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Palatal expansion (rapid maxillary expansion)

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Indications and benefits

  • Rapid palatal expansion is a preliminary treatment procedure that aims at enlarging the maxillary dental arch and the palate (roof of the mouth) to re-establish balance between the width of the jaws. This procedure is also called “maxillary expansion”.
  • Expansion is indicated when the upper jaw is too narrow compared to the lower jaw. This often causes an abnormal dental relationship and/or deviation of the lower jaw (see pictures).
  • A jaw that is too narrow can often limit the airway located above the palate (nasal cavity) and expansion may sometimes help this condition. Palatal enlargement can facilitate the flow of air in the nasal cavity and allow the patient to breathe more easily through the nose.
  • By widening the jaw, expansion may create more space to align crowded teeth.
  • This procedure can be done at an early age because jaw width problems are visible early and will not be fixed with time.
  • It is important to note that most of the time, a second phase of treatment will be necessary when all the permanent teeth have erupted to complete the corrections of the malocclusion.
  • Expansion is not aimed at correcting dental malpositions but only harmonizing the width of the jaws instead. This can sometimes improve the position of the teeth but, sometimes, the position of the upper incisors may seem to be not as good after the expansion (to see examples). This will be fixed during a second phase of treatment.
  • Ideally, expansion using an “expander” is performed at an early age (mixed dentition).

Why correct a jaw that is too narrow?

Because:

  • This condition will not be fixed with time and growth;
  • Most of the time, an upper maxilla that is too narrow also affects the mandible by deviating it;
  • This can cause tooth wear and periodontium, as well as problems to temporomandibular joints.

 

Crossbite requiring rapid maxillary expansion in orthodontics

(A) 6-year-old boy with a narrow upper maxilla. When the mouth closes, the mandible is aligned with the upper jaw (blue arrow). (B) At the end of closing, interference between the right canines (circle) makes the mandible shift to the right in a crossbite. Rapid maxillary expansion will correct this shift.

Relapse of maxillary expansion correction
(A) At the end of the expansion treatment, the maxillary arch is “overcorrected”; there is a lot more expansion than necessary. The posterior segments are wider than the lower posterior teeth. The mandible now deviates to the left, which shows occlusal instability at that moment. This is more obvious with an upper occlusal view (B, arrows). This excess in expansion will disappear once the expander is removed. (C) 2 months after removing the appliance, the excess in expansion starts to decrease. (D) After 5 months, the maxillary arch width is normal, the crossbite is corrected, the midlines are aligned and the mandible is centered.
Posterior crossbite with mandibular deviation

(A and C) 7-year-old young patient with a posterior crossbite (arrow) caused by a narrow maxilla. This makes the mandible deviate to the right. (B) This deviation is visible when looking at the face; the chin is shifted to the right.

 

Correction of a mandibular deviation and a crossbite in orthodontics

After expansion, the posterior crossbite is corrected (arrow), the maxillary arch is wider and the chin has shifted toward the middle, thus eliminating the asymmetry. Notice that there is still a significant space between the central incisors (diastema). This space can close a little in the following months, but a diastema will remain because this boy already had a significant space before expansion.

➡ To see other examples of mandibular deviation corrections following rapid palatal expansion, follow this link.

What is an expander and how does it work?

  • The expander is a custom-made orthodontic appliance which is bonded (cemented) to the posterior upper teeth and which allows enlargement of the palate.
  • It includes a screw placed in the middle that can be turned to activate the appliance and generate a force that delicately separates the two palatal bones where the suture that unites them in the middle is located.
  • The patient (or the parent) must perform 1 or 2 screw activations per day, never more, until desired enlargement is obtained.
  • The activation period can last from 2 to ± 3 weeks and will result in activating the screw between 40 and more than 50 times.
  • The patient is seen regularly (every 7-15 days) during the activation period.
  • Once necessary expansion is obtained, activations of the screw are stopped and the appliance stays in place ±3 months to allow the bone tissue to form in the middle of the palate, in the suture that has been enlarged.
  • Illustration: The palate is composed of several bones united in the middle by the medial palatal suture (red line). The rapid expansion appliance acts on this suture to separate the bones by moving them laterally (blue arrows) thus widening the palate. (adapted from Timms 1979)

Palatal maxillary suture and orthodontic expansion

Opening of the maxillary suture during rapid expansion

 

  • During maxillary expansion, the opening of the suture is made progressively but rapidly:
    • (A) The first 3-4 turns of activation of the appliance will not produce visible changes, but still start to act on the suture.
    • (B) After a few turns, the suture starts to open. A diastema (space) that appears between the upper central incisors confirms that the opening of the suture occurs normally. Activation is continued until the desired amount of expansion is obtained (± 3 weeks).
    • (C) At the end of the activation period, the suture is maintained open by keeping the appliance in the mouth approximately 3 months without turning the screw. This immobilization period is necessary to allow remineralization of the opening zone of the suture. After this period, the expander can be removed. The space between the central incisors starts to close during immobilization.
  • The opening of the suture is not visible in the mouth but it is visible on an X-ray. The X-rays below show a palate with an expander in place while the palatal suture opens during the rapid maxillary expansion phase. When the suture opens normally, a diastema (space) will appear between the upper central incisors.
  • The red arrows indicate the opening zone of the palatal suture.
  • The immobilization period (± 3 months) after the activation of the screw allows this area to undergo recalcification and form bone in the opening zone of the suture.
  • It is possible to radiologically confirm that a maxillary suture is opening properly as shown on the examples below. Having to take such radiographs is however uncommon.
Radiographs of the palate and palatal expansion palatine in orthodontics

(A) Before activation of the appliance; the expansion screw and the suture are closed. (B) Toward the end of expansion, the screw is open (blue arrows) and the suture is open by several millimetres. The red arrows indicate the dark zone which represents the opening of the suture. (C) Another case showing a very wide opening during maxillary expansion. The expansion screw was open by 14 mm and the dark zone of the suture is well visible.

Front (anteroposterior) view, a radiograph clearly shows the opening of the palatal suture indicated by yellow arrows. A, B and C represent the same enlarged radiograph. The expansion screw, which reached its maximum opening, is also visible. The red arrow in (C) indicates the opening between the central incisors. (D) Occlusal radiograph where the opening of the suture is clearly visible. The darker areas on the radiographs are where the maxillary bones were separated.

Front (anteroposterior) view, a radiograph clearly shows the opening of the palatal suture indicated by yellow arrows. A, B and C represent the same enlarged radiograph. The expansion screw, which reached its maximum opening, is also visible. The red arrow in (C) indicates the opening between the central incisors. (D) Occlusal radiograph where the opening of the suture is clearly visible. The darker areas on the radiographs are where the maxillary bones were separated.

How to activate the appliance

Instructions to patients having a rapid expansion appliance

  • Note: Several variations in the design of expanders exist and each orthodontist has his own preferences. Certain appliances have more or less acrylic that covers the palate, they can have molar bands, acrylic that covers the posterior teeth, springs or extensions behind the anterior teeth, etc. Regardless of the kind of appliance used, they all have a screw in the middle that must be “turned” or activated and they are fixated permanently to the posterior teeth (until the end of the treatment) and the activation principles and the instructions below apply. Every type of fixed appliances can be efficient if they are used properly with known protocols.
  • The activation is performed by inserting the special key that we have given you into the screw located in the middle of the expander and by turning the screw backward (toward the throat). Do not be afraid to insert the key all the way through the hole of the screw, the key has a stopper that will prevent it from being inserted too deeply.
  • It is normal to see the child produce an exaggerated amount of saliva in the few hours following the insertion of the appliance. The mouth thinks that the appliance is food! This will disappear rapidly.
  • The activation should not be painful to the patient. In fact, turning the screw is often more “traumatic” psychologically for the parent who does it than for the child! 🙂
  • This must generally be done twice per day; once in the morning and another time in the evening, unless we tell you otherwise. Never perform more than 2 turns per day. If you have to “skip” a turn for some reason, do not try to “make up for lost time” by doing more turns the following days. The total number of turns is more important than the rate (turns/day) at which they are made.
  • We will see the patients ± two weeks after the expander is installed to verify that everything goes as planned, that the expansion progresses normally, etc. Afterward, and depending on the amount of expansion required, we will see the patients every two weeks until the total desired expansion is obtained.
  • Once the expansion is obtained, we will stop turning the screw and will “immobilize” the appliance for a period of approximately three months (immobilization period) before removing it.
  • It is preferable to make the turns before eating to minimize the discomfort sensation that can follow activation.
  • Avoid activating the appliance right before going to bed.
  • Ensure that you see the screw well. For the parents: when you activate the appliance, make the patient sit on a chair and make him/her tilt his/her head backward to get a better view. Good lighting is also essential. If you activate your own appliance, do so in front of a mirror.
  • Ensure that you wrap the string of the key around your finger or wrist. This important precaution will prevent you from swallowing the key accidently.
  • Insert the key in the hole in front of the screw. Then push the key delicately, but continuously, from the front to the back of the mouth. Remove the key at the end of the turn (toward the back of the mouth). A new hole will automatically appear in front of the screw when you push the key backward as far as possible. The screw is now ready for the next activation. The screw contains 4 different holes and each activation is equal to one-quarter turn.
  • The upper jaw is generally wide enough in 15 or 20 days. However, the appliance must stay in the mouth for an immobilization period of ± 3 months to allow the formation of bone to fill up the space created by expansion. The appliance will thus remain in the mouth for a total of ± 4 months.

How is an expander installed?

Main steps of the installation of a rapid maxillary expansion appliance. (A) Expander as received from the lab. (B) Retractors and saliva succion devices to isolate the dentition and keep it dry. (C) Etching of the surface of teeth. After cleaning and drying the surface of teeth, a special acid contained in a syringe is applied on the dental enamel only where the appliance must be bonded. The teeth are rinsed and dryed out again and are then ready to receive the appliance. (D) The adhesive is put on the appliance which is then positioned on the surface of teeth. Special blue lights harden the adhesive rapidly (polymerization). This step lasts less than 30 seconds. (E) Final result with the well-bonded expander. The whole procedure only takes a few minutes.

Installing a fixed expander bonded to the teeth only takes a few minutes. To see how this appliance is installed, follow the link below.

To see a video showing the installation of an expander.

What happens during activation of the appliance?

