ORIGINAL ARTICLE

Immediate effects of rapid maxillary expansion with Haas-type and hyrax-type expanders: A randomized clinical trial
 Andre Weissheimer,a Luciane Macedo de Menezes,b Mauricio Mezomo,a Daniela Marchiori Dias,a Eduardo Martinelli Santayana de Lima,b and Susana Maria Deon Rizzattoc Porto Alegre, Rio Grande do Sul, Brazil Introduction: The purposes of this study were to evaluate and compare the immediate effects of rapid maxillary expansion (RME) in the transverse plane with Haas-type and hyrax-type expanders by using cone-beam computed tomography. Methods: A sample of 33 subjects (mean age, 10.7 years; range, 7.2-14.5 years) with transverse maxillary deciency were randomly divided into 2 groups: Haas (n 5 18) and hyrax (n 5 15). All patients had RME with an initial activation of 4 quarter turns followed by 2 quarter turns per day until the expansion reached 8 mm. Cone-beam computed tomography scans were taken before expansion and at the end of the RME phase. Maxillary transversal measurements were compared by using the mixed analysis of variance (ANOVA) model and the Tukey-Kramer method. Results: RME increased all maxillary transverse dimensions (P \0.0001). There was less expansion at skeletal than dental levels. The hyrax group had greater statistically signicant orthopedic effects and less tipping tendency of the maxillary rst molars compared with the Haas group. Conclusions: Both appliances were efcient in correcting a transverse maxillary deciency. The pure skeletal expansion was greater than actual dental expansion. The hyrax-type expander produced greater orthopedic effects than did the Haas-type expander, but this effect was less than 0.5 mm per side and might not be clinically signicant. (Am J Orthod Dentofacial Orthop 2011;140:366-76)

apid maxillary expansion (RME) is an important method used to correct a transverse maxillary deciency. It was rst described in the literature over a century ago by Angell,1 and it has been disseminated and made widely popular by Haas since 1961.2 In RME, rigid and xed expanders are used to produce heavy forces to obtain the maximum skeletal response by opening the midpalatal suture, with minimum orthodontic movement.2-5 Among the appliances used for RME, the toothtissueborne (Haas-type) and the tooth-borne (hyraxtype) expanders are the most recognized in the literature. The main difference between them is the acrylic pad that leans on the lateral walls of the palatal vault (Haas-type)

From the Department of Orthodontics, Pontical Catholic University of Rio Grande Do Sul, Porto Alegre, Rio Grande do Sul, Brazil. a Postgraduate student (Ph.D.). b Professor. c Assistant professor. The authors report no commercial, proprietary, or nancial interest in the products or companies described in this article. Reprint requests to: Andr Weissheimer, Pontif Universidade Catlica do Rio e cia o Grande do Sul, Faculdade de Odontologia, Prdio 6, Avenida Ipiranga, 6681, sala e 209, Porto Alegre, RS, Brazil, CEP 90619-900; e-mail, andre5051@hotmail.com. Submitted, March 2010; revised and accepted, July 2010. 0889-5406/$36.00 Copyright 2011 by the American Association of Orthodontists. doi:10.1016/j.ajodo.2010.07.025

to reinforce the anchorage for greater orthopedic response and better force distribution during RME.2,4 In the hyrax-type expander, there is no acrylic pad; therefore, it is more hygienic and prevents soft-tissue irritation caused by food impaction under the acrylic plate.6 Although a cephalometric investigation has not demonstrated any differences between Haas-type and hyrax-type expanders,7 there is no consensus in the literature regarding the differences in the immediate RME effects produced by these appliances. Several investigations have analyzed the effects of RME through 2-dimensional cephalometric radiographs, which do not allow accurate identication of dentoskeletal structures because of the superimposition of many bones in the different planes of space.2,7-9 To overcome these limitations, computed tomography (CT) for the assessment of the transverse dimensions of the maxilla was introduced by Timms et al10 in the 1980s. However, the use of conventional CT scans in orthodontics has been limited because of cost and radiation concerns.11 Cone-beam CT (CBCT) has ushered in a new era in dental diagnostics. This technology was designed for imaging hard tissues of the maxillofacial region with minimum distortion at a lower cost and with lower radiation emissions compared with

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Fig 1. A, Haas-type expander and B, hyrax-type expander at the end of the active phase of RME.

