Non-Surgical Maxillary Expansion Techniques

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METHODS OF GAINING
SPACE.

Key-stoning procedure-
Harry G.Barrer JCO Aug 1975
A. Malposed incisors B. interproximal relationship after key stoning
Rounded surfaces slip and
rotate.www.indiandentalacademy.com

Key-stoning procedure:

Nonsurgical rapid maxillary alveolar
expansion in adults:a clinical evaluation.
Chester S. Handelman, Angle Orthodontist, 1997 vol 67
•Late teens and early 20’s questionable.
•Sutures: rigid and fuse.
•SA-RME.
Non Surgical Maxillary expansion:
Pain, swelling, ulceration, flared posterior teeth, bite opening,
gingival recession, and perforation of the buccal alveolus.
Vanarsdall: in children, gingival recession and dehiscence of bone

Haas appliance
• 5 adults with transverse deficiency- treated
nonsurgically using Haas appliance.
•RMAE- expansion centered in the alveolar process of
maxilla rather than the body.(lateral walls of the
palate)
•Bilateral/unilateral crossbites, arch constriction.
2 quarter turns/day
Later 1 quarter turn/day
U 1 no separation.
12 weeks retention.

Displaces the alveolus with the teeth rather than
expanding the teeth through the alveolus.

bilateral

Unilateral
crossbite –
left

RMAE acceptable alternative to SA-RME in adults for maxi deficiency.

Nickel-Titanium Palatal expander.
2 properties: Shape memory & superelasticity.
Exists in more than 1 crystal structure.
Lower temp-martensite. Transition
temp:94degree
Higher temp-austenite {phase transition}

MOLAR DISTALIZATION

Indications for Molar distalization
1. In a growing child
- to relieve mild crowding
- causes permanent increase in arch
length of about 2mm on each side.
2. Late mixed dentition
- When lower E space –utilized for relief of
anterior crowding,
- Upper molars distalized to get a class I
relation

3. Non-growing patient
- To regain lost arch length
- Blocking out of canines
4. Upper second molar extraction
- Lower arch normal

 Class I malocclusion- with highly placed canine/impacted
canine
 Lack of space for eruption of premolars due to mesial
migration of permanent first molars

 Good soft tissue profile
 Borderline cases
 Mild to moderate space discrepancy with missing
3rd
molars/2nd
molars not yet erupted
 End on molar relation with mild to moderate
space requirement.
 Cases with less than full cusp class II molar
relation.

Case selection
1. Normal or near normal mandibular arch
2. Late mixed dentition-ideal
- Early permanent dentition-growth still left in maxillary
tuberosity area.- 16-17 yrs-males
14-15 yrs-females
3. Molars placed normally- buccopalatally.
4. 3rd
molars-absent –stacking of upper molars – unsuitable
5. Profile considerations- well developed nose & chin
6. High MPA- contraindicated-wedging effectwww.indiandentalacademy.com

Classification
1. Location of appliance
 Extra-oral
 Intra-oral
2. Position of appliance in mouth
 Buccal
 Palatal
3. Type of tooth movement
 Bodily movement
 Tipping movementwww.indiandentalacademy.com

Classification
4. Compliance needed from patient
 Maximum compliance
 Minimum or No compliance
5. Type of appliance
 Removable
 Fixed
6. Arches involved
Intra-arch
Inter-arch

Various appliances used for
Molar Distalization :
 Head gears
 Pendulum appliance.
 Coil springs Niti and S.Steel
 Distal jet
 K loop
 Jones Jig
 Magnet
 Wilson’s Bimetric loop
 Use of super elastic NiTi
 Franzulum appliance.

Various appliances used for Molar
Distalization
 ACCO
 Crozat appliance
 Crickett appliance
 Modified Nance lingual appliance
 Schmuth and Muller double plates
 Claspring
 Removable molar distalization splint
 Fixed piston appliance
 Using implants
 Fixed functional appliance

Distalization using Headgears
 Very efficient
 Reciprocal forces are not transmitted to other teeth
 Molar movements depends on direction of force in relation to
the C Res of the molar & magnitude of force

Biomechanics of Headgears:
 C Res
 Moments

Cervical Headgear
 Short face Class II
maxillary protrusive
cases with low MPA
& Deepbites
 Extrusive & distalizing
effect
 Lower anterior facial
height is less.