Pain and discomfort

  • When you turn the screw, a sensation of pressure in the palate will occur. It is also possible to feel a tingling sensation in the nose and under the appliance. It is normal to feel a slight pressure in the palate and on the posterior teeth. The incisors can also become slightly sensitive.
  • All of this is normal. This temporary discomfort should disappear after 15 or 30 minutes. It is also possible, in some patients, that teeth be sensitive for a few days.
  • Expansion mainly occurs in the palatal suture but several other facial sutures may be indirectly affected by expansion (see red lines on the images on the opposite side) and cause various sensations which may vary from one person to another.
  • Sometimes, a pressure sensation can also be felt in the sutures of nasal bones (near the forehead) and cheeks. This is normal but does not occur in all patients.
  • If required, a mild pain killer (Advil, Motrin, etc.) will be able to relieve most of the discomforts, but for most patients, this procedure is not painful.
  • If intense pain appears, this is not normal. Stop activating the appliance and communicate with us.
    If required, you can even try to “undo” a turn of the screw by activating the screw from the back to the front (opposing direction).
  • In older patients (older than 16 years of age), the discomfort may remain. If this is the case, do not activate the appliance anymore and communicate with us.
Several facial sutures can be affected by the expansion
  • Never perform more than two turns of the screw per day.
  • Stop activating the appliance when your orthodontist asks you so, even if you do not have an appointment on that day.
  • Never perform additional turns.
  • You will notice that, as the palate widens, a space will appear between both upper central incisors. This temporary spacing is normal and will close naturally when activation of the appliance is finished.
  • Carefully follow the activation schedule and the instructions that we have given you.

Enlargement of the palate using palatal maxillary expansion

A significant space will appear between the upper central incisors during expansion. This space will close within a few weeks. Sometimes, a tooth tilted inward, like this lateral incisor (*) will be corrected with the effect of expansion.

Orthodontic dental appliance to enlarge the palate with maxillary expansion

The screw of an expander can be open by more than 1 cm to enlarge the palate.

 

Rapid palatal expansion to correct a crossbite orthodontically

8-year-old young girl with a posterior crossbite treated using rapid expansion. (A) The narrow upper jaw causes interferences between the teeth when the mouth closes (arrows), which make the lower jaw deviate to the right. The midlines (middle of the dental arches, in blue) are not aligned. (B) At the end of the expansion phase with the appliance in the mouth. (C) Once the appliance is removed, the width of the maxillary arch is adequate and the mandible repositioned itself in the middle (aligned blue lines). Deviation of the jaw is no longer present.

 

Dental crossbite of upper canines

These temporary upper canines present a crossbite (tilted inward) but this is a dental problem rather than a skeletal one. Correcting this does not necessitate rapid palatal expansion.

 

Closing of the diastema created during expansion

  • As described previously, it is normal to see a space (diastema) appear between the upper central incisors during rapid maxillary expansion. This is an indication that the palatal suture is opening and the treatment progresses well.
  • The width of this space will vary depending on the number of turns of the screw performed, the rate at which activation of the screw is performed (number of turns/day) and the presence of a space between the central incisors before expansion. Expansion may necessitate between 40 and more than 50 turns of the screw. The more turns there are, the bigger the diastema will be. We recommend to perform 1-2 turns per day, never more. If turns are performed at a slower rate (for instance 1 turn every 2 days), the diastema will be smaller, because teeth may come back toward the middle as expansion occurs.
  • If a space is present between the central incisors before the beginning of expansion, the final diastema will be bigger and can reach up to more than 10 mm.
  • When activation is finished, the space will close progressively during a few weeks. It can close completely or almost completely if there were no space to begin with.
  • If a space were present before expansion, a diastema will remain after the anterior teeth “return” to the middle. It will be equivalent in width to the initial space or sometimes slightly wider. This is normal and should not worry you.
  • It is possible to close this residual space and any other space present between the upper incisors using fixed appliances while the expander is in the mouth, but after activation of the screw is finished. This may be indicated if the residual space is an esthetic problem or if there were any benefits to bringing the teeth “closer together” to help the eruption of the permanent canines that have not erupted yet and that have a problematic eruption path (visible on an X-ray).
  • However, you must remember that expansion is only a preliminary step and it will have to be followed by additional corrections to correct the other aspects of the malocclusion. It is thus normal that several irregularities remain once this phase of the treatment is finished.
Significant diastema opened during the rapid maxillary expansion.

(A) When a space (diastema) is already present before the beginning of rapid maxillary expansion, the opening of the space between the teeth will be more significant. Right posterior crossbite (arrows). (B) The initial space of 2.5 mm increased to 10 mm when the expander was immobilized. (C) Such a space will not close completely on its own, but it is possible to close it using fixed appliances. This correction can be performed while the expander is in the mouth once the activation turns are finished. (D) Result after the closing of the diastema, the removal of the appliances and the posterior relapse of the overcorrection.

Will incisors return to their initial position?

  • In the vast majority of cases, incisors that have been separated by the expansion process will reposition themselves similarly to the position they had prior to expansion. However, it is sometimes possible to see teeth, mostly the central incisors, have a different position after expansion.
  • These teeth may have different vertical positions (a central incisor becomes slightly “longer” than the other one), be mesially tilted, show rotations (teeth that are turned) or even be more advanced or tilted forward. These movements are caused by the periodontal fibers in the gingiva that join teeth together. During expansion, these fibers are “stretched” and they tend to “loosen” or contract at the end of expansion. This thus acts like an elastic band on the teeth by pulling them one toward the other to bring them closer. This relapse movement does not always occur symmetrically, resulting in teeth that can move differently on one side or another, thus creating an asymmetric position of the teeth which is different than what it was initially.
  • As described previously, if a space (diastema) between the central incisors were present before expansion, a space will remain after the expansion relapse and that space will be similar or slightly wider than the one at the beginning. If there were no space to begin with, there should not be any at the end of the relapse or a small one may remain.
Movement of teeth during relapse of the maxillary expansion

(A) Before expansion, the upper central incisors are straight. (B) At the end of expansion, a significant space will appear between the central incisors which are still straight (arrows). (The hygiene problem and dental plaque accumulation are to be noted.) (C) After a few months, the central incisors have relapsed mesially, but they also titled mesially, which may occur sometimes. This will be corrected during a subsequent step.

  • Although such variation in the position of teeth may cause a small esthetic damage in some rare cases, this usually does not cause any functional problems. Let’s also remember that expansion being only a first phase of treatment, other corrections will be necessary later anyway to finalize and optimize the position of incisors and all the irregularities will thus be corrected. Moreover, it is possible that these teeth will move again when the permanent canines erupt.
Rapid maxillary expansion in orthodontics and improved palatal width

(A) 9-year-old young girl showing a bilateral posterior crossbite (arrows) caused by a significant constriction of the upper maxilla (B).
(C and E) At the end of the expansion phase with the expander still in the mouth. (D) After the relapse of the overcorrection of expansion, the posterior teeth bite into a normal relationship (in width), but the upper central incisors have a different inclination. (F) Immediately following the removal of the expander; the palate shows redness and inflammation that will quickly disappear with a good oral hygiene. The yellow line has the same dimension as on image (B) and makes it possible to see the increase in the palatal width obtained.

 

Movement of incisors during the rapid maxillary expansion in orthodontics

(A) Bilateral posterior crossbite (arrows) caused by a maxillary constriction in an 11.9-year-old girl. The upper central incisors are relatively parallel from one another. (B) After 4 weeks of activation of the rapid expansion appliance, the central incisors are not at the same level and are starting to tilt toward the midline. (C) One week later, when the expander is immobilized, the central incisors seem to upright slightly. (D) 2 years after the expansion, the permanent teeth have all erupted, but the central incisors are still tilted even if they came closer together a few weeks after the expansion ended. A second step of treatment will correct these dental malpositions.

Opening of a space during the rapid maxillary expansion in orthodontics

(A and B) Right posterior crossbite in a patient with mixed dentition (arrows). There is no space between the upper central incisors before the beginning of expansion. (C) Maxillary constriction causing the crossbite. (D and G) Expansion created a 8-mm diastema between the upper central incisors which is visible during immobilization of the expander. (G) This upper occlusal view shows the amount of overcorrection obtained. (E) After 3 months of immobilization and the removal of the appliance, the space has closed completely (black arrow). (F) Maxillary expansion is maintained when the permanent premolars and canines erupt.

Opening of a dental space during the rapid maxillary expansion.

(A) Another example of a significant dental space present before the treatment. (B) After expansion, the diastema almost reaches 10 mm and will close partially afterwards.

Dental expansion overcorrection in orthodontics

OPTICAL ILLUSION; These pictures show that it is hard to evaluate the amount of expansion obtained by only using pictures. (A) A front view does not seem to show a significant posterior expansion, but still, the screw was “open” by 11.5 mm! (B) An upper occlusal view makes it possible to appreciate that the posterior segments go past 100% the lower posterior teeth to the right and ~ 90% to the left (arrows), which confirms that a lot of expansion was obtained. Remember that “optical” phenomenon by looking at expansion cases!

What is “overcorrection” during expansion?

Overcorrection is the requirement to obtain a lot more expansion than what is ultimately necessary because we know that most part (up to more than 50%) of the gains obtained with the expander will be lost.

The following image illustrates a transverse cut of the palate where a crossbite is present on the right side.

(A) Unilateral posterior crossbite (blue circle on the patient’s right side). The opposite side can be normal (no crossbite) or could also present a crossbite (bilateral crossbite).
(B) As expansion progresses, teeth are moved outward. Interference between the tips of the teeth may occur on the side where the crossbite was; the teeth will then momentarily fit in a tip-to-tip relationship (red circle). On the opposite side, teeth may separate vertically (absence of contact). The patient may then be under the impression that teeth only touch on one side. The interference may sometimes be adjusted by polishing the tips of the teeth if this causes discomfort to the patient.
(C) At the end of expansion, overcorrection that makes the upper teeth “go over” the lower teeth is seen on each side (more on the side where there was no crossbite to begin with). This is normal and desirable.
(D) Normally, after the relapse following the removal of the appliance, the overcorrection disappears and teeth touch normally after having returned partially toward the middle.

Overcorrection and dental interferences during the rapid maxillary expansion in orthodontics

The red line represents the initial palatal width and serves as a comparison to appreciate the enlargement of the palate.
The blue line shows that the mandibular arch width is relatively stable compared to the maxillary arch. In fact, however, a little bit of expansion may occur in the mandibular arch that tends to follow the upper one.

Hygiene and care of the expander

  • Ensure to clean the appliance well when you brush your teeth after each meal.
  • A good hygiene will prevent accumulation of food debris and will avoid inflammation of the gum and palate.
  • The regular use of a mouthwash containing fluoride is also recommended.
  • There are no reasons not to use an electric toothbrush.

