angular diffcrenccx is 6 di~gr~s
Or more or the point A to facial pl:lilV liieasiur~~nicnt, as suggcstcd bp Ricketts,‘!
is 6 or 7 mm. or grcatcr. E’or more than 10 years, ltickctts has cmphaticall>~
stated that “such a face c&s for orthopedic reduction.” Since then, others have
written (in sonic instariccs il~)OlOg(~ti(~~~ll~
1 0 t’ art hopcdic maxillary changes
produced with extraoral forces. Among these are Klein,‘” Poulton,“l Moor~,~~
Wieslander,2Z and Sassouni.‘,’
The skeletal changes sought can bc gained in approximatelp 9 to 15 months,
tlepcnding on the severity of the condition and the cooperation of the patient
during treatment. Ideally, the cast should be startcad about 12 months before
t,lle anticipated clruption of the maxillary caninrs in order that a smooth transi-
tion may occur when one is proceeding from orthopedic treatment to ortho-
dontic treatment.
If a case requiring orthopedic reduction is not s(‘en until the full dcntition
has erupted, orthopedic force fan st,ill bc administered through a conrcntional
strall-up of the upper tlrntal arch. 111 this mann(‘r, the arch as a unit provides
the required anchoragcx.
The orthopedic crib helps to climinatc some of the problems presented when
hcayy forces are applied only to first permanent molars. If the outer bows arti
bent high, too much extrusion of the molars is induced. Generally, when cervi-
cal gear exclusively is applied to molars, more tooth movement than ortho-
pcdic change will take place, since the anchorage unit is relatively weaker.
In an open-bite case, it would bc more desirable to inhibit maxillary growth
than to drire t,hc first molars distally. For example, in the case shown in Fig.
35 the point A to facial plane measurement, is 10 mm., the ANB angular differ-
ence is 11.5 degrees, and the mandibular plant angle is 46 degrees. Orthopedic
reduction of the maxilla would be most advantageous, while distal driving of
the denture would be disastrous.
Occasionally in my enthusiasm to apply heavy forces to the maxilla pri-
marily through first-molar anchorage, the position of the second molar was
deopardized, as the dental x-ray film in Fig. 36 will verify.
Fig. 37 exhibits before- a,nd after-treat,met profile comparisons of twelve
cases from a sample of more than 300 nonextraction Class II, Division 1 cases
which I believe show changes in the facial profile as a result of orthopedic
 Palatak expansion 249

Fig. 35. Fortunately, this is a relatively rare case in which the ANB angle is 11.5 degrees,
the point A to facial plane distance is 10 mm., and the MP angle is 46 degrees.

Fig. 36. Roentgenogram showing a second molar which must await growth in order to
erupt. There is possible resorption of the distobuccal root of the first molar unless it is
behind the crown of the second molar.

reduction. It would be impossible to show such profile changes due to the use of
intraoral forces without the removal of teeth. Even then, the change could not
be of the same quality, since the original problem was skeletal and would thus
best be corrected by modifying the skeletal pattern rather than the denture
pattern, as the latter correction could have only limited influence on the skele-
tal base.
As assessed by Nance,2” many of these cases had 4 to 8 mm. mandibular
arch-length problems. However, all were treated without extraction, by means
of a light Class III elastic traction to the lower arch and heavy cervical force to
the upper arch, while awaiting eruption of the succedanous teeth. In this man-
ner, A-P correction was gained by interfering with maxillary growth and space
became available in both dental arches for potentially blocked-out teeth. The
250

Fig. 37. Dramatic demonstration of the potential of orthopedic forces in the treatmer 1t of
the skele !tal Class II case.
 Paiatal expansion 251

Fig. 37-cont’d. For legend, see okposite page.

