C L I N I C A L P R A C T I C E
Background. The authors were not able
Skeletal and dental
changes with fixed
slow maxillary
expansion treatment
A systematic review
` Results. With the help of a health sci-
MANUEL O. LAGRAVERE, D.D.S., M.Sc.;
PAUL W. MAJOR, D.D.S., M.S.;
CARLOS FLORES-MIR, D.D.S., M.Sc., Cert. Orth., Ph.D.
axillary expansion treatments have been
M used for more than a century to correct
maxillary transverse deficiency. Three
expansion treatment modalities are used
today: rapid maxillary expansion (RME),
slow maxillary expansion (SME) and surgically assisted
maxillary expansion. Since each treatment modality has
advantages and disadvantages, contro-
versy regarding their use exists. Practi-
Clinicians need
tioners select treatment appliances
to rely on based on their personal experiences and
their clinical on the patient’s age and malocclusion.1,2
experience, RME has been used extensively.3,4
experts’ Some limitations associated with it have
5 Implications. The authors found only a
opinions been reported, including bite opening,
6
relapse, microtrauma of the temporo-
and the limited
mandibular joint and the midpalatal
evidence suture,7,8 root resorption,7,8 tissue
concerning impingement and pain,9 and excessive
slow maxillary tipping of anchorage teeth.9
SME procedures produce less tissue
expansion
treatments. resistance around the circummaxillary
structures and, therefore, improve bone
formation in the intermaxillary suture,
which theoretically should eliminate or reduce the limi-
tations of RME.2,10,11 For SME, only 10 to 20 newtons10,12
of force should be applied to the maxillary region,
depending on the age of the patient, compared with 15 to
50 N for RME.1,2,13 The most frequently used SME appli-
ances are minne-expanders3,8,10,14 and quad-helixes.15-17
Although the objective of both appliances is to achieve
194 JADA, Vol. 136, February 2005
Copyright ©2005 American Dental Association. All rights reserved.
ABSTRACT
to identify any systematic reviews or meta-
analysis on the dental or skeletal changes
associated with slow maxillary expansion
(SME). Therefore, they conducted a study to
evaluate skeletal and dental changes after
fixed SME treatment in orthodontic
patients with constricted arches.
Methods. The authors included in their
evaluation clinical trials that assessed
skeletal and dental arch changes through
measurements on dental casts or cephalo-
metric radiographs. The authors did not
consider trials involving surgical or other
simultaneous treatment interventions
during the active expansion period.
ences librarian, the authors searched the
following electronic databases: PubMed,
MEDLINE, MEDLINE In-Process and
Other Non-Indexed Citations, Evidence
Based Medicine Reviews (Cochrane
Database of Systematic Reviews, American
College of Physicians Journal Club,
Database of Abstracts of Reviews of Effects
and Cochrane Central Register of Con-
trolled Trials), EMBASE Excerpta Medica,
Thomsen’s ISI Web of Sciences and
LILACS. Eight articles met the initial
inclusion criteria. The authors found that a
significant deficiency in the studies was the
lack of a control group to factor out changes
in the dental arch and skeletal structures
associated with normal growth.
Conclusions and Clinical
lower level of evidence. Therefore, they
could make no strong conclusions on dental
or skeletal changes that occurred after SME
treatment. Clinicians need to rely on their
clinical experience, experts’ opinions and
the presented limited evidence concerning
SME treatments.
Key Words. Slow maxillary expansion;
slow palatal expansion; treatment outcome;
systematic review.