What about diet?

  • The expander being quite voluminous, a certain adaptation is necessary to eat with this appliance, but it is possible!
  • The appliance is solid and sturdy, so do not hesitate to chew on the parts that cover the teeth.
  • At first, while you get used to it, you can be on a softer yet nutritive diet (soups, blenderized foods, omelets, ground beef, etc.).
  • You will however be able to go back to a “normal” diet after a short time.
  • It is possible that certain teeth, such as the incisors, become more sensitive and it will thus be harder to bite strongly with these teeth for some time.

Speech, language and phonetics

  • An expander is a quite bulky appliance that impinges on the available space for the tongue in the mouth. It is thus not abnormal to see phonetics being slightly affected immediately after the appliance is inserted. This should however return to normal after a few days in the vast majority of cases.
  • Practice: to facilitate speech, the patient may practice himself/herself by reading out loud or exaggerate enunciation of sounds and words to “train” himself/herself with the appliance in the mouth. Learning will be very fast.

What to do if problems arise?

  • If you cannot insert the key in the hole of the screw, you probably have not completed the previous turn.
  • To complete it, try to reinsert the key in the hole that is now at the back of the appliance (to do so, the key should be oriented toward the throat instead of the opening of the mouth).
  • Complete the turn by pushing the key as far away backward as possible. Then, remove it while it faces the throat instead of bringing the key forward.
  • A new hole should have appeared in front of the screw. Do not forget to always wrap the string around your wrist.
  • If you feel pain in the jaw joints or any other symptoms that seem abnormal, let us know. It may be necessary to do certain minor adjustments to the appliance or to the posterior teeth.
  • The expander must stay fixated to the teeth for a period of about 4 months. If you ever notice that the appliance moves or is debonded, stop the activation and communicate with our office.

Insertion of the key in the expander with the string wrapped around the fingers or wrist.

Activation of an expander in the mouth using the key.

  • A special activation “key” that allows for a better grip on the rod that must be inserted in the hole of the expansion screw exists. This may be useful for patients who have a more limited opening of the mouth or if you have a hard time with a standard key. We will provide you with this key if necessary.
Maxillary expansion activation key appliance orthodontics

(A) Activation key with a plastic “handle” (blue). (B) When the tip of the rod is inserted in the hole of the expansion screw and (C) during activation by pushing the handle backward to complete the one-quarter turn.

Expansion and dental alignment

  • As described previously, the goal of expansion is to re-establish the balance between the jaws rather than correct the individual position of teeth.
  • So if there were “crooked” or malpositioned teeth before the expansion treatment, these teeth will have a similar position after expansion.
  • Dental corrections will be performed in a subsequent step when the dentition is completed.
  • However, in certain situations, it may be indicated to correct the position of the upper incisors on top of doing expansion. This may be the case when the incisors show a crossbite or a significant malposition (rotation, spacing, interference that shifts the jaw, etc.).
Orthodontic maxillary expansion and braces

(A) 8-year-old young girl showing a bilateral posterior AND anterior crossbite. A significant space (diastema) is present between the upper central incisors. (B) After the end of activation of the expander, brackets were put on the incisors to align them. The expander stays in the mouth. (C) After alignment of the incisors with the expander in the mouth. (D) When the expander and braces are removed, the teeth got closer and the crossbite is corrected. These preliminary corrections will have to be followed by more complete corrections (using braces) a few years later when the permanent dentition is completed, but this preliminary intervention re-established the balance between the jaws and eliminated a functional mandibular shift.

 

Expansion in adults – SARPE

  • If expansion is necessary in adulthood or after the palatal suture (in the middle of the palate) is fused, certain practicians recommend to perform a surgical intervention to help enlarge the palate using an expander. The surgery includes making an incision that weakens the maxillary bone and facilitates its enlargement where the suture is located.
  • This procedure called SARPE (Surgically Assisted Rapid Palatal Expansion) aims at weakening the bone to allow it to “yield” when the expander applies a lateral pressure which will lead to separation of the palatal suture.
  • Alternative: clinical protocols that allow palatal enlargement using “braces” that create slight expansion forces without using an expander or a surgical intervention now exist.
  • In our practice, we no longer use SARPE.
  • To see examples of cases treated with expansion but without an expander or SARPE.
  • To see a video describing SARPE in its slightest details (people having a weak stomach, please refrain…!)
Rapid maxillary expansion without surgery in an adult

Maxillary expansion obtained without an expander or surgery in a young adult. The space where a damaged tooth had to be extracted (indicated by a *) was closed during the treatment.

Can a narrow jaw enlarge with growth?

  • The quick answer to this question is NO!
  • The width of the jaw is the first of the 3 dimensions to stop growing, so if an arch is narrow at an early age, this problem will not be fixed with time or years even if growth is not finished.
  • This residual growth will affect the other dimensions of the jaws and the posterior width of the arches where new teeth will erupt, but not where a crossbite is already present.
  • The following cases, which did not undergo any orthodontic intervention, have the same width problem (crossbite) 3 years, 6 years and 20 years later, which demonstrates this point..

Posterior crossbite that was not corrected without an orthodontic treatment.

A crossbite will not correct itself without any orthodontic intervention

Example showing that crossbites do not “auto-correct” with time, years and growth. See below for more details on this case.

  • (A) At 5 years of age, this boy showed a narrow upper maxilla. When he closes his mouth, an interference is present between the temporary right canines (blue circle). In this incomplete closing position, the midlines of both jaws are aligned (blue dotted lines).
  • (B) When he closes his mouth completely, which is necessary to get the posterior teeth to touch and chew, the interference “forces” the mandible to shift to the right (white arrow), thus creating a right posterior crossbite (blue arrows) and a significant deviation of the midlines (blue lines). We refer to this type of crossbite as being functional because, even if the cause of the problem is a maxilla that is too narrow, the crossbite is visible when the function (closing) is used (functional crossbite).
  • (C and D) 6 years later, that is at 11 years of age, the permanent teeth have started to erupt and, despite growth, the same maxillary constriction is still present with the posterior crossbite and the deviation of the midlines. This condition does not get fixed without orthodontic intervention.

At what age can rapid maxillary expansion be performed?

  • As discussed previously, the width of jaws is the first of the three dimensions (width, height and length) to stop growing and this occurs relatively early, even before the permanent teeth erupt. Thus, a jaw that is too narrow will stay that way unless an orthodontic intervention aiming at “widening” the upper maxilla is performed. The question then becomes at what age it is preferable to intervene if such intervention (any kind of expansion) will be necessary one day or another anyway.
  • Opinions on the ideal period to perform rapid maxillary expansion vary. Although it is theoretically and technically possible to do this treatment at a very early age (for instance at 3, 4 or 5 years of age), the “limiting” factor at this age is a lot more the patient’s cooperation than the orthodontic indication to intervene. Most orthodontists will prefer to wait toward 6-7 years of age before intervening to be able to use the permanent first molars as anchor for the expander. At this later age, it is usually easier to take diagnostic material (study models, radiographs, pictures, etc.), even if certain younger patients can do it very well.
  • The severity of the problem (crossbite, mandibular deviation, etc.) can also influence the moment chosen by the orthodontist to intervene. However, it is relatively rare to see incapacitating crossbites at an early age to the point where it is impossible to wait toward 6-7 years of age to envision orthodontic corrections… but it is not impossible.
  • In certain cases of sleep apnea affecting young children where there is no obstruction of the upper airways by tonsils and/or adenoids and a significant maxillary constriction is present, it can be justified to envision rapid maxillary expansion before 5-6 years of age.
  • If the “motivation” to start such a treatment at a very early age (either it be from the parents or the orthodontist) is to avoid the need to have more elaborated global corrections afterward (braces, multiband appliances, etc.), this will not happen (or very rarely; see example below) and everyone might end up being disappointed.
  • So the question on the ideal age to perform rapid maxillary expansion should rather be “is it necessary to do it at this moment?” than “is it possible at a very early age?”.

Is everything corrected after expansion?

  • As described above, expansion aims at correcting an imbalance in width of the jaws rather than dental malpositions. However, widening a dental arch may sometimes have an effect on the position of teeth by providing additional space. In certain cases, this may allow the teeth to correct certain aspects of their malposition.
  • In the vast majority of cases, maxillary expansion is only a preliminary step needed to be followed by additional corrections that aim at either correcting the other dimensions of the jaws (height and length) and/or dental malposition and irregularities. Most of the time, the preliminary interventions must be followed by a second corrective phase when the permanent (definitive) dentition is completed.
  • However, in some very rare cases, when the malocclusion was not too severe to begin with and was mainly caused by maxillary constriction, correcting this constriction by rapid maxillary expansion may allow for sufficient corrections that will make a second phase of treatment using “braces” optional. Here is an example of such a case:
Rapid palatal expansion and correction of malocclusion orthodontics Sherbrooke

(A) Malocclusion with a left posterior crossbite (arrows) caused by maxillary constriction. (B) At the end of expansion, with the appliance in the mouth. The diastema was created during expansion and will progressively close. (C) After more than one year and once the eruption of the permanent teeth is completed, the occlusion is functional and esthetically acceptable. No other corrections were performed. (D) Open mouth showing an alignment that is relatively acceptable despite a few irregularities.

It may sometimes occur that a preliminary intervention, such as palatal expansion, be sufficient to obtain a functional and esthetic occlusion that does not require any other interventions when the patient is a teenager. This is what happened in the following example where a 9.4-year-old young boy had a right posterior crossbite accompanied by a mandibular shift on the same side. Maxillary expansion and a short treatment to align the incisors resulted in an acceptable occlusion.

Expansion phase 1 only RPE orthodontic interception

(A) 9.4-year-old boy – Posterior crossbite (yellow arrows) and mandibular shift to the right when the mouth closes. This is obvious by comparing the midlines (blue dotted lines). (C) Immobilization of the rapid maxillary expansion appliance at 9.5 years of age. (D) The use of a few orthodontic brackets to correct a persistent anterior crossbite and align the upper incisors. (E) These corrections only lasted for a few months. (F) 11.3 years of age – The correction of the incisors is maintained and we are waiting for the other permanent teeth to erupt. (B) When the permanent teeth have all erupted (13.5 years of age), the occlusion is esthetically and functionally acceptable and does not necessitate any other corrections. The midlines remain aligned. Let’s also note the improvement of the level of gingiva where the left lower incisor is located and which was slightly receding (blue arrows). Correcting the crossbite by these simple preliminary interventions prevented additional gingival loss with the years to come.