 Amer. ?I. Orthodont.
252 Ham March1970

Fig. 38. Superimposed tracings of the last case depicted in profile. The films used were the
before-treatment tracing and the tracing made from the head film taken on the day guid-
ing treatment ended and anterior bands were placed. Therefore, the change in point A
reflects a change in the entire posture of the maxilla and not anterior tooth movement
other than that of a physiologic nature.

end result of such guiding treatment is a rather simple case, easily completed
in a relatively short time in the early full dentition.
Notice that the beginning severely convex profile arcs are transformed to
essentially straight lines and cvcn mildly concave arcs. The comment is fre-
quently made that changes in point ,4 depend primarily on movement of the
upper incisors. In maxillary orthopedics, point 9 certainly reflects the altera-
tion in maxillary posture. Fig. 38 shows a superimposed tracing of the last case
just viewed in profile (Fig. 37, L), The before-treatment tracing is at the sta.rt
of guiding treatment; the after-treatment, tracing is at its completion with the
banding of anterior teeth 26 months later.
Nasion moved forward 3 mm. Point A moved posteriorly with the maxilla
4 mm.; accordingly, there was a net posterior movement in point A of 7 mm.
(previously esplaincd) , without banding or external traction on the incisor
teeth. Similar findings could be demonstrated in most of the other eleven cases.
None of these cases wcrc treated with the orthopedic crib. However, by
utilizing the crib in similar cases, it is possible to attain equivalent or better
results in a shorter period of time with less possible hazard. Fig. 39 displays
the profile change and Fig. 40 shows the superimposed tracing of a case which
was subjected for 10 months to a cervical force of 3 to 5 pounds using the ortho-
pedic crib. It shows changes similar to those demonstrated in Fig. 38 (Patient
11. K.). Patient 1). K. reqniretl 26 months of guiding treatment with cervical
gear and a maximum force of 1.5 to 2 pounds delivered to first molar anchorage.
Volume
Number
57
3
Pnlatal expansion 253

Fig. 39. Profile comparisons of a case treated orthopedically for a mere 10 months utilizing
the maxillary orthopedic crib.

Fig. 40. Superimposed tracings of the case demonstrated in profile in Fig. 39. Observe the
significant maxillary reduction in a relatively short time with the application of an average
of 4 pounds of force.
254 Haas Amer. J. Orthodoat.
Mcwclc1970

In almost one third less time, wit,h double force to a superior anchorage unit, it
was possible to produce a comparable correction.
Patient C. I). (Fig. 22)) the first, Class II case presented, n-as t,reat,ed OWL
a -15month period of time, during 16 months of which anterior bands wel’cx
horn. Success was acahicved berausc~ of interfcrcncdc with gro\vth over this ex-
tended period of time. With the ort,hopedic crib, the same result should bc
possible in far less time bceausc~, in addition to arresting growth, it, woultl
appear that growth is subtracted. Inhibitive orthopedic forces exert kvo prob-
able effects, and possibly thrcv. One> is to retard anteropostorior growth ; thca
second is to actuallv lessen the mass of the bone 1)~ rcsorpt,ion at the articula-
tions that it, shares with contiguous bones. Thircl, it nla~y br that some or mucah
of the suppressed incrctmt~nt of horizontal growth is channclcd into a greater
vertical component of growth. In Patknt. C”. I)., the depth of the maxilla was
several millimeters less at the time of retention, I T-ears later. than at the start
of treatment.
NaxillarJT expansion is definitely not a prerequisite to the use of the expan-
sive and inhibitive orthopedic dcvicrs dcmonstratcd in this articlc. They may
be used in any case requirin g dentofarial orthopetlics prior to or during con-
ventional orthodontic treatment.
Even though much of t,his article has dealt with facial esthetics, the ulti-
mate purpose of orthopedic movcmcnt is to achie\c the most stable correction
of the dental malocclusion. It follows t1la.t when the teeth are in an esthetic and
stable relationship, the facial profile will also bc as near ideal as possible for
the individual. One complements the other.