physiological intermaxillary sutural expansion,
the design and activation are different. Clinicians
should not assume that the skeletal and dental
effects of the two appliances are equivalent, and
they should consider the two treatment modali-
ties separately.
We identified in the dental literature a system-
atic review18 and two meta-analyses3,19 that
reported dental arch changes after RME, but we
could not find any systematic reviews or meta-
analyses on the dental or skeletal changes asso-
ciated with SME treatment. We conducted a
study to evaluate skeletal and dental changes
after fixed appliance SME in orthodontic patients
with constricted arches, using all available pub-
lished scientific literature.
MATERIALS AND METHODS
We selected two literature search terms—“slow
palatal expansion” and “slow maxillary expan-
sion”—with the help of a librarian who had expe-
rience in searching health sciences
databases. We conducted computer-
ized searches using the following
All of the eight
databases: MEDLINE from 1966 to
studies the authors
week three of July 2004; MEDLINE
In-Process and Other Non-Indexed finally selected lacked EBM reviews—Cochrane DSR, ACP
Citations July 23rd, 2004; LILACS, control groups.
a literature database of Latin
American and Caribbean health
research, from 1982 to July 2004;
PubMed from 1966 to week three of July 2004;
EMBASE Excerpta Medica from 1988 to week 30
of 2004; Thomsen ISI’s Web of Science from 1975
to week three of July 2004; and all databases in
the Evidence Based Medicine (EMB) Reviews
database—Cochrane Database of Systematic
Reviews (DSR), American College of Physicians
(ACP) Journal Club, Database of Abstracts of
Reviews of Effects (DARE) and Cochrane Central
Register of Controlled Trials (CCRCT)—to the
second quarter of 2004.
We used the following inclusion criteria to
select the appropriate articles: clinical trials,
measurements made from dental casts or facial
radiographs, and no surgical or other simulta-
neous treatment that could affect SME during the
evaluation period.
We read the articles’ abstracts to determine the
eligibility of articles. Two of us (M.O.L., C.F.-M.)
independently completed the selection process. If
a discrepancy arose, a third researcher (P.W.M.)
helped make the final decision.
Copyright ©2005 American Dental Association. All rights reserved.
C L I N I C A L P R A C T I C E
We obtained articles for which the abstracts
did not present enough relevant information to
help us make a final decision regarding their
inclusion. We also searched the reference lists of
the selected articles for additional relevant publi-
cations that we may have missed in the database
searches.
All three of us obtained and independently
evaluated all of the articles from the selected
abstracts. Then we reached a consensus
regarding which articles should be included in the
systematic review. For articles in cases in which
relevant data were not available in the publica-
tion, we contacted the authors to obtain the
required extra information.
RESULTS
We observed that MEDLINE and PubMed had
the greatest diversity of abstracts, but these
databases did not include all of the abstracts
included in other databases (Table 1). All except
one of the selected abstracts from
PubMed were included in MED-
LINE and vice versa. All of the
abstracts selected by Thomsen ISI’s
Web of Science, EMBASE and all
Journal Club, DARE and CCRCT—
were included in MEDLINE. After
we reviewed the selected abstracts’
reference lists, we included only one
more article20 that did not appear in any of the
database’s searches (Table 1).
All of the eight studies we finally selected had
specific methodological issues. Each lacked a con-
trol group,8,10,14-17,20,21 and four also did not have a
measurement error statement.10,15,16,21 A control
group is necessary to factor out normal growth
changes in the dental arch and craniofacial struc-
tures. Measurement error statements are impor-
tant to evaluating the clinical significance of the
reported findings. A summary of sample size,
methodology used and appliance used is pre-
sented in Table 2 (page 197).
DISCUSSION
An evidence-based practice aims to provide the
best possible treatment based on sound evi-
dence.22 There are different levels of evidence. The
highest level is represented by randomized con-
trolled trials (level I), followed by nonrandomized
controlled trials or quasiexperimental studies
(level II). Both of these levels have two subcat-
JADA, Vol. 136, February 2005 195
C L I N I C A L P R A C T I C E

TABLE 1

SENSITIVITY OF ELECTRONIC DATABASES SEARCHED.