Secondary benefits to expansion

  • As described earlier in this section, palatal expansion allows the enlargement of the upper jaw, improvement of the relationship between the jaws, improvement of the function, elimination of jaw deviations, etc.
  • There are also several secondary benefits that cannot be obtained as directly or as predictably as palatal enlargement and the movement of teeth, but which may still occur frequently and result in significant benefits for patients.
  • Mandibular deviations: maxillary expansion often makes it possible to get rid of a mandibular deviation caused by interferences between the teeth of opposing arches when the jaw closes. The expansion eliminates the interferences and very often allows the mandible to reposition itself in a position that is more centered (see the examples at the top of this page and below).
  • The “repositioning” of the mandible can prevent growth from creating a permanent skeletal asymmetry, one that is a lot more difficult to correct later on (and that can necessitate a surgery) and minimize the risks of premature and abnormal tooth wear.
  • Mouth breathing: several patients having undergone palatal expansion report having an easier time breathing through the nose, saw their snoring decrease or improvement of their allergies. Even though these cases are anecdotal and the goal of expansion is not obtaining these positive secondary effects, they occur from time to time.
  • The example below is of a 7-year-old young boy who suffered from sleep apnea at an early age. His tonsils and adenoids were removed, which eliminated sleep apnea. He also suffered from several ear infections mainly during winter (up to 8 episodes). After undergoing maxillary expansion, he did not suffer from ear infections afterwards. It is hard to explain the relationship between these elements, but these benefits sometimes occur.
Palatal expansion and ear infections

This 7-year-old young patient who shows maxillary constriction suffered from several ear infections each winter. After palatal expansion, he did no longer suffer from ear infections.

 

Snoring and sleep apnea in a child presenting a malocclusion with a crossbite

(A) Narrow maxilla in a 9-year-old boy who suffers from chronic snoring. (B) View of the upper jaw that is too narrow compared to the mandible. Although there are no “guarantees”, maxillary expansion often decreases snoring problems in children.

A crossbite and mandibular deviation will not correct themselves with growth without any orthodontic correction.

(A, B) Interference between the temporary canines that makes the mandible deviate to the right in a crossbite when it closes (B) in a 5-year-old boy. (C, D) Without any orthodontic intervention, the same condition remains 5 years later at 11 years of age. Growth is insufficient to correct such a problem. The upper right teeth are still tipped inward (arrows in B, D, E and F). (G, H) The maxillary expansion will have made it possible to re-establish the balance between the width of the jaws and correct the mandibular deviation.

Expansion and periodontium

  • Rapid maxillary expansion is an orthopedic movement that mainly puts a strain on the maxillary suture (but other sutures are also affected), the maxillary bones, the teeth and the periodontium.
  • Particular care must be taken for the gum (width and thickness) when expansion (regardless of the method used) is planned.
  • Adults show more gingival recession problems and expansion may have a negative effect on the gum and the periodontium if it is not planned or executed properly.
  • To know more on gingival recession during orthodontics.
Gingival recession present before the beginning of an orthodontic treatment. Dental malocclusion; transverse maxillary deficiency, maxillary contraction. Can necessitate a gingival graft

This 18-year-old young man, who will start an orthodontic treatment to correct his malocclusion, shows a V-shaped maxillary arch that is very narrow (D) and a bilateral posterior crossbite. (A, B, C) Even if his gums are generally of good quality (width and thickness of tissues), even before the beginning of treatment, several teeth (indicated by the arrows) have different degrees of recession. The maxillary arch having to be enlarged, the level of gingiva will have to be monitored closely during the orthodontic treatment. If it diminishes significantly, gingival grafts or similar procedures may be necessary. The patient will have to pay particular attention to his oral hygiene and his brushing technique during the treatment to avoid contributing even more to gingival loss.

Maxillary deficiency – Extraoral mask

  • A maxillary deficiency affects more often the maxilla in the width dimension (narrowness), but there may also be an anteroposterior imbalance (in length).
  • The treatment of such malocclusions necessitates a particular approach using an extraoral face mask.

Installing and removing the expander

Installing the expander

  • Installing an expander is relatively simple. This appliance is simply bonded to a part of the surface of the posterior teeth using the same composite as the one used to make “white” dental restorations (“white fillings”).
  • The surface of the teeth where the appliance will be installed is first cleaned. Then, retractors are used to keep the lips and the cheeks away from the dental surfaces while teeth are dried out and a special product is applied for 15-20 seconds to make the dental enamel more porous to retain the adhesive (etching) that will be applied. The teeth are then rinsed and dried out again and are now ready for the expander.
  • Adhesive is put on the appliance only where it will be in contact with the surface of the teeth. It is then positioned on the surface of the teeth and a special polymerization light is used to harden the adhesive in 15-20 seconds.
  • No anesthesia, injection, surgery, etc. is necessary and installing the appliance is done in only a few minutes.
  • Once expansion is completed, the adhesive is easily broken with special pliers and the appliance is removed in a few seconds. If adhesive remains on the teeth, it is removed and the surface of the teeth is cleaned and there you go, that’s all there is to it!

To learn about the steps and see videos illustrating how a rapid expansion appliance is installed and removed, follow this link.

Main steps of the installation of a rapid maxillary expansion appliance. (A) Expander as received from the lab. (B) Retractors and saliva succion devices to isolate the dentition and keep it dry. (C) Etching of the surface of teeth. After cleaning and drying the surface of teeth, a special acid contained in a syringe is applied on the dental enamel only where the appliance must be bonded. The teeth are rinsed and dryed out again and are then ready to receive the appliance. (D) The adhesive is put on the appliance which is then positioned on the surface of teeth. Special blue lights harden the adhesive rapidly (polymerization). This step lasts less than 30 seconds. (E) Final result with the well-bonded expander. The whole procedure only takes a few minutes.

Steps of the installation of a rapid maxillary expansion appliance. To learn more and see a video, follow the link above.


Original publication 2009-09-19 © Jules E. Lemay, orthoLemay.com

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Comments and/or questions (95)

  1. Toe Pyi Aung says:

    This is a good article.

  2. 2093210115 says:

    I’m only 16 years old but I’m wondering if the sides of the expander is supposed to be black and give a extreme pain to my teeth where it’s attached

    • Dr Jules says:

      I can’t comment about the color of your appliance as I don’t know what kind of expander you have. However, having extreme pain is not normal during an expansion treatment so stop activating your appliance and contact the practitioner who inserted this appliance asap.

  3. monserrat hinojosa says:

    Upper lip numbness after surgery for jaw expansion

    Hello so I had my expander jaw maxillary surgery on Friday and my expander is going to start moving this Monday that means I’m going to a appointment,I feel like I have my upper lip attached with my upper teeths and is numb what can I do ?
    Do you think my lips are actually attached to my upper lip? When is my numbness going away?
    (I’m taking antibiotics )

    • Dr Jules says:

      Your lip is certainly not attached to the expander.
      It is normal to feel a certain degree of numbness following an upper jaw surgery aimed at weakening the bone to allow maxillary expansion. This may last weeks or even months depending on what was exactly done.

      Ask questions to your orthodontist or to the surgeon who did the surgery about this. They sould be able to reassure you.

    • Kayleigh says:

      I precisely wished to thank you very much all over again.
      I do not know the things that I could possibly have sorted out without the type of techniques documented by you relating to such a field. It was before a very intimidating problem in my cintamscurces, however , seeing this specialized technique you processed the issue made me to weep for gladness. Now i am thankful for this advice as well as have high hopes you realize what an amazing job your are accomplishing teaching the mediocre ones through the use of your blog post. Probably you have never met all of us.

      tag #merci

      • Dr Jules says:

        In fact I don’t think that I have ever met anyone who asked questions on this blog (15,000+ so far…) but it is a pleasure to be helpful at a distance ant demystify orthodontics.
        Thanks for your kind words.

  4. T says:

    I am 49 years old and am planning to get braces but my dentist wants to me to have expanders first. Will expanders help my teeth become straighter?

    • Dr Jules says:

      An expander is an orthodontic appliance used to expand or enlarge the dental arches. Expansion provides space which can be used so align and straighten teeth but they don,t straighten teeth by themselves.

      I don’t know what he refers to by “having expanders first”

  5. Class III Chump says:

    Maxillary expansion in an adult doesn’t work, no garantees

    I’d like your opinion on my case.

    25 years old. Class 3 Malocclusion. Went through TAD (Temporary Anchorage Device) expansion with no incisions – just install and turn.
    After 40 turns, TAD screw was “maxed-out”. Some expansion occurred but not enough. Still a cross-bite. Turning process was painful 90% of the time.

    I’m to go through another TAD expander with no guarantees that’ll it work a second time – very reassuring hearing this (sarcasm). They’re planning to modify the design by covering more surface area at the screw locations.

    I don’t know if you’re willing to discuss past failures, but I’d like to hear your opinion on what seems to be an experimental method.

    • Dr Jules says:

      40 turns of an expansion screw in a 25 year old patient… and not obtaining the necessary expansion. If this was done without a surgical procedure (corticotomy or Surgically Assisted Rapid Palatal Expansion (SARPE)) this is an unusual treatment protocol that I have never heard of.

      Furthermore, they plan to use a second similar appliance to attempt even more expansion? This protocol goes against all the standard teachings of adult orthodontics! Rapid maxillary expansion is usually done in growing patients in whom the mid-palatal suture is not fused ans can be readily separated to widen the bony palate. In adults, this suture is fused and cannot be as easily opened to obtain sutural expansion unless the bone is “weakened” by a surgical procedure (SARPE).

      Dento-alveolar expansion can be done in certain cases by tipping the teeth and remodeling the maxillary bone (NO SUTURE opening) but there is a limit to this technique. To see some examples.

      I am afraid I can’t comment more than that about a treatment protocol which I have never heard of.

      Ask your orthodontist how many cases similar to yours (similar malocclusion treated in an adult) he has treated successfully and ask to see the results…

  6. monserrat hinojosa says:

    Hello I’m a 15 year old I had my maxillary expansion surgery 2 or 3 weeks ago ,i have these question so i can’t close my lips for some reason “why I can’t close my lips?”I mean I can but I feel alot of pressure i don’t know but I think it might be because of the new stitches I got maybe one week ago since I was bleeding alot or maybe is just the gap since I been moving the expander

    • Dr Jules says:

      It could be because of inflammation in your muscles resulting from the surgery. Discuss that with your surgeon.