Fig 2. Transverse maxillary posterior region evaluation: A and B, preexpansion; C and D, at the end of the active phase of expansion.

conventional CT. The high resolution of CBCT images is due to the isotropic voxel (equal in all 3 dimensions), which produces submillimeter resolutions ranging from 0.4 mm to as low as 0.125 mm.11 Several investigations have shown the high accuracy of CBCT images for quantitative and qualitative analyses.12-15 Its use is recommended in orthodontics for several purposes such as evaluation of impacted teeth,16,17 evaluation

of bone grafts in cleft regions,18 analysis of alveolar bone before placement of orthodontic temporary anchorage devices,19 and evaluation of RME effects on nasomaxillary structures.20 The purposes of this study were to evaluate and compare the immediate effects of RME on the transverse plane with Haas-type and hyrax-type expanders by using high-resolution CBCT.

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Fig 3. Landmarks used in the evaluation of the maxillary posterior region. MATERIAL AND METHODS

This study was approved by the ethical committee of the Pontical Catholic University of Rio Grande do Sul in Brazil. Informed consent was obtained from the parents of all patients who agreed to participate in this study. The sample was selected by examining subjects in need of orthodontic treatment at the Department of Orthodontics of the School of Dentistry. The inclusion criteria for this study were transverse maxillary deciency, mixed dentition or early permanent dentition, and no surgical or other treatment that might affect the RME effects during the expansion period. Patients with congenital malformations or periodontal diseases, or above 15 years of age were excluded from the study sample. In this prospective study, the sample comprised 33 healthy white children (11 boys, 22 girls) with a mean chronologic age of 10.7 years (range, 7.2-14.5 years) and a mean skeletal age of 10.9 years (range, 6.8-15 years). These patients were randomly divided into 2 groups: Haas (n 5 18) and hyrax (n 5 15). In the Haas group, the Haas-type expander, with 4 bands (rst permanent molars and rst premolars or rst deciduous molars) and buccal and lingual stainless steel bars of 1.0-mm diameter was used (Fig 1, A). In the hyrax group, the hyrax-type expander, with 4 bands, buccal and lingual stainless steel bars of 1.0-mm diameter and a jackscrew

with 1.4-mm stainless steel extensions soldered to the lingual surfaces of each pair of bands, was used (Fig 1, B). Both appliances had expansion jackscrews with activations of a quarter turn equivalent to a 0.2-mm expansion. All patients in the Haas and hyrax groups had RME, with initial activations of 4 quarter turns (0.8 mm) followed by 2 quarter turns per day (0.4 mm) until the expansion screw reached 8 mm. The i-CAT (Imaging Sciences International, Hateld, Pa) was used to obtain CBCT images before RME (T1) and at the end of the active expansion phase (T2). The CBCT scans were performed at 120 kV, 8 mA, scan time of 40 seconds, and 0.3-mm voxel dimension. The data for each patient were reconstructed with 0.3-mm slice thickness, and the digital imaging and communications in medicine (DICOM) images were assessed by using the EFILM workstation software program (version 2.1.2, Merge Healthcare, Milwaukee, Wis). All linear and angular measurements were made by a blinded examiner (M.M.), who had no access to the data or the clinical consultations of the patients in this sample. For transverse maxillary posterior region evaluation, the DICOM les with CBCT images at T1 and T2 were imported into EFILM and visualized as axial images arranged side by side. To obtain standardized axial and coronal slices and thus allow the comparisons between T1 and T2, the following references were used. In the

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Table I. Landmarks for transverse maxillary evaluation