DATABASE KEYWORDS* NO. OF NO. % OF EIGHT SELECTED
RESULTS SELECTED ABSTRACTS †
MEDLINE Slow maxil$ expan$ or Slow palat$ 20 6 75
expan$; limit to human

PubMed Slow maxillary expansion; slow palatal 31 6 75

expansion; #1 OR #2‡

MEDLINE In-Process Slow maxil$ expan$ or Slow palat$ 1 0 0

and Other Non-Indexed expan$; limit to human
Citations

EMBASE (Excerpta Slow maxil$ expan$ or Slow palat$ 1 0 0

Medica) expan$; limit to human

Databases Included in Slow maxillary expansion; Slow palatal 5 4 50

Evidence Based Medicine expansion; #1 OR #2
Reviews Database—
Cochrane Database of
Systematic Reviews,
American College of
Physicians Journal Club,
Database of Abstracts of
Reviews of Effects and
Cochrane Central
Register of Controlled
Trials

Thomsen ISI’s Web of Slow maxillary expansion; slow palatal 13 5 62.5

Science expansion; #1 OR #2

LILACS Slow maxillary expansion; Slow palatal

expansion; #1 OR #2 1 0 0
§
Reference Lists NA NA 1 12.5

* $: Truncation of the word in the database.

† Percentages do not add up to 100 percent, as the same reference could be found in several databases.
‡ #1 OR #2: Combination of the search hits of the first and second word.
§ NA: Not applicable.

egories each: systematic reviews (if possible,
meta-analysis) (subgroup A) and analyses of indi-
vidual studies (subgroup B). Nonexperimental
descriptive studies (observational, cohorts and
case reports) are level III, and expert opinions are
the lowest level (level IV). Basic research (animal
and human physiology) can lead to inaccurate
assumptions and does not represent direct evi-
dence for clinical practice.23
In the absence of the highest level of evidence,
clinicians have to make decisions based on lower
levels of evidence. Because lower levels of evi-
dence are prone to confounding and selection
bias,24 clinicians should carefully analyze the
studies’ limitations.
Scientific evidence alone does not dictate the
selection of the treatment. When making health
care decisions, clinicians also should consider a
combination of values from patients and from pro-
fessionals (clinical, personal and social) that
determine if the intervention benefits are worth
the costs.25 Therefore, the application of evidence
into clinical practice has to be related to profes-
sional expertise and the needs of the patient.
Since SME involves an active expansion period
of up to four months, clinicians cannot eliminate
a patient’s normal growth as a confounding factor
for the changes found. Because none of the
reviewed studies reported the use of a control
group for comparison at the end of treatment,
clinicians should interpret carefully the clinical
significance of the findings. No strong conclusion
can be made on dental or skeletal changes after
SME. When evaluating studies on SME treat-
ments, we noticed some trends in the studies’
results. For example, the greatest changes
reported were on the transverse plane, especially
interdental widths, compared with those on the
sagittal and vertical planes.
The studies we selected that used quad-helix
and minne-expander appliances reported active
treatment times that varied from one to 3.6

196 JADA, Vol. 136, February 2005

Copyright ©2005 American Dental Association. All rights reserved.
 C L I N I C A L P R A C T I C E

TABLE 2

METHODOLOGY OF SELECTED STUDIES.

AUTHORS SAMPLE SIZE CONTROL MEASUREMENT EVALUATION APPLIANCE ACTIVE
GROUP ERROR EXPANSION
STATEMENT PERIOD

Akkaya and Five females No < 1 millimeter Model casts Minne- One-5.16
colleagues 8 and seven expander months
males (9.91- (bands)
13.75 years of
age; mean,
12.19 years)

Hicks 10 Three males No No Posterior anterior Minne- Eight-

and two (PA) cephalometric expander 13 weeks
females (10-15 radiographs, lateral (bands)
years of age) cephalometric
radiographs and
model casts

Akkaya and Five females No < 1 mm Lateral cephalo- Minne- One-5.16

colleagues 14 and seven metric radiographs expander months
males (9.91- (bands)
13.75 years of
age; mean,
12.19 years)