  7. Christopher Campbell says:

    Do I need expansion, surgery for a narrow jaw?

    Hi , i wonder if you can help me as i have the damon brace system installed and have a cross bite my upper jaw is much more narrow than my lower i find as i get older i have more tmj pain and a lot more pressure in my lower jaw , it feels like when i smile the top jaw is way to narrow so thus placing all the pressure to the laser jaw , do you think i need a expander or surgery to expand my upper bite and help the alinement . I feel like if my upper bite was the same as bottom or wider it would even out the pressure stress on the facial muscles.

    • Dr Jules says:

      If you are already in braces, the treatment plan should have already been established by your orthodontist, presented to you and discussed… The need for expansion must be planned frem the very start or treatment.

      Depending on how your orthodontist works, some form of expansion may be obtained with braces alone such as in these cases or with a surgical procedure. I can’t tell you what applies to your specific case, You’ll need to discuss that with your orthodontist.

  8. Class III Chump says:

    I’d like your opinion on my case.

    25 years old. Class 3 Malocclusion. Went through TAD (Temporary Anchorage Device) expansion with no incisions – just install and turn.
    After 40 turns, TAD screw was “maxed-out”. Some expansion occurred but not enough. Still a cross-bite. Turning process was painful 90% of the time.

    I’m to go through another TAD expander with no guarantees that’ll it work a second time – very reassuring hearing this (sarcasm). They’re planning to modify the design by covering more surface area at the screw locations.

    I don’t know if you’re willing to discuss past failures, but I’d like to hear your opinion on what seems to be an experimental method.

    • Dr Jules says:

      I can’t discuss pass failures with such an approach because I would never use it!
      Using a TAD anchored rapid palatal expansion appliance without a surgically assisted intervention (SARPE; surgically assisted rapid palatal expansion) in an adult is far from being a recommend approach. And they are going to add a second appliance using the same protocols on top of that? Why don’t you ask your orthodontist to show you 10 similar cases that he treated the same way with success? I personnaly don’t have any to show so I can’t recommend this approach…

      You have to realize, and I hope that someone has explained that to you, that the expansion they are attempting is not sutural expansion but dento-alveolar expansion and if this is not properly done or done too rapidly, the anchor teeth can literally be pushed out of the bone.
      This is experimental indeed at best and I don’t know anyone recommending this.

      • Class III Chump says:

        Thanks for the replies, I’ll ask my ortho for similar cases and find out what was done with previous successes and failures.

        You mentioned dento-alveolar expansion. The appliance, as far as I’m aware, has no contact with the teeth. In a basic description, it has 4 “legs” with a “loop” at each end where the screw goes. Each screw is put in through the “loop”, through the upper gums, and directly into the jaw bone – it’s not the one that wraps around the upper molars.
        The initial idea was to keep turning and cause “mini-fractures” where the suture eventually splits. The problem was it split at around 30 turns, and not enough turns remaining to fix the cross-bite. Bad appliance design.

        One last question, is it common to first make an incision to weaken the suture in adults and then try expansion?

        • Dr Jules says:

          If the aim was to obtain sutural micro-fractures and with the rate of expansion screw activationthat you described, this is not dento-alveolar expansion but an attempt at sutural or skeletal expansion, regardless of the appliance design.

          Making an incision in the cortical bone on each side of the maxilla to “weaken’ the bone and facilitate sutural expansion is called Surgically Assisted Rapid Palatal (or Maxillary) Expansion (SARME or SARPE) and is very common in adults who have a fused suture. In fact it is considered the best practice in such cases.

  9. skylar says:

    Bump on the palate during maxillary expansion

    i have an expander installed and just had surgery one week ago, the incision on top of my gum line on the outside of my teeth is healing nicely with stitches but the hole in the top center of my mouth is very sore and seems to healed into a bump, it’s very tender and causes pain when air passes over it while breathing through my mouth and when i try to chew anything less soft. Will this pain go away and will the bump on top of my mouth recess and heal normally or will i always have this soft tissue bump right behind my two front teeth where i think they saw’d the bone?

    • Dr Jules says:

      I can’t tell you what exactly this bump is. It could be many things; an infection, inflamed tissues, etc. Clean the area thoroughly and if the situation doesn’t improve don’t hesitate to contact your orthodontist. Succh a bump is not normal and it should eventually disapear.

  10. Denise says:

    How do I know how much expansion is needed?

    Hi i had surgery September 22 and it is now october 26 my surgeon said to stop turning the appliance but i feel like its not enough expanded because i read that i Will lose 50 percent of what has expanded and i am 28 years old. How can i know how much expansion is needed so that i don’t get a crossbite again and another question is : when does the palate stop expanding and fuse back? Why does the palate get narrow again 50%?

    • Dr Jules says:

      Your orthodontist should have told you exactly the number of turns that you must do with the expansion screw to obtain the necessary expansion. If he/she didn’t tell you, go back to the office so that they explain exactly what you must do.

      The 50% loss is not at the middle of the palate (suture level) but at the tooth level; teeth that were inclined and pushed out with the expansion tip back towards the inside
      The palate stops expanding with growth very early (4-5 years of age). That is why expansion treatment is done in young children.
      It stops expanding with an expansion appliance as soon as the activation of the screw is stopped and after that, the open suture will progressively calcify over a few months.

  11. The roof of my mouth is very narrow says:

    Jaw surgery to close a space between the front teeth?

    I am 47 yrs old My dentist sent me to an orthodontist because I was interested in getting braces for the top teeth cause my 2 front teeth are separated like a v kinda and the right side sits differently from the left side .. the orthodontist suggested that I have my jaw broke in 3 different places .. I am not a fan of having jaw broke or my mouth wired shut at all ! Can you suggest any other options please ?

    • Dr Jules says:

      I think that you are describing 2 problems that are completely different.
      Having a space between 2 front teeth (incisors) is a detanl problem which can usually be dealt with by moving the teeth (orthodontics) or enlarging the teeth).

      If you were told that you need jaw surgery this is to solve a skeletal problem or a severe jaw discrepancy or imbalance ant that has nothing do do with a little space between 2 upper front teeth.

      Make sure that you understand correctly the different options that were presented to you and that you make your demands (chief complaint about your dentition) very clear sot that the orthodontist can propose a treatment accordingly. If you can’t get answers, get a second opinion.

  12. Ian Burberry says:

    Maxillary expansion or extractions to gain space

    My son is 14 Yrs 9 Mnths old and his orthodontist has now recommended the removal of his upper right and left first premolars (UR4 / UL4) to create space for his ‘canine’ teeth. Both premolars are healthy, cavity free, adult teeth and I am not keen on their removal.
    At no point in his treatment plan (he has had braces for 18 months) has there been any discussion about the possibility of maxilla expansion to create the necessary space. Is this likely to be because of his age (is it too late now without surgical intervention), or other considerations such as treatment cost? I am concerned our treatment options are being unreasonably constricted.

    Also, I found your article extremely informative, can you recommend any information sources relating to the risks, issues, or potential long-term impact of the removal of adult teeth in young teenagers?

    • Dr Jules says:

      Extractions and expansion have two different purposes even if both can provide some space for the alignment of the teeth.

      Maxillary expansion is aimed at widening an upper jaw (bone) at the suture level (rapid maxillary expansion). It is not aimed at avoiding extractions which, by the way, may still be required in expansion cases.

      There are different reasons to extract teeth in orthodontics, the main one being a need for space.
      To learn more about extractions in orthodontics.

      It is however surprising that an orthodontist would suddenly decide to extract upper first premolars to help the eruption of canines after 18 months of treatment, not because it is not indicated but because that indication was very likely present at the beginning of the orthodontic treatment when your son was ± 12 years old.

      Tooth extraction will not have a long term negative impact if it is indicated and part of a well planned orthodontic treatment plan.

  13. Helen Tran says:

    What are difference between a removable expander vs a fixed expander? Will the removable expander be able to achieve the same goal with also opening up the nasal airway too?

    • Dr Jules says:

      Fixed vs removable orthodontic expansion appliance

      A fixed palatal expander is aimed at doing rapid maxillary expansion to open the mid-palatine suture. This is an orthopedic movement aimed a widening the upper arch by moving the 2 bony segments of the palate (maxilla).

      A removable expander will provide dento-alveolar expansion. There is no sutural opening in the middle of the palate adn the arch width increase is done more by tipping the teeth in (and with) the alveolar bone around the teeth. The activation regimen of the expansion screw with removable appliances is usually 1 turn per 7-10 days whereas with a fixed appliance it is 1-2 turns per day.

  14. Nicole says:

    Why do maxillary expansion if the teeth are already expanded

    I had an expander put in November 2013 at 17 years old and I got it removed August 2014 at 18 years of age. My concerns about the expander right away during the treatment were that my teeth were being over-expanded, of course, after some research I realized this was normal..

    Fast forwarding to November 2014 my concerns great more as time has passed and the left side of my teeth were still protruding forward, this bothered be a lot because it wasn’t aesthetically pleasing, I have smaller teeth and a lot more gum surface so there was a lot more gum showing on one the left side verses the right.

    Fast forward to today, November 2016, and my teeth, although they look a lot less dramatic, still are over expanded maybe by about 2-4mm starting from my left lateral incisor. Also when I stick my pointer fingers around my maxillary I can actually feel where the left side is pushed out further to a point where theres a ridge formed. Currently my doctor is just having my wear bands but when I ask her about this she tells me my teeth were always like that and they were not. I mean if my teeth were already over expanded I wouldn’t need a hyrax right? Basically I don’t know what to do at this point…is this fixable? I’m really upset about this any help is welcomed.

    Thank you for your time.

    • Dr Jules says:

      Your reasoning is not faulty! Although I don’t know all the details of your case, expansion is usually indicated when the upper arch is too narrow compared to the lower one (there are exceptions). Is seems therefore logical that if you start with an upper arch that is too wide, it doesn’t require expansion!

      Chances are that the width of your upper jaw is the result of remaining over expansion during the expander treatment… but that is really beside the point because regardless of what is the cause of that extra upper width, it should normally and usually be corrected to “harmonize” the size, form adn with of both jaws unless there is a good reason not to do it… and none come to my mind now!

      • Nicole says:

        Thank you so so much for taking your time out to respond.