Skeletal Line 1-2 Line 13-14 Distance 5-6 Posterior baseline Anterior baseline Posterior apical base width Line formed by the 2 lower points at the inferior inner contour of the posterior nasal cavity on the right and left sides, respectively. Line formed by the 2 lower points at the inferior inner contour of the anterior nasal cavity on the right and left sides, respectively. Distance between points 5 and 6 (points formed by the intersection of the line 1-2 with buccal contour of maxilla on the right and left sides, respectively). Distance between points 11 and 12 (lower points at medial limits of maxillary palatine processes, on the right and left sides, respectively), representing the midpalatal suture. Distance between points 15 and 16 (points formed by the intersection of line 13-14 with buccal contour of maxilla on the right and left sides, respectively). Distance between points 17 and 18 (intersection of the straight line, which is parallel and 5 mm superior to line 13-14, with buccal contour of maxilla on the right and left sides, respectively). Distance between points 21 and 22 (lower points at medial limits of maxillary palatine processes, on the right and left sides, respectively), representing the midpalatal suture in the anterior region. Distance between points 3 and 4 (coronal-most points of the maxillary buccal alveolar processes, on the right and left sides, respectively). Distance between points 19 and 20 (intersection of the straight line, which is parallel and 5 mm inferior to line 13-14, with buccal contour of maxilla on the right and left sides, respectively). Distance between points 7 and 8 (points formed by the intersection of a straight line, that superimpose the long axis of the root canal of rst permanent molar palatine root, with the occlusal surface on the right and left sides, respectively). Distance between points 9 and 10 (apices of palatine root of permanent rst molars, on the right and left sides, respectively). Angle formed by the straight line from point 7 and that superimposes the long axis of the root canal of permanent rst molar palatine root, on the right side, with line 1-2. Angle formed by the straight line from point 8 and that superimposes the long axis of the root canal of permanent rst molar palatine root, on the left side, with the line 1-2.

Distance 11-12

Posterior midpalatal suture width

Distance 15-16

Anterior apical base width (inferior)

Distance 17-18

Anterior apical base width (superior)

Distance 21-22

Anterior mid-palatal suture width

Alveolar Distance 3-4 Distance 19-20

Posterior width at the alveolar crest level Anterior width at midalveolar level

Dental Distance 7-8

Intermolar width at occlusal surface

Distance 9-10 Angle 1MD

Intermolar width at palatal root apices Right rst molar angulation Left rst molar angulation

Angle 1ME

axial slices, the images that displayed the root canal in the most apical region of the palatal root of maxillary rst permanent molars were selected. By using the MultiPlanar Reformation tool, the MultiPlanar Reformation line was positioned at the root canal in the most apical region of the palatal root of the maxillary rst permanent molars on the right and left sides. From these references, standardized coronal images were produced, and the measurements were made (Fig 2). The landmarks used for evaluation of the maxillary posterior region are shown in Figure 3 and described in Table I. The analyses of the transversal changes in the maxillary anterior region were performed in a similar way to those of the posterior region. In the axial slices, images at T1 and T2 were selected with the root canals in the most apical region of the roots of the maxillary permanent canines visualized. After that, the MultiPlanar

Reformation line was positioned at the root canal in the most apical region of the maxillary permanent canine root on the right and left sides. From theses references, standardized coronal images were produced, and the measurements were made (Fig 4). The landmarks used to evaluate the RME effects in the anterior region of maxilla are shown in Figure 5 and described in Table I.
Statistical analysis

Intraexaminer reliability of the measurements was determined by intraclass correlation coefcients. Double assessments of each parameter at T1 and T2 (10 days apart) of 15 randomly selected patients from both groups were compared (Table II). The data obtained from all measurements were processed with SAS software (version 9.0.2, SAS, Cary, NC). Means and standard errors for each parameter were calculated, and data at T1

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Fig 4. Transverse maxillary anterior region evaluation: A and B, preexpansion; C and D, at the end of the active phase of expansion.

and T2 were compared by using the mixed analysis of variance (ANOVA) model and the Tukey-Kramer method at a signicance level of 5%.
RESULTS

linear measure (distance 9-10), which indicated greater inclination of these teeth in the Haas group than in the hyrax group (Table VI).
DISCUSSION

The overall immediate effects of RME on the transverse plane are shown in Table III. There were signicant increases in maxillary width at the skeletal, alveolar, and dental levels for both the Haas (Table IV) and the hyrax (Table V) groups in all parameters (P \0.05). There was less expansion at the skeletal than at the dental level, just as the increase in the maxillary apical base was smaller in the posterior region (distances 5-6 and 11-12) compared with the anterior (distances 15-16, 21-22) (Tables III-V). The hyrax group had greater statistically signicant increases in the maxillary transverse dimensions at the skeletal level than did the Haas group in both posterior (distances 5-6 and 11-12) and anterior (distance 2122) regions (Table VI). There was no signicant difference between the groups for the buccal inclination of the maxillary rst permanent molars, except for the