Malagola and Three females No No PA cephalometric Quad-helix 69-88 days

colleagues 15 and four males radiographs, lateral (mean, 77
(7-12 years of cephalometric days)
age) radiographs and
model casts

Boysen and 15 females No No PA cephalometric Quad-helix 42-147 days

colleagues 16 and two males radiographs, lateral (mean, 101.2
(6.7-11.3 years cephalometric days)
of age; mean, radiographs and
8.3 years) model casts

Sandikcioglu 10 subjects No < 0.5 mm PA cephalometric Quad-helix 56 days

and Hazar 17 (8.6 years of radiographs, lateral
age) cephalometric
radiographs and
model casts

Karaman 20 Four males No < 0.9°, < 0.9 mm PA cephalometric Nitanium 3.6 months
and 12 in cephalometric radiographs, lateral maxillary
females radiographs, cephalometric expander
(mean, 13.8 < 0.5 mm in radiographs and
years of age) model casts model casts

Mossaz- Three males No No PA cephalometric Minne- Seven-15

Joelson and and two radiographs, lateral expander weeks
Mossaz 21 females (8.7- cephalometric (bonded)
10.9 years of radiographs and
age) model casts

Three males No No PA cephalometric Minne-

and two radiographs, lateral expander
females (8.8- cephalometric (bands)
12 years of radiographs and
age) model casts

months.8,10,14-17,20,21 These studies reported dental
and skeletal changes through the use of dental
casts and cephalometric radiographs. Both of
Akkaya and colleagues’ studies8,14 reported the
same sample and expansion protocol, differing
only on the auxiliary examination used for mea-
suring the changes; thus, clinicians could combine
their results and consider them one whole study.
It appears that approximately 1 millimeter per
week is the maximum rate at which the tissue of
the midpalatal suture can adapt so that tearing
and hemorrhaging are minimized compared with
rapid expansion protocols.10 The overall result of
rapid versus slow expansion is similar; however,
with slower expansion, a more physiological
sutural response should be obtained.12