        I just want to say, I do believe my upper jaw teeth were SLIGHTLY narrow, however, I still think she overcorrected my left side too far over, and after two years they have not returned to the same size as the other side of my mouth. I guess really my question is, is there a way to fix this? Right now what I believe my orthodontist is trying to do is use triangle elastics (on left lateral) to close the gap the has formed since my teeth are too far over. But, all it’s doing is pulling my teeth down lower than those on the other side.

        Is there a way for my orthodontist to push my teeth back over? Do you recommend that I go to someone else for a consultation. I no longer trust her judgement as I feel that she has far worsened my teeth.

        Again, thanks so much for replying. I hope this isn’t too much.

        • Dr Jules says:

          There probably is a way to correct what is bothering you but you will have to discuss it with your orthodontist. If she thinks that is is not possible to correct, she will tell you. In that case, and make sure to understand WHY it can’t be done. Before going to another orthodontist, it is certainly easier and simpler to try to solve this issue with your current practitioner.

          • Nina says:

            Is reversing the palatal expansion possible

            I appear to have the exact same issue as Nicole with the left side over expanded and more protruding than the right. I have only recently stopped the turning of my removable expander to be given an essix retainer. As it is only very recent and I wore the expander for circa 4/5 months I have a bizarre question for you…… Is one able to turn the expander in reverse motion to get the opposite effect and in essence go backwards? I was turning my expander once a week only. I have probably achieved a 6 mm expansion, if that in the time I have been wearing my device. I am 41 years of age and was told I have a slight relapse and overbite from previous ortho treatment. The expander I was initially given was expanding equally on either side (open sutre in the middle) which was fine but I reached its max turns and I was actually quite happy with the progress and expansion at that point but my orthodontic insisted there is room for a little more expansion and of course there will be some form of relapse too so I agreed to a 2nd device. The 2nd expander device was different and aimed at pushing the left side out further that is when I noticed the changes……after a few turns I noticed the left side was expanding more rapidly than the right thus my smile and laugh lines are no longer symmetrical either.

            I have mentioned this to my orthodontic who seems to think my upper arch was this way prior to using the expander but I have photographical evidence to suggest otherwise and get told I am being paranoid!

            I have generically asked the question of another orthodontist (without letting on my own situation) about screwing the key in my appliance in reverse mode and if this would take me backwards/in the opposite direction and have been told yes it would and wondered what your take on this was? I would quite gladly turn the key backwards for the 5/6 turns/weeks to go back to the end of the 1st device and get a retainer made at that point, if it was possible……… the 2nd expander hasn’t even expanded 3mm but the facial deformity/or deformed aesthetics are highly visible not to mention worrisome…….

            I would appreciate all advice and feedback or whether I should speak with another orthodontic?

            The only other and last alternative I can see is to not wear my retainers and let it all go back to how it was, assuming it will do…. which would have been a complete waste of my time and money….

            Nina

            • Dr Jules says:

              If you had a removable expansion appliance at 41 years of age and were doing a few turns per week, this did not open the mid-palatal suture. It rather “pushed” the teeth to the side by doing dento-alveolar expansion which is very different but could still provide a wider arch. In such a case, I imagine that it could be possible to revert the process to a certain extent by bringing the teeth back toward their starting point…. but it may also be indicated to modify the lower arch to match that newly expanded upper arch. Your orthodontist would be able to determine what is best for your case.

              It is very easy to know how your arch was prior to treatment, just ask your orthodontist to compare your initial study models (cast of your dentition) with your actual arches.

              Depending on your occlusion (bite), stopping your retainer may allow some relapse.
              I cannot comment on your treatment plan but if you are unsure if what was done was indicated, you could always ask for a second opinion with another certified specialist in orthodontics (orthodontist).

  15. josh says:

    Hi im 16 and have got a removable expander I am worried that I am to late and it might mess my teeth
    up

    • Dr Jules says:

      It the appliance is designed properly, used correctly by a practitioner who knows what he/she is doing in orthodontics, it should not “mess up” your teeth. If you have any fears, discuss them with your practitioner asap.

  16. Nate says:

    Why use a bone screw for surgical maxillary expansion?

    Thanks for this site and for answering questions. It’s very helpful. I was worried before reading about pain but you’ve help calm my fears as I’m over 30.

    I will be having the procedure done by a very reputable Ortho school and their description is a surgical separation before the expansion to help start. However, along with the adhesive to the teeth they described using a screw into bone that will help keep the device in place (if needed). Not sure if this is a normal procedure.

    Also, I didn’t see any description of the gap formed in the upper plate during and post procedure. Is there a risk at puncturing my upper palate skin while there is no bone underneath?

    Thanks for also describing the secondary benefits for sleep apnea sufferers. I didn’t know about that and can see how it can possibly help. I’m not expecting it but am definitely hoping it helps my snoring. Unexpected bonus to the procedure.

    • Dr Jules says:

      If you are having this surgical expansion procedure done in a certified graduate orthodontic program, don’t worry, they know what they are doing!

      Using a palatal implant (bone screw) is a way to obtain additional anchorage for the expansion appliance. There are various reasons for doing this. It is not done regularly but it is an accepted procedure that we occasionally see in the scientific orthodontic literature. Do not hesitate to ask your orthodontist why he wants to use this specific protocol. He certainly has excellent reasons!

      No gap forms in the mucosa of the palate (palatal skin) during expansion, it happens only at the bony suture level, under the palatal mucosa and this is not visible.

      The benefits of expansion can be numerous and it is not rare to see patients reporting that they breathe better after such a procedure, that they snore less and it may sometimes help sleep apnea in certain cases but this is unpredictable.

  17. Nix says:

    Hi Dr Jules,

    I’m 16 years old and currently have an expander. Considering my age, will my suture likely open up?

    • Dr Jules says:

      WHAT? Someone put a palatal expander in your mouth without describing to you what will happen or explaining the possibilities of the suture opening or not?
      I think you should have a serious talk with your “orthodontist” and fast…

      A maxillary suture will usually open up at 16 years of age but there may be exceptions (especially in females who mature earlier).

  18. Dr Jules says:

    Hello there! My platel expander has stopped expanding when I activate it with my key. Is something broken or does it stop after expanding after 4 weeks?

    Thank you for your time,
    Andrea

    • Dr Jules says:

      You will reach the end of the expansion screw after a certain number of turns or activation not necessarily after a number of days (although they may be related). Ask your orthodontist about the specifics of your appliance but he should have explained that in the first place when he inserted the appliance…

  19. Angela M. says:

    Special expansion appliance after speech therapy?

    Excellent article, the most informative I have read!

    My 7 year old daughter has been under the care of a speech pathologist for 2 years and they are now recommending we see an Orthodontist for pallet expansion. They say her pallet is ‘small’ and causing tongue placement and usage issues which may be affecting her speech. Is a different type of expander used for this purpose? My concern is that if ones speech is affected by having the appliance in, will this cause her further delay? Thank you for any guidance.

    tag #merci

    • Dr Jules says:

      Further delay caused by using an expansion appliance for ± 6 months? Yous should know that there has been a significant delay already as the need for expansion was already present 3-4 years ago and could have been done 1-2 years ago. Did the speech therapy change anything so far? I doubt it… you will get more positive results for tongue placement from expansion which will concretely enlarge the palate and provide more space for the tongue. However, this doesn’t guarantee that it will help or cure the speech issues but it shouldn’t hurt…

      Any “proven” expansion appliance will do.

  20. Dr Jules says:

    Is there a maximum number of turns on expansion screws?

    Hello there!
    I’m a 27 year old female and I have had an upper expander installed a few months ago and was still prescribed to turn once a day. I still am turning it but unfortunately I do not feel that the turns are successful (like they were before with the tightness when activating the device). Does the device have a max number of turns?

    • Dr Jules says:

      If you have been doing screw turns for many months, I hope that it is with a removable appliance and not a fixed one!
      Expansion screws do have a fixed number of maximum turns that can be done but your orthodontist should have told you this and explained exactly what to expect with the treatment that he proposed. Ask him for additional information.

  21. Mauricio says:

    Can I take the plane after a SARPE at age 57?

    Dr Jules, I am a 57 years old man with a malocclusion type III derived from a narrow upper jaw. I am scheduled to go through SARPE in the third week of January. From your experience I would like to know whether at my age I can expect to have a good outcome from the surgery in terms of achieving the necessary expansion of the upper arcade and afterwards getting the gap closed and the teeth well repositioned with orthodontics. I will have to fly back home after the surgery which I am planning to do 24 hours later and I would like to know if this is something that can be done or whether I should allow 48 or 72 hours before flying back. Thanks.

    • Dr Jules says:

      If you are in good general and dental health, the outcome of a SARPE procedure has not much to do with age. You oral surgeon and orthodontist will be better at answering this question for you but if they recommended such a procedure, I imagine that they think that it is indicated and they anticipate that you will benefit from it and have a positive outcome.

      If there are no complications (they are rare), I don’t think it should prevent you from flying the next day but double check with the surgeon to see what he thinks.

  22. Alicia says:

    My 7 year old daughter just got her pallet extender on the top. We are on day 3 of turns and she is complaining of ear pain. Could ear pain be a side effect?

    • Dr Jules says:

      It is very unlikely that ear symptoms are directly caused by the rapid maxillary expansion. She may have a separate condition affecting her ears. Discuss this with your orthodontist. In the mean time, you may want to stop the activation of the expansion screw.

  23. Jane Politi says:

    When can an expansion appliance be removed?

    Hello,
    My 8 year old son has the plastic type palletal expander and our turning is complete. Now it’s the (6 month or so) waiting period. I see food getting INSIDE the plastic where his teeth are and when I water-pic it, a lot of debris is being removed. It is not loose but it isn’t completely bonded inside. When I water pic it in the mornings there is a foul odour and it’s getting dark inside of the clear plastic. Our orthodontist is aware of the problem but he says it’s fine for 6 months. I’m very uncomfortable with this. I will be seeing the dental hygienist soon.

    Question: At what point can’t this device safely be removed and replaced with a metal type to spare his teeth this bacteria? Thank You

    • Dr Jules says:

      An rapid maxillary expansion appliance is normally left in the mouth at least 3 months after the end of the active expansion phase (turning the expansion screw) but if there are problems, it can be removed at any time to be replaced by a different holding or retention appliance if necessary.

  24. Jeanette A. says:

    Correcting an anterior cross bite in a 7 year old

    Thank you for this informative site.

    My 7 y/o son has a front cross bite where his front top upper tooth is behind his front bottom tooth. Our dentist recommended we see an orthodontist due to the effect of negative pressure on his bottom gum. He has crowding already and his teeth take a while to fall out (we had to have the bottom 4 pulled because his permanent teeth were starting to grow in).