High pull Headgear
 Produces intrusive &
Posterior direction of pull
 Long face class II
patients with high MPA
 Force through C Res –
Intrusion & distal
movement of molar
 6-8 months – class II-
class I

Straight pull headgear
 Class II Malocclusion with
no vertical problems
 Prevent anterior
migration of maxillary
teeth, translate them
posteriorly
Adv-effective, no reciprocal forces
Disadv- Patient compliance

Modification of the Bimetric arch
 Class II correction- Distalization + expands canine-
premolar area- unlocks the occlusion
 A mild-moderate class II div 2 with normal mandibular
arch-easily corrected

Modification of the Bimetric arch
Archwire design:
 .016”premium wire
 Premolars bonded if
expansion is
required
 Teardrop shaped
loop
 Bite opening bend
 Mild toe-in
 2mm activation

Elastic load reduction principle:
 Class II elastics – used sequentially
T.P Green – 1st
week
Pink - 2nd
week
Yellow – next 2-3 weeks
 Initial heavy force- to resist forward
pushing force of new wire- force
transferred distally
 Later Molar uprights-mesially directed
archwire force decreases- support with
light forces.
 Extrusive component of class II- kept
to a minimum
 1mm/month.wire
activated for 3
visits.
 Borderline
cases –Non Ext

K-Loop molar distalizing
appliance Valrun Kalra – JCO 1995
 K-loop – forces - .017 x .025 TMA
 Nance button – anchorage
 8mm long , 1.5 mm wide
 Legs- 20 degree bend
 Inserted into molar and first
premolar tube, marked
 Stops bent 1mm distal , 1mm
mesial
 Stops- 1.5mm long

 Reactivated by 2mm 6-8 weeks later.
 molars move by 4mm, premolars by 1mm
 Anchorage can be reinforced by headgear

K- loop Appliance

Distalization of Molars with
Repelling Magnets Gianelley etal JCO 1988
 Anchorage – Modified Nance
appliance
 Wire extending from 1st
premolars
 Acrylic button anteriorly
contacting the incisors
 Auxiliary wire with a loop at its
end soldered - premolars bands

Distalization of Molars with
Repelling Magnets
 Incisor brackets – passive
sectional wire- maintain incisor
alignment
 Repelling surfaces of magnets
brought into contact by passing
an .014 ligature through the loop,
then tying back a washer anterior
to the magnets
 Force- 200-225 gms , dropped as
space opened
 3mm in 7 weeks
 Anchor loss – 1mm

Molar distalization with Superelastic
NiTi wire Gianelly JCO 1992
 100gm Neosentalloy upper
archwire
 3 markings
 Stops crimped, hook added
 Insert wire such that posterior
stop abuts mesial end of molar
tube, anterior stop abuts distal of
premolar.Xs wire deflected gi
 Anchorage reinforced by class II,
or Nance appliance
100g

Molar distalization with
Superelastic NiTi wire
Case report :
 12 yr / F
 Unilateral class II
 Class II elastic against
upper 1st
premolar
 Overcorrected- 4 months

NiTi Double Loop system for simultaneous
distalization of first and second molars
Giancotti JCO 1998
 Mandibular molars and 2nd
premolars
banded, other teeth bonded
 Lip bumper- prevent extrusion
 Maxillary molars and bicuspids –
banded, aligned
 80 gm Neosentalloy – maxillary
archwire placed – marked
1. Distal to 1st premolar
2. 5mm distal to 1st
molar tube
 Stops crimped on markings

NiTi Double Loop system for
simultaneous distalization of first and
second molars
 2 Sectional NiTi archwires
– crimp stops
1. Mesial and distal to 2nd
premolar
2. 5mm distal to 2nd
molar
tube
 Uprighting springs on 1st
bicuspids
 Class II elastics
 Simultaneous, bodily
movement

24yr/f, class II div I
5months- overcorrected

NiTi Double Loop system for simultaneous
distalization of first and second molars
 Useful technique – Class II div I
 Minimal patient co-operation
 Ideal for simultaneous distalization U7 easier ‘.’ anatomy.
 Due to stretching of transeptal fibers, 1st
molars can be distalized using
lighter 80 gm force
 Anchorage easily controlled , without need for TPA/Nance’.’light forces

NiTi Open Coil Springs
Dia 0.012”
Lumen 0.030

Pendulum Appliance for class II non-
compliance therapy
JAMES J.HILGERS,JCO 1992
 Nance button for anchorage
 .032” sTMA springs-light
continuous forces
 Broad swinging arc
(Pendulum) of force from
midline of palate to upper
molars

Pendulum Appliance
Fabrication :
Pendulum springs
consist
Recurved molar insertion
wire
1. Horizontal adjustment
loop
2. Closed helix
3. Loop for retention in
acrylic button
 Springs- close to center
of Nance button

Springs close to center of
palatal button:to maxi range
of action, easy insertion.
Retaining wire is soldered to
the U4 and extended into
acrylic.