After Broadbent21 introduced the cephalostat in 1931, several investigations have analyzed the effects of RME through cephalometry in 2-dimensional radiographs.3,8,22 The major problem associated with cephalometry is projection errors, which have an effect on linear and angular measurements, caused by magnication and distortion and are compounded by incorrect patient positioning.23,24 To overcome these limitations, we evaluated and compared, using highresolution CBCT, the immediate effects of RME on the transverse planes with Haas-type and hyrax-type expanders. CBCT was used because it is a suitable examination for imaging craniofacial areas, with minimum distortion, at a lower cost and with lower radiation dosages than conventional CT.11,25,26 In addition, CBCT is an accurate and reliable method for assessing changes associated with RME on nasomaxillary structures.20

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Fig 5. Landmarks used in the evaluation of the maxillary anterior region.

Table II. Intraclass correlation coefcients of the mea-

surements
Measurement Distance 5-6 Distance 11-12 Distance 15-16 Distance 17-18 Distance 21-22 Distance 3-4 Distance 19-20 Distance 7-8 Distance 9-10 Angle 1MD Angle 1ME ICC 0.98 0.94 0.96 0.95 0.61 0.98 0.96 0.95 0.97 0.93 0.74

Regarding previous reports that used CT images to evaluate RME, our study had an adequate sample size (33 subjects).10,20,27-33 Furthermore, this study design had some important features: (1) it was a prospective study; (2) the patients were randomly divided between the groups; (3) the methodology was highly standardized in terms of appliance fabrication, and rate and amount of expansion; and (4) it used highresolution CBCT. In this study, since the active expansion phase lasted only 19 days, there was no need to use a control group without treatment since normal growth was not an inuencing factor in this short time. In this

study, the overall effects of RME produced a signicant skeletal increase in the transverse maxillary dimension, conrming previous reports.2-5,20,28,30,34,35 The skeletal expansion amounts were greater in the anterior region2.82 mm (distance 17-18), 3.48 mm (distance 15-16), and 4 mm (distance 21-22)compared with the posterior2.64 mm (distance 5-6) and 2.88 mm (distance 11-12) (Table III). In agreement with previous authors, the expansion pattern was triangular with a wider base at the anterior portion of maxilla.20,29,35 The greater expansion in the anterior region could be explained by the resistance of the medial and lateral pterygoid plates of the sphenoid bone to the maxillary tip movement during the RME.35 Another feasible explanation would be through maxillary expansion biomechanics: ie, the direction of the expansion force produced by the expanders would be located anterior to the center of resistance of each maxillary half.36 The hyrax-type expander produced greater skeletal expansion3.14 mm (distance 11-12) and 4.37 mm (distance 21-22)than did the Haas-type expander 2.62 mm (distance 11-12) and 3.63 mm (distance 21-22) (Table VI). The skeletal gain in the hyrax group accounted for 38.5% to 39.2% (posterior region) and 37.5% to 54.7% (anterior region) of the total expansion (8 mm). In the Haas group, the increases were smaller, ranging from 27.2% to 32.7% in the posterior region

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Table III. Immediate changes in the maxillary transverse plane with RME
T1 Variable Skeletal Distance 5-6 (mm) Posterior apical base width Distance 11-12 (mm) Posterior midpalatal suture width Distance 15-16 (mm) Anterior apical base width (inferior) Distance 17-18 (mm) Anterior apical base width (superior) Distance 21-22 (mm) Anterior midpalatal suture width Alveolar Distance 3-4 (mm) Posterior width at alveolar crest level Distance 19-20 (mm) Anterior width at midalveolar level Dental Distance 7-8 (mm) Intermolar width at occlusal surface Distance 9-10 (mm) Intermolar width at palatal root apices Angle 1MD ( ) Right rst molar angulation Angle 1ME ( ) Left rst molar angulation *Statistically signicant (P \0.05). Mean SE Mean T2 SE Change Mean SE P