REFERENCES
1. Richer, H.: Oral anatomy, St. Louis, 1947, The C. V. Mosby Company, pp. 109-110.
2. Haas, A. J.: Rapid expansion of the maxillary dental arch and nasal cavity by opening
the midpalatal suture, Angle Orthodontist 31: 73-90, 1961.
3. Hans, A. J.: The treatment of the maxillary deficiency by opening the midpalatal suture,
Angle Orthodontist 35: 200-217, 1965.
4. Brodie, A. G.: Anatomy and physiology of head and neck musculature, A&I. J. ORTIIO-
DONTICS 36: 831-844, 1950.
5. Rrodic, A. G.: The fourth dimension in orthodontia, Angle Orthodontist 24: 15-30, 1954.
6. Hertz, R. A.: Changes in nasal airflow incident to rapid maxillary expansion, Anglo
Orthodontist 38: l-9, 1968.
7. Isaacson, R. J., and Murphy, T. D.: Some effects of rapid maxillary expansion in cleft
lip and palate patients, Angle Orthodontist 34: 143-154, 1964.
8. Goddard, C. L.: Separation of the superior maxilla at the symphysis, Dental Cosmos 35:
X80-882, 1893.
9. Thorne, N. A. Hugo: Expansion of maxilla; spreading the midpalatal suture ; measuring
the widening of the apical base and nasal cavity on serial roentgenograms (Abst.)
AM. J. ORTHODONTICS 46: 626, 1960.
10. Zimring, J. F., and Isaacson, R. J.: Forces produced by rapid maxillary expansion,
Angle Orthodontist 35: 178-186, 1965.
11. Hrodie, A. G.: Cephalometric appraisal of orthodontic results, Angle Orthodontist 8:
"61.351, 1938.
12. Clark, R. R. (orthopedic surgeon) : Personal communication.
13. Sassouni, V., and Nanda, S.: Analysis of dentofacial vertical proportions, AM. J. ORTHO-
DONTICS 50: 801-822, 1964.
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Number
57
3
Palatai expansion 255

14. Ricketts, R. M.: The influence of orthodontic treatment on facial growth and development,
Angle Orthodontist 30: 103-133, 1960.
15. Brodie, A. G.: On the growth pattern of the human head from the third month to the
eighth year of life, Am. J. Anat. 68: 209-262,194l.
16. Lande, M. J.: Growth behavior of the human bony facial profile as revealed by serial
cephalometric roentgenology, Angle Orthodontist 22: 78-90, 1952.
17. Broadbent, B. H.: The face of the normal child, Angle Orthodontist 7: 183-208, 1937.
18. Brodie, A. G.: Late growth changes in the human face, Angle Orthodontist 23: 146-157,
1953.
19. Ricketts, R. M.: Cephalometric analysis and synthesis, Angle Orthodontist 31: 141-155,
1961.
20. Klein, P. L.: An evaluation of cervical traction on the maxilla and the upper first per-
manent molars, Angle Orthodontist 27: 61-68, 1957.
21. Poulton, D. R.: Changes in Class II malocclusion with and without occipital headgear
therapy, Angle Orthodontist 29: 234-250, 1959.
22. Moore, A. W.: Orthodontic treatment factors in Class II malocclusion, AM. J. ORTHO-
DONTICS 45: 323-352, 1959.
23. Wieslander, L.: The effect of orthodontic treatment on the concurrent development of
the craniofacial complex, Ant. J. ORTHODONTICS 49: 15-27, 1963.
24. Nance, H. N.: The limitations of orthodontic treatment, AM. J. ORTHODONTICS & ORAL
SURG. 33: 253-301, 1947.

1634 Portage Trail.

As orthodontists we must ever place foremost in importance the normal occlusion of the
teeth, for only in normal occlusion is their greatest usefulness possible. But many of our
patients would never reach us were it not for the inharmony of their facial lines result-
ing from malocclusion, and if our efforts are intelligently directed we can do far more
to render plain or even distorted facial lines pleasingly symmetrical, or even beautiful,
than anyone else who has to do with the human face. Indeed the improvement in the
proportion and artistic effect which may often be wrought by intelligent effort on the
part of the orthodontist is marvelous and almost incredible, but his efforts may also
result in producing or enhancing ugliness and deformity if unintelligently directed.
(Angle, Edward H.: Treatment of malocclusion of the teeth, ed, 7, Philadelphia, 1907,
S. S. White Dental Mfg. Co., p. 60.)