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Copyright ©2005 American Dental Association. All rights reserved.
C L I N I C A L P R A C T I C E
To produce expansion at this rate, 10 to 20 N of
force appear optimal, depending on the age of the
patient.10,12 When comparing the forces applied by
the different appliances used in SME, the minne-
expander appliance spring applies forces of up to
10 N (2 pounds),10,21 while the quad-helix appli-
ance exerts an average of 5 N (1 pound).16 In con-
trast, RME has a cumulative force of approxi-
mately 100 N.1,2,13
Since a direct relationship has been reported
between increased resistance to skeletal expan-
sion and increasing patient age, the use of SME
could be questioned for older patients.2 Thus, the
degree of orthopedic change during SME is con-
sidered to be related inversely to the patient’s
age.13
When reviewing the appliances used in SME
treatments, we found that minne-expander8,10,14,21
and quad-helix15-17 appliances were used most fre-
quently. Although both types of appliances obtain
maxillary expansion, their approaches are dif-
ferent. The minne-expander appliance uses a coil
spring, and the quad-helix appliance uses wire
bending with helixes to exert the expansion force.
Concerning maxillary expansion with a quad-
helix appliance, Boysen and colleagues16 reported
that a small percentage of expansion was caused
by skeletal separation. The greatest percentage
was caused by expansion of the teeth and tipping.
Sandikcioglu and Hazar17 reported similar find-
ings; they compared expansion tooth gain with
RME hyrax appliance, semirapid expansion with
a removable plate and SME with a quad-helix
appliance. All three treatments presented the
greatest change on the transverse planes. Expan-
sion with a quad-helix appliance was primarily
dentoalveolar, with more tipping of teeth than the
other groups. Malagola and coleagues15 reported
similar results.
Chaconas and Caputo26 reported that the
effects produced by a quad-helix appliance are
dependent on the patient’s age. When midfacial
sutures are patent, as seen in children seven to
nine years old, activation of the quad-helix appli-
ance meets with little resistance, meaning that
more skeletal expansion can be obtained than for
older patients. Conversely, during treatment of
adults, the intermaxillary and surrounding
sutures are less patent and, in some cases, fused,
which makes orthopedic results difficult to obtain.
In most cases, an interdental width increase
along with often severe tipping of the posterior
teeth is observed in adults with expansion pro-
198 JADA, Vol. 136, February 2005
Copyright ©2005 American Dental Association. All rights reserved.
duced by a quad-helix appliance. The effect of
palate separation in older patients is minimal
even with increased activation of the quad-helix
appliance. The result of more aggressive activa-
tion is increased tipping of the posterior teeth,
especially those used for anchorage.
Different studies reported maxillary expansion
obtainment using minne-expander appliances,
but the dental to skeletal ratios varied. Hicks10
attributed 28 percent of the expansion gained to
skeletal response or separation of the suture,
whereas Mossaz-Joelson and Mossaz21 attributed
50 percent to skeletal expansion. Although both
studies involved adolescents, the patients in
Hicks’ sample were older than those in Mossaz-
Joelson and Mossaz’s study. Also, the appliance
used in Mossaz-Joelson and Mossaz’s study was
of a much more rigid design than the one used in
Hicks’ study, even when both were based on the
use of similar coil springs.
Mossaz-Joelson and Mossaz21 found no signifi-
cant differences regarding the amount of maxil-
lary expansion, percentage of skeletal response
and degree of dental tipping between banded or
bonded minne-expander appliances for SME.
Another type of appliance used for SME treat-
ments is a nitanium maxillary expander.20 This
appliance is similar to the quad-helix appliance in
that it applies approximately 5 N of force on the
dental structures. Although this appliance does
not need activation appointments, it produces
results similar to those of the quad-helix appli-
ance, especially concerning the ratio of dental to
skeletal expansion. Karaman20 also reported that
there was significant buccal crown tipping after
the expansion.
Subjects who had undergone SME had less
relapse compared with subjects who had under-
gone RME.3,8,14 This can be explained because of
the lower forces applied on the suture over a
longer period, which could permit a continuous
adaptation of the tissues to the skeletal and
dental changes.
CONCLUSIONS
Although several studies concerning SME treat-
ment outcomes have been published, none of
them included a control group that did not receive
treatment to factor out changes in the dental arch
and skeletal structures associated with normal
growth. Even though SME treatments involve an
average treatment time of three to four months,
normal growth patterns can produce some dental

and skeletal changes during that time. When the
reported treatment changes were small—with
significant standard deviations and measurement
errors—the importance of the use of a control
group increased. Thus, we recommend that fur-
ther research on the effects of SME treatments on
patients should include a control group.
Since the research studies on SME treatment
we reviewed failed to give a higher level of scien-
tific evidence, we could not make strong conclu-
sions regarding dental or skeletal changes after
SME. We recommend that clinicians use the
results of the studies we reviewed with caution.
As in any clinical environment, clinicians should
rely on their clinical experiences, the opinion of
experts and the limited evidence concerning SME
treatments. ■
Dr. Lagravère is a doctoral student, Orthodontic Graduate Program,
University of Alberta, Edmonton, Alberta, Canada.
Dr. Major is a professor and the director, Orthodontic Graduate Pro-
gram, University of Alberta, Edmonton, Alberta, Canada.
Dr. Flores-Mir is a postdoctoral fellow, Orthodontic Graduate Pro-
gram, University of Alberta, Edmonton, Alberta, Canada. Address
reprint requests to Dr. Flores-Mir at Faculty of Medicine and Den-
tistry, Room 4051A, Dentistry/Pharmacy Centre, University of Alberta,
Edmonton, Alberta, Canada T6G 2N8, e-mail “carlosflores@
ualberta.ca”.
The authors thank Linda Seale for her professional assistance with
the database search.
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