60.29 00.00 38.37 38.96 00.00

0.64 0.08 0.61 0.83 0.10

62.93 02.86 41.85 41.78 04.00

0.64 0.08 0.61 0.83 0.11

2.64 2.88 3.48 2.82 4.00

0.11 0.09 0.23 0.23 0.13

\0.0001* \0.0001* \0.0001* \0.0001* \0.0001*

51.65 40.06

0.51 0.58

57.28 44.46

0.51 0.58

5.63 4.40

0.16 0.22

\0.0001* \0.0001*

43.51 29.90 110.6 117.7

0.44 0.52 1.4 1.2

51.31 32.55 118.1 123.8

0.44 0.52 1.4 1.2

7.80 2.65 7.53 6.17

0.15 0.14 0.74 0.68

\0.0001* \0.0001* \0.0001* \0.0001*

and 32.7% to 45.2% in the anterior region. These comparison results between the appliances differ from previous reports.7,28,37 Siqueira et al7 compared the Haas-type and hyrax-type expanders through frontal cephalometric radiographs and found no differences between them. Garib et al28 also found no differences between these 2 expanders using spiral CT. This phenomenon could be explained by the small study sample (n 5 8), which reduced the power of the t test to show statistically signicant differences. When signicant differences are demonstrated in such situations, they clearly exist and most likely have clinical importance. However, the absence of signicant differences does not necessarily indicate that they do not exist. In addition, the RME changes were analyzed 3 months after the active expansion phase, unlike our study, with the immediate effects of RME on 33 patients evaluated. In disagreement with the present study, Oliveira et al37 found that the Haas-type expander achieved expansion with a greater component of orthopedic movement than the hyrax-type expander. However, the comparison between the 2 kinds of expanders was performed on study models and anteroposterior cephalograms. The main difference between Haas-type and hyraxtype expanders is the acrylic pad close to the palate in

the Haas-type appliance. According to Haas,4 a purpose of the acrylic pad is to reinforce the anchorage for greater orthopedic response during RME. However, the results of our study did not support this theory, at least regarding the immediate effects of expansion. Better results in the immediate skeletal response were obtained by the hyrax-type expander vs the Haastype. This fact can be explained by differences in appliance design: more specically, in the connection mechanism of the jackscrew to the bands of the anchorage teeth. In the hyrax-type appliance design, the jackscrew was directly connected to the bands by a rigid stainless steel framework (1.4 mm), unlike the Haas-type appliance design, where the acrylic was responsible for connecting the stainless steel framework (1.0 mm) to the jackscrew. According to a previous study about the biomechanics of RME, appliance designs that use an acrylic interface with the teeth are far less stiff than those constructed solely of soldered stainless steel wire, as in the case of the hyrax-type expander.36 However, the acrylic pad against the palate would be important, especially during the retention period, when it would prevent the bone from moving through the teeth, thus averting an orthopedic relapse of the expanded maxilla.4,5,20

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Table IV. Immediate changes in the maxillary transverse plane with RME in the Haas group
T1 Variable Skeletal Distance 5-6 Posterior apical base width Distance 11-12 Posterior midpalatal suture width Distance 15-16 Anterior apical base width (inferior) Distance 17-18 Anterior apical base width (superior) Distance 21-22 Anterior midpalatal suture width Alveolar Distance 3-4 Posterior width at alveolar crest level Distance 19-20 Anterior width at midalveolar level Dental Distance 7-8 Intermolar width at occlusal surface Distance 9-10 Intermolar width at palatal root apices *Statistically signicant (P \0.05). Mean (mm) SE (mm) T2 Mean (mm) SE (mm) Change Mean (mm) SE (mm) P