    I’ve been to 3 orthodontists and they all have different strategies!
    – The first one wants to put a permanent expander in and 2×4’s on the top and bottom at the same time (that seems like a lot for his little mouth at once).

    – The 2nd wants to put in a permanent expander on top, removable expander on the bottom. Then after expansion, put 2×4’s on the top and bottom.

    – The 3rd orthodontist just wants to put 2×4 on the top and bottom to address the cross bite (no expansion at all).
    She said that just because you wear expanders during phase 1 does not mean that they won’t be necessary again during phase 2 and she wouldn’t want to put him through that twice. She said his palate has a good shape. She’d rather only put the expanders on during phase 2 if necessary, around 12-13yrs old. She also said that the thinks with baby teeth falling out and others coming in, there would be a give a take with space that could possibly prevent the need for expansion. As a child, I had 6 teeth removed so I’m concerned about his crowding. I’m afraid of making the wrong decision and feel like this is a crap shoot. I can’t find any information about the likeliness of expanders again during phase 2. I’m considering seeing a 4th orthodontist, but I’m afraid that they will just have a different approach as well! Thank you for any insight you may have!

    • Dr Jules says:

      All these opinions are not that far off from one another.
      On thing they all agree on is that braces on the upper incisors are indicated to “jump” and correct the anterior cross bite (2×4).
      The controversial point seems to be the need for expansion and when.
      One thing must be understood; true maxillary rapid expansion is indicated to widened an upper jaw (palate) which is too narrow. The purpose of such a procedure is not to provide extra space to align the crowded teeth, even if it can do that as a side effect. That can be done with braces much more easily that with an expander.

      So… either your son has a true skeletal transverse (width) discrepancy or he doesn’t. If he does, rapid maxillary expansion is indicated. If he doesn’t, the expansion process car certainly be postponed and could probably be done eventually with braces (to see some examples).

      ➡ To see examples of anterior correction with braces (upper 2×4).

  25. Anna Martin says:

    Hi,

    I am a 15 year old girl and I got my RME fixed nearly a week ago. I had a couple questions that my orthodontist never really answered could you please help:

    Are there ways to help pronounciation issues caused by the RME? (I take drama and I currently cannot speak too great and fear it may affect me during class)
    Can you suggest foods to eat? (I’ve been trying to find foods that I can eat and some days I can eat them others I cannot)
    Is it ok to do two turns one after the other in a 10 minute time period?
    Thanks

    • Dr Jules says:

      Most people adapt fairly fast to RPE appliances and they can speak normally.
      You can eat any food you want but try to have nutritious and complete meals…

      Don’t do more expansion screw turns that what was prescribed and don’t do 2 in a row. In the end, it won’t change anything whether you finish your expansion 1 or 2 weeks earlier than planned but that can be damaging for your teeth and gums. The usual expansion rate is 1 or 2 turns per day. Don’t do more than that and always check with your orthodontist before modifying anything that he has prescribed.

  26. Karen says:

    7 mm of maxillary expansion at age 54?

    I am 54 and my two front teeth are going inwards and the two side teeth are coming forward like fangs. This has only really happened over the last 5 years. because I have a very narrow arch, My orthodontist said to have the expander for 4/5 months, top and bottom, (I think it needs to widen by 7mm) and then I will have braces for approx. 10 months to straighten the teeth. does this sounds right to you. I am concerned to have the expander at my age – you hear so many different stories. What is your opinion?

    • Dr Jules says:

      Well… if you are dealing with a certified specialist in orthodontics (orthodontist), you should be in goods hands and he should know what he is doing and recommending.

      There are different types of expander that can be used; fixed and removable. Fixed expanders usually require a surgical procedure in adults if the rate of activation is 1-2 turns per day (Surgically Assisted Rapid Maxillary Expansion (SARME)).

      I cannot comment if the treatment plan you described is adequate for you as I don’t have enough information about your case but do not hesitate to ask all your questions and interrogations to your orthodontist, he is the best person to answer them.

  27. Tracy M. says:

    Expansion screw activation rate for SARPE

    Hello,
    First of all, fantastic and informative article. I am a 24 year old female who had my SARPE surgery 3 days ago. My ortho instructed me to turm my device 4 times a day (2 in the morning, 2 at night); however I see your article advises no more than 2 turns in a single day. Should I be concerned?
    Thank you for your time,

    -Tracy

    • Dr Jules says:

      During SARPE (Surgically Assisted Palatal Expansion), it is usually recommended to activate the expansion screw at least 0.5 mm per day to allow for osseous distraction. Expansion screws will expand at a rate of between 0.20 and 0.25 mm per activation (1/4 turn of the screw) depending on the model used. So doing 3-4 tunrs per dan is not unrealistic.

      With regular expansion protocol in younger patients however, we do 1 or 2 turns (activation) per day depending on the age of the patient but never more than 2 turns.

  28. Coreen says:

    An palatal expansion appliance keeps coming off

    Hi Dr. Jules,
    My 9 year old son has had a Palate Expander for 26 weeks. The original appliance slipped and detached 2 or 3 times at which time the Orthodontist took new impressions and had a second expander made. After a couple of weeks my son received a new expander. The new expander detached twice. The orthodontist reattached it and added a face mask. My son wore the face mask for 12-14 hours a day for six weeks. The new expander has detached yet again (after the Orthodontist used the strongest adhesive he could.) The Orthodontist has now decided to scrap the Palate Expander and Face Mask completely and has opted to attach brackets to my son’s upper molars. He has extended elastics from the upper brackets to two of his lower incisors.

    My question is this: Is it normal for an expander to fall out six times or does the orthodontist potentially lack the skill to keep it in place? Will elastics from the upper molars to the lower incisors adjust the jaw as well as the teeth? When we began treatment my son’s entire upper jaw fit into his lower jaw.
    Thanks in advance for your help!
    Coreen

    • Dr Jules says:

      I imagine that you are referring to a FIXED or “glued” rapid maxillary expansion appliance because if it is a removable one, I don’t see how can an extra-oral face mask could be attached to such an appliance with success!

      NO, it is not normal for a fixed appliance to come off even once… although this car happen at times. The main reason for this problem is that it was hard to glue the appliance initially (perhaps indirectly due to patient cooperation (moving too much, not opening wide and long enough, etc.) and there might have been contamination with the glue or the teeth surfaces were not perfectly dry (which is essential for bonding success), a bad batch of glue (but not 6 times in a row I would hope!). Appliances will not glue well on amalgams, stainless steel crowns, etc. You will need to ask your orthodontist why he thinks that there are so many bonding failures.

      Using elastics in a “class 3” configuration as you are describing would not, in theory, achieve the exact same thing as what was planned with an expansion appliance coupled with an extra-oral orthopedic force applied with a facial mask. The purpose of this treatment is to obtain an orthopedic correction whereas using class 3 elastics would provide more dentoalveolar corrections (moving teeth as opposed to trying to move the upper jaw as a whole).

      This is a little bit technical but don’t hesitate to question your orthodontist about the treatment objectives and the means takes to achieve them. He is really the best person to answer you. If he can’t or won’t, ,get another opinion.

      ➡ To learn more about facial masks in orthodontics and elastics.

      ➡ To learn more about class 3 malocclusions and see treated cases.

  29. Mary says:

    Skeletal or dento-alvéolaire expansion?

    Hello.I am 20 years old with class III malocclusion.After consulting with an orthodontist she told me to use a palatal expander. After consulting another orthodontist he told me that palatal expanders will not work on my case ,i will not have skeletal expansion,only dent-alveolar expansion that can be achieved with braces to.Can you help me please?

    • Dr Jules says:

      In an adult, if we want to open the mid-palatal suture, a surgical procedure is indeed recommended (SARPE; Surgically Assister Maxillary Expansion). . Another alternative to obtain expansion is to do dento-alvéolaire expansion in which the arches are remodeled without affecting the palatal suture. (To see examples)

  30. Cynthia says:

    Orthognathic surgery for sleep apnea

    I am a 49 year old looking into orthodontics to help not only my underbite and underdeveloped palat but I also suffer from sleep apnea.
    I am wondering if you know what the success rate is of curing sleep apnea using surgery. I have a trusted orthodontist which I had three children use for expansion and braces. all of their bites are perfect now. I went to a new dentist with some TMJ issues and a bite where only two teeth were actually meeting. She suggested ortho and at the appointment it was brought to my attention that with surgery There was a high chance of not needing a CPAP machine. I have been investigating on the web and it looks like that might be the case but can not find a great deal about sleep apnea success rates during my research I found this one and would be very appreciative to get your advice.

    The surgery/ortho treatment seem long and expensive but I would be willing to try it if there is a high chance I can stop using the CPAP. My sleep apnea was minor but with a firefighter husband and registered nurse mother I am well aware of the complications if I didn’t use my CPAP. I have a love hate relationship with it and the chance I could not need it in the future is tempting to say the least.

    • Dr Jules says:

      Studies have shown that to be efficient, the surgical advancement of the mandible must be at least 10 mm and this sometimes requires that a maxillary (upper jaw) advancement be done also.

      A study in the scientific journal SLEEP reviewed 9 studies on maxillary advancement surgery in which 234 patients with severe obstructive sleep apnea had orthognathic surgery. They observed a 87% reduction of the overall AHI (apnea hypopnea index). This reduction allowed 232 of the 234 patients to completely correct their sleep apnea or at least lower it to a moderate level which, in both cases, symptoms were alleviated and CPAP wear was no longer required.
      Source : http://www.cliniqueronflement.com/en/faq/what-is-the-orthognathic-surgery-success-rate-in-severe-apnea-treatment/

      Another study in which maxillomandibular advancement (MMA) which involves forward-fixing the maxilla and mandible approximately 10 mm resulted in an 83% reduction in the group mean apnea-hypopnea index (AHI) per polysomnography an average of 6.7 months after surgery.

      Reference :Ranji Varghese et al, Maxillomandibular Advancement in the Management of Obstructive Sleep Apnea, Int J Otolaryngol. 2012; 2012: 373025.
      Published online 2012 Jan 29. doi: 10.1155/2012/373025 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3299305/

  31. Karen says:

    Braces during rapid maxillary expansion?