Pendulum Appliance
 Nance button- extend to about 5mm
from teeth
 Anterior retention loops fixed on
model, later soldered to bicuspid
bands
 Acrylic pressed against the palatal
vault
 Pendulum springs inserted

Pendulum Appliance
Pend-X
Expansion needed:
Jack-screw-One-quarter turn
every 3 days

Pre activation and placement
After cementation,before
activation:
Springs prefabricated to lie
parallel to midsagittal plane,
Which produces 60* of
activation after insertion.
As the molar distalizes it
moves on an arc towards
midline-counteracted by
opening horizontal loop

Intra oral reactivation:
Center of helix held with bird
beak plier while, spring is
pushed distally & reinsert.
Stabilization:
•Nance button
•Upper utility arch- anterior segment- anchorage.
•Full arch bonding:continuous wire with omega loop.
•Head gears ?

Pendulum Appliance
 Unilateral correction

Pendulum Appliance
Conclusion :
 Excellent patient tolerance
 Upto 5mm distalization in 4 months
 Distalization + Expansion
 Patient compliance not needed

Franzulum appliance
Friedrich Byloff et al JCO2000 sep
 Anterior anchorage : acrylic
button-5mm wide
 Rests on canine and
premolars - .032”S.Steel
wire
 Tube from acrylic button to
receive active component
 NiTi coil springs-100-
200g/side
 J-shaped wire inserted into
tube

Franzulum appliance:
Niti spring over J shaped
wire
Inserted into tube of anterior
anchorage unit
Tied into lingual sheath
•Anchor unit bonded
with composite.
•Close to CR of molar-
pure bodily movement.
compressed

Case report
 11yrs 10mts / M
 end on molar relationship
 Space deficiency in both the
arches
 Premolars blocked out
 Fixed appliance with cervical
headgear and Cl II elastics
 End of treatment; Class I molar
relation, no significant change in
facial profile
 U6:3mm,L6:6mm Lower incisors
proclined. Extrusion of U&L 6
 Long term stability????

Distal jet Appliance
Aldo Carano, Mauro Testa JCO 1996
 Lingual molar distalizing
appliance
 Appliance design :
 Wire extending from acrylic
through tube ends in a bayonet
bend-inserted into lingual sheath
 Coil spring clamped on tube
 Clamp
 Anchor wire to 2nd
premolar
.036” int dia

 Reactivation- sliding clamp
closer to first molar,once a
month.
 After distalization –
- clamp-spring assembly-
acrylic,
- premolar arms cut off.

Case report
 18/F, Class II div I
 No skeletal abnormalities
 Non-extraction therapy (3rd molars
removed)
 Distal jet
 4 months- Class I ,2mm-L, 3mm-R

Advantages :
 Bodily movement
 Easy insertion
 Well tolerated
 Esthetic
 Unilateral, Bilateral
 Permits simultaneous use of full bonded appliances.

Open Coil Jig
Jones, White –JCO 1992 Oct
NiTi springs 70-75g
Nance button attached to
U5
Assembly tied in place

1. Heavy round wire
2. Light wire
3. Fixed Sheath
4. Hook
5. Sliding Sheath
6. Open coil spring
4-5mm of distal
movement.
3
1
2
5
6
4
Open Coil Jig

Conclusion
 Borderline cases
 Space gaining procedures
 Simplicity
 Clinical effectiveness
 Patient compliance factor

Distraction Osteogenesis:
 New bone formation b/w the surfaces of bone
segments gradually separated by incremental traction.
 Tension-stimulates new bone parallel to vector of
distraction.
 tension in surrounding soft tissues, initiating a
sequence of adaptive changes termed as distraction
histogenesis.
 Skin, fascia, bl vessels, nerves, muscles, cartilage,
periosteum.
 Illizarov.

Mandibular Sympyseal distraction.
 Mandibular symphyseal distraction- space gaining.
 Intra oral mandibular distraction device.
 More stable results.
 Corticotomy.
 Latent period.5-7days.(fibro vascular bridge)
 Activation.optimum rate: 1mm/day(0.5mm-premature
ossification,2mm-fibrous CT , ischemia)
 Consolidation (remodeling) concomitant soft tissue
expansion.
 Retention.

Non-Surgical Maxillary Expansion Techniques

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