61.10 00.00 38.98 39.70 00.00

0.87 0.11 0.82 1.12 0.15

63.29 02.61 42.28 42.33 03.63

0.87 0.11 0.82 1.12 0.15

2.19 2.62 3.29 2.62 3.63

0.15 0.12 0.30 0.31 0.17

\0.0001* \0.0001* \0.0001* \0.0001* \0.0001*

51.96 40.56

0.69 0.79

57.41 44.59

0.69 0.79

5.44 4.03

0.25 0.30

\0.0001* \0.0001*

43.42 30.57

0.59 0.71

51.12 32.72

0.59 0.71

7.70 2.15

0.20 0.18

\0.0001* \0.0001*

Table V. Immediate changes in the maxillary transverse plane with RME in the hyrax group
T1 Variable Skeletal Distance 5-6 Posterior apical base width Distance 11-12 Posterior midpalatal suture width Distance 15-16 Anterior apical base width (inferior) Distance 17-18 Anterior apical base width (superior) Distance 21-22 Anterior midpalatal suture width Alveolar Distance 3-4 Posterior width at alveolar crest level Distance 19-20 Anterior width at midalveolar level Dental Distance 7-8 Intermolar width at occlusal surface Distance 9-10 Intermolar width at palatal root apices *Statistically signicant (P \0.05). Mean (mm) SE (mm) T2 Mean (mm) SE (mm) Change Mean (mm) SE (mm) P

59.48 00.00 37.75 38.22 00.00

0.92 0.12 0.87 1.19 0.16

62.58 03.14 41.42 41.22 04.37

0.92 0.12 0.87 1.19 0.16

3.10 3.14 3.66 3.00 4.37

0.17 0.14 0.34 0.35 0.20

\0.0001* \0.0001* \0.0001* \0.0001* \0.0001*

51.34 39.58

0.73 0.83

57.15 44.34

0.73 0.83

5.80 4.76

0.28 0.34

\0.0001* \0.0001*

43.60 29.24

0.62 0.75

51.50 32.38

0.62 0.75

7.90 3.14

0.23 0.21

\0.0001* \0.0001*

In the hyrax group, the transverse expansion at the suture gradually decreased from the anterior, by 4.37 mm (distance 21-22), to the posterior, by 3.14 mm

(distance 11-12) (Table V). This sutural orthopedic separation accounted for 54.7% and 39.2% of the total expansion (8 mm) at distances 21-22 and 11-12,

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Table VI. Comparison between the changes in the maxillary transverse planes in the groups
Haas group T2-T1 Variable Skeletal Distance 5-6 (mm) Posterior apical base width Distance 11-12 (mm) Posterior midpalatal suture width Distance 15-16 (mm) Anterior apical base width (inferior) Distance 17-18 (mm) Anterior apical base width (superior) Distance 21-22 (mm) Anterior midpalatal suture width Alveolar Distance 3-4 (mm) Posterior width at alveolar crest level Distance 19-20 (mm) Anterior width at midalveolar level Dental Distance 7-8 (mm) Intermolar width at occlusal surface Distance 9-10 (mm) Intermolar width at palatal root apices Angle 1MD ( ) Right rst molar angulation Angle 1ME ( ) Left rst molar angulation *Statistically signicant difference (P \0.05). Mean SE Mean Hyrax group T2-T1 SE P

2.19 2.62 3.29 2.62 3.63

0.15 0.12 0.30 0.31 0.17

3.10 3.14 3.66 3.00 4.37

0.17 0.14 0.34 0.35 0.20

0.0002* 0.010* 0.427 0.438 0.007*

5.44 4.03

0.25 0.30

5.80 4.76

0.28 0.34

0.342 0.119

7.70 2.15 8.25 6.14

0.20 0.18 0.98 0.90

7.90 3.14 6.80 6.19

0.23 0.21 1.11 1.02

0.526 0.0008* 0.334 0.975

respectively. These ndings endorse a previous report in which, of the total expansion achieved, the hyrax-type expander produced 55% of the suture expansion in the anterior and 38% in the posterior regions.20 However, the RME changes were analyzed 3 months after the active expansion phase, unlike our study, where the immediate effects of RME were evaluated. This investigation showed a more signicant skeletal response compared with other studies.29,30 In a study by Lione et al,29 the RME was performed with a modied hyrax-type expander (bands on the rst permanent molars only), and less sutural expansion was obtained in both the anterior (2.17 mm) and the posterior (1.15 mm) regions. This small orthopedic effect could be explained by (1) the use of a modied hyrax-type expander, which had less anchorage; (2) less total expansion (7 mm); and (3) the sutural expansion evaluated in a more posterior region (posterior nasal spine) than in our study (in the rst molar region). In our investigation, the amounts of sutural expansion (2.88 mm in the posterior and 4 mm in the anterior regions) were greater than the amounts