    My 6yo daughter has a crossbite, baby teeth that are crowded (she has lost two on the bottom and one on the top), and an ankylosed 2nd molar. I have done 4 consults with orthodontists, all of whom would use a RPE to correct the crossbite and provide more space for the teeth to come in. 3/4 of them would want to wait to remove the ankylosed tooth. At our most recent consult, the ortho wanted to wait until she gets her permanent teeth in front (maybe all 4 of them?) and put on braces in conjunction with the RPE. He says it will create more space for the other teeth as they move in, but then I wonder if we would be looking at having braces 2x instead of getting it done once when she is older and all the permanent teeth are in. An assistant stated that the braces work in conjunction with the RPE, they have always done them together, and it helps prevent the teeth from tipping (I think that was the term she used). Is there any medical evidence either for or against the use of braces and RPE in a child of perhaps 7yo, or does it really vary by case? Or is it just an ortho preference? I don’t want to end up paying for or going through braces twice if there isn’t a sound reason for it. Thank you for your input.

    • Dr Jules says:

      There are indications to use braces in RPE cases but not in most cases. The purpose of rapid maxillary expansion is to widen the maxilla, not align the teeth but if there are major alignment problems, braces can be user on the incisors to improve the situation. However, it is almost always unavoidable that a second phase of comprehensive treatment will later be necessary when all the permanent teeth will have erupted.

      Here’s an example where braces were used with an RPE appliance.

      Expansion maxillaire orthodontique et broches

      It doesn’t really matter if the incisors tip during RPE (it is normal) because there will be other changes occurring as the other teeth erupt RPE is not a finality it itself but just a preliminary phase of treatment in most cases.

    • Dr. Sylvain Chamberland says:

      I would like to add my 2 cents to your question and Jules’s answer with whom I agree 100%.
      If you 6 year old has a posterior crossbite it is indicated to do RPE and I would recommend it now if she is not the type of person who would be afraid of receiving dental care. I treat many 5, 6, 7 years old patient who need RPE without any problem.

      It is not necessary to wait until the permanent incisors erupt to do RPE. In patient of 7, 8, 9 that have their incisors erupted, it is the exception that I would uses braces on the incisors. The exception being that severe rotation and crowding mays become a social issue. Most of the time, the patient and the parents understand that there will be a second phase of treatment where we will use braces.
      If braces is use in phase 1, which I sometime does, I explain that there is an extra cost for the 4 braces this is needed (1 per incisor).

      Best regards
      Dr Sylvain Chamberland

      • Dr Jules says:

        Furthermore, one of the advantages of doing RPE at 6, 7 or 8 years of age is that the child will benefit from it much sooner than if one waits for the teenage years to intervene. This may make a significant difference in the oral development of the child.

  32. Melissa says:

    Can palatal expansion be done at age 4?

    I can’t thank you enough for this article. My son turns 4 in July and we are contemplating starting palatial expansion. He has congenital myasthenia syndrome, a rare neuromuscular disorder. He has a narrow, high arched palate, a severe open bite and over bite, labial closure is difficult due to positioning and his speech pathologist says his progress is starting to be limited by his anatomy. He is a very complaint patient which is amazing considering everything he has been through. Would you consider this a candidate for the very early intervention?

    • Dr Jules says:

      There are special circumstances and conditions where it may be indicated to do palatal expansion at an early age and what you are describing may be one of them. It may be however difficult to correct the other aspects of his malocclusion at such an early age (open bite, and protruding teeth) but palatal expansion can make a big difference. Discuss all that with a certified orthodontist.

  33. Gergana says:

    So I carry a palatal expander in my mouth from five days and in the first three days tightening was easy and I felt pain in the gums but yesterday when my mom try to tight the palatal expander it was very hard and now almost can’t get tightened. Is it normal?

  34. Christine Robin says:

    Can I have palatal expansion at 17 years of age?

    Hello! I am 17 years old and have a very narrow upper arch. An Orthodontist in the past tried to place a RME when I was 7 or 8 but I dont think it ever worked, so they took it out. My upper teeth are crooked all around and I have a major overbite. Is it possible for me to get the expander again and have the bone in the palate separate like it’s supposed to, given my age?

    • Dr Jules says:

      There are ways of doing palatal expansion at your age, either with rapid palatal expansion of with dento-alveolar expansion. Consult a certified specialist in orthodontics (orthodontist) who should be able to properly diagnose your problem and make the appropriate treatment recommendations.

  35. Jamie Ryan says:

    Expansion appliance burried in palatal tissue

    First, thank you very much for all of the information on your site and for answering questions. I have been very comforted by knowing as many details as I can about this process. My ortho is a wonderful doctor but he is very busy and I tend to learn more by reading.

    I’d like to ask a question about adult expansion with a fixed appliance. I am 40 and have 4 screws in my palette. The turns have been completed and there has been successful expansion. I now have braces on to adjust alignment of my teeth. That said, I have noticed that one side of the expander is being covered by soft tissue, in where one screw is covered completely now. I am being very diligent about hygiene. Should I be worried about this? Do you think they will be able to find the appliance if it’s so buried? I really do not want to take the appliance out early and lose the expansion I’ve gained. Can you please tell me your opinion and thank you in advance!

    • Dr Jules says:

      If there is no too much inflammation, soreness and bleeding on the mucosa covering the screws or appliance, there should not be major problems but you have to mention this to your orthodontist, busy or not, because he’ll need to see this first hand to evaluate what to do and when. It may be necessary to remove some of that excess tissue to remove the expansion appliance.

  36. S Johnson says:

    Is there a maximum age when the palate is fused and the rapid (key turn style) expander will not work. My child is 13 and orthodontist wants to put on expander with braces but I’ve been reading that maximum age is 10 before the palate is fused? Just wondering if will do any good or just cause unnecessary pain. Thank you.

    • Dr Jules says:

      Rapid palatal expansion can usually be done during adolescence without any problems, especially in a 13 year old boy.

  37. Emily Polanco says:

    Can SARPE procedure be undone ? I had SARPE surgery 7 months ago and I’m still swollen and very unhappy with my results , is it possible to have your jaw repositioned back to its original place ?

    • Dr Jules says:

      SARPE can’t be undone by simply reversing the screw action. Arches can be narrowed orthodontically afterwards to a certain extent but you would have to discuss this with your orthodontist to see if it is indicated and possible.

  38. Monta says:

    Dental pocket appearing during SARPE expansion

    Hello. I am 32 y, I had SARPE two weeks ago. First 4 days I was turning expander twice a day, but surgeon said my gum can’t keep up and suggested one turn per day. After 5 days I found out that I have a pocket between gum and one of the front teeth ( where the gap is forming) surgeon suggested make one turn in 3 days. So after 3 days pocket is still there. I did turn anyway like surgeon suggested, but I am worrying is that normal ( having pocket between front tooth and the gum). Because on all the pictures other people have nice gum in the gap between teeth with no pockets, or this some kind of complication? Or it is normal?

    • Dr Jules says:

      It is not uncommon to be able to probe a little deeper (to a certain extent) on the side of a central incisor during palatal expansion but there are other causes to deep probing and this would require a baseline measurement to compare it to in order to be certain that this pocket was not present or deep before treatment. A deep pocket will not disappear instantly (in a matter of days). Make sure that you have impeccable oral hygiene so that there is no inflammation contributing to cause damage to the gum tissue.
      Your orthodontist may consider discussing this issue with a periodontist.

      • Monta says:

        Thank you for your reply. Luckily my gum is not inflamed and pocket is not too big. I am doing my best with the hygiene ( using water pick and mouth wash after every meal) and I booked and appointment with hygienist who is also capable to go deeper and take care of periodontal pockets. Thank you for your help.

  39. Dr Sylvain Chamberland says:

    It may be normal to have some deepening of the papilla at the expansion site but is likely not normal to have a pocket near the root of one incisor during expanion. Can you send a selfie of you diastema to Jules so I can have a better idea of your problem. I hope it does not look like this case that was posted on my website: fistule oro-nasale.

    • Monta says:

      Thank you for your reply. Luckily no, my pocket doesn’t look like the one on the link. It is a lot smaller and my gum is nice and pink, not red and inflamed.
      I am afraid I don’t know the email where I can send the picture and I don’t see the option to attach the picture with the comment.

  40. Monta says:

    Hello. I have another question. ( I was just asking about pocket near tooth) Because my gum couldn’t keep up with expanding and I have a pocket near tooth and that tooth is wobbly and aches my orthodontist suggested to make one turn in 4 days. I am just wondering if there any effect? Because normally patient should do two turns per day. Or bone is loose after surgery and it doesn’t really matter am I doing it once a day or once in 4 days?

    • Dr Jules says:

      There are a lot of variables which must be taken into consideration during palatal expansion and I don’t have all the necessary information to specifically comment on your case or make recommendations except to follow your orthodontist’s advice as he is the best person to understand what is going on in your mouth and with the treatment plan that he elaborated for you.

  41. James D says:

    I am 34 and had jaw surgery 3 weeks ago and have the palatal expanded fixed in with wires as it previously came out.

    It went in on Monday and since yesterday I have a clicking sensation when I swallow, but I only have to turn it once more tomorrow.

    Is this sensation normal?

    Thanks,
    James.

    • Dr Jules says:

      I am not sure what this clicking can be. Stop the turns and get in touch with your orthodontist to see how he/she interprets this.

  42. Wendy W says:

    Will too much expansion prevent proper tooth alignment later?

    Thank you for the great detail here. My 8 year old daughter had an expander during phase one of her treatment and is currently wearing a retainer as we wait for phase 2. However, at a recent visit with a new dentist, he was shocked at the reverse cross bite the expansion had created and told us the Orthodontist has caused a great disservice to my daughter. He claimed that it would be a real struggle to get her upper teeth eventually aligned with her bottom (currently, the upper teeth sit over the bottom teeth). I asked the Orthodontist about this reverse cross bite and the challenges we will face going forward and he was confident that this is the process with all his patients – even his own child. The dentist – on the other hand – says this kind of extreme treatment is nothing he has ever seen before. So who is correct?

    • Dr Jules says:

      If your dentist has never seen overcorrection during palatal expansion, I think that he hasn’t seen much in his career on the topic of palatal expansion.

      Proper rapid palatal expansion always involves a significant over correction in the transverse (with) dimension, frequently to the point that the inside of the upper posterior teeth bite outside the lower posterior teeth. This will eventually relapse and leave a with that is appropriate to match the lower jaw in the end. Some orthodontists may prefer to maintain over expansion a little longer, for instance in the presence of a very narrow lower dental arch. Than can be done with an upper space maintainer and any competent orthodontist will know how to complete the transverse correction eventually and it is not much of a challenge except perhaps for the dentist!

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