reported by Podesser et al30 (1.6 mm in the posterior and 1.5 mm in the anterior regions). This difference could be explained by less total expansion (7 mm) and the relapse that might have occurred because of appliance removal and replacement at the end of the active phase of RME for CT scan acquisition in their study. In our investigations, there was no need to remove the appliances before the CBCT examination at T2 because of the lower level of metal artifacts produced by CBCT compared with conventional CT.11,38 The greater amounts of expansion at the alveolar level (distances 3-4 and 19-20) than the sutural expansion (distances 11-12 and 21-22) (Table III) show the bending of the alveolar processes of the maxilla; this result agrees with previous reports.20,28,30 The expansion at the alveolar level (distance 3-4) accounted for 70% of the total expansion, 36% of which represents sutural expansion and 34% is purely alveolar bending toward the buccal aspect. The great changes in maxillary transverse dimensions occurred at the dental level, where the expansion accounted for 97% (distance 7-8) of the total expansion

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(8 mm) (Table III). This greater expansion at the dental level compared with the skeletal level agrees with previous reports.3,4,20,28,30,34,37 However, the actual dental expansion can be found by subtracting the total expansion at the dental level (distance 7-8) from the suture and alveolar expansions (distance 3-4). Thus, from 97% (7.8 mm) of the total expansion at the dental level (distance 7-8), only 27% (2.17 mm) represents actual dental expansion, which was smaller compared with 36% (2.88 mm) of pure skeletal expansion (distance 11-12) and with 34% (2.75 mm) of pure alveolar bending. RME produced signicant buccal tipping of the rst permanent molars, accounting for 7.53 (angle 1MD) on the right side and 6.17 (angle 1ME) on the left side (Table III). There were no statistically signicant differences between the 2 groups in angular measurements. The amounts of buccal tipping of the rst permanent molars for the Haas group were 8.25 on the right side (angle 1MD) and 6.14 on the left side (angle 1ME), whereas, in the hyrax group, the tipping amounts were 6.80 on the right and 6.19 on the left sides. However, there was a statistically signicant difference between the Haas and hyrax groups in the linear measurement (distance 9-10), which represents the distance between the apices of the palatal roots of the rst permanent molars. The higher values for distance 9-10 (nearly 8 mm of expansion) reected a small buccal tipping of the rst molars. In the hyrax group, distance 9-10 increased by 3.14 mm, whereas, in the Haas group, there was an increase of 2.15 mm, showing greater tipping of the rst permanent molars with that expander (Table VI). Similar results were reported in other investigations.28-37 In the study of Garib et al,28 the Haas-type expander produced greater buccal tipping of the rst permanent molars (3.5 ) than did the hyrax-type expander (1.6 ). Oliveira et al37 found that the Haas-type expander produced greater buccal tipping of the rst permanent molars (7.12 right side, 6.64 left side) compared with the Hyrax-type expander (6.94 right side, 1.21 left side). However, these differences were not considered statistically signicant in either study. We assessed the immediate effects of RME; therefore, long-term evaluation is necessary for a better understanding of the differences between Haas-type and hyrax-type expanders, especially during the retention and postretention phases of RME.
CONCLUSIONS

1.

2.

3.

RME produced signicant increases in all maxillary transverse dimensions. The expansion pattern was triangular, with smaller effects at the skeletal level than at the dental level. However, the pure skeletal expansion was greater than actual dental expansion. The sutural expansion showed a wedge shape with the wide base in the anterior maxilla. The opening of the midpalatal suture accounted for 50% of the total expansion (8 mm) in the anterior region and 36% in the posterior region (there was a decrease from anterior to posterior). The hyrax-type expander produced greater orthopedic effects in 3 of the 5 skeletal points measured compared with the Haas-type expander. However, the effects were less than 0.5 mm per side and might not be clinically signicant.

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Based on this clinical trial with CBCT to assess the immediate effects of RME on the transverse plane with 2 kinds of palatal expanders, the following conclusions can be drawn:

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