CLINICIANS CORNER

Upper midline correction in conjunction

with rapid maxillary expansion
Toros Alcana and Cenk Ceylanoglub
Istanbul, Turkey

Introduction: The purpose of this study was to investigate a simple method for correcting upper dental
midline shift, by physiologic movement of the incisors during the retention period of rapid maxillary
expansion. Methods: Thirty-two patients with upper midline shifts due to constricted maxillae and anterior
crowding were selected. All had undergone radiological and clinical examinations to be sure that the midline
shift was not functional and was caused only by crowding. The patients were randomly divided into 2 groups.
In both groups, acrylic cap splint type expansion appliances were used. In group 1, the acrylic cap covered
all the dentition except the incisors and the canine on the shifted side. After expansion, the incisors on the
shifted side were allowed to move toward the midline, and the incisors of the other side were held by the
acrylic cap. In group 2, the acrylic cap covered only the posterior teeth, from the first premolars on both
sides. After expansion, the incisors on the shifted side were allowed to move toward the midline diastema,
whereas those on the other side were held in place by ligation of the brackets, which had been placed
immediately after expansion. Results: In both groups, the midline shift was corrected by the movement of
the shifted incisors toward the midline diastema, without orthodontic force. Conclusions: Residual or
unwanted forces produced during rapid maxillary expansion can be used to correct an upper dental midline
shift. (Am J Orthod Dentofacial Orthop 2006;130:671-5)

A
nterior crowding is associated with many fac-
tors; the most common is narrow arches.1 If
anterior crowding results in an infrapositioned
canine or a palatally positioned lateral incisor on 1 side,
this leads to an upper midline shift toward the crowded
side. Because this crowding is caused by constriction of
the maxilla, the first possible solution is rapid maxillary
expansion (RME).
With RME, the midpalatal suture opens; the alve-
olar processes bend and move laterally with the
maxilla; and the central incisors are separated, and a
midline diastema occurs.
During the retention period of expansion, the cen-
tral incisors start moving toward the midline diastema
reciprocally by the residual forces of the elastic trans-
septal fibers. After about 4 months of retention, the
central incisors come into contact, but the axial incli-
nations of the roots might need more time.2-4 This
treatment protocol would possibly correct the constric-
tion of the maxilla and provide enough space to correct
the anterior crowding, but it would not correct the
a
Assistant professor, Department of Orthodontics, Faculty of Dentistry,
Marmara University.
b
Private practice, Istanbul, Turkey.
Reprint requests to: Cenk Ceylanoglu, Valikonagi cad. Kse apt. No: 101
D: 3-4, Nisantasi, Sisli, Istanbul, Turkey; e-mail, cceylanoglu@allianoi.com.
Submitted, January 2005; revised and accepted, February 2005.
0889-5406/$32.00
Copyright 2006 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2005.02.020
midline shift because the central incisors move recip-
rocally toward each other.2,3,5,6 When the retention
period of expansion ends, a clinician might find less
crowding on 1 side and some diastema on the other
side. The midline can be corrected later by moving the
anterior teeth from 1 side to the other.
According to Timms,4 the dental relapse that ap-
pears after the expansion of maxilla should be controlled
and used to advantage, with a suitable plan of retention.
Moreover, Follin et al7 stated that an attempt to move an
incisor toward the midline immediately after RME
would not be successful because the suture dislocates in
front of the orthodontically moved incisor.7 Likewise,
Graber and Vanarsdall8 recommended placing the
brackets 3 to 4 months after starting RME.
In this study, we introduce 2 RME protocols to
correct the upper dental midline shift during the reten-
tion period of RME without active forces, but with the
physiologic forces produced by the transseptal fibers.
MATERIAL AND METHODS
The study group consisted of 32 adolescents (20
girls, 12 boys) whose ages ranged from 12 to 19 years
of age, with a mean age of 14.2 years. They all needed
RME as part of their treatment. Panoramic radiograph,
lateral and posteroanterior cephalometric films, models,
and intraoral photographs were taken initially. The
patients were examined clinically and radiologically
671
672 Alcan and Ceylanoglu American Journal of Orthodontics and Dentofacial Orthopedics
November 2006

Fig 1. A, Bilateral constricted maxilla with upper midline shift; B, type 1 RME appliance in mouth;
C, end of expansion; D, correction of upper midline shift at end of retention period.

Fig 2. A, Bilateral constricted maxilla with upper midline shift; B, type 2 RME appliance in mouth;
C, end of expansion; D, correction of upper midline shift at end of retention period.

to be sure that their upper midlines were shifted
dentally relative to the facial midlines as a result of
the anterior crowding and that there were no skeletal
mandibuler shifts from occlusal interference (Figs 1,
A, and 2, A).
The patients were randomly selected and divided
into 2 groups for the application of the 2 RME
protocols. The occlusal radiographs were taken after a
week of expansion to see the opening of midpalatal
suture. One patient from the first group and 2 patients
from the second group were excluded from the study
because of noncooperation during treatment.
Appliance designs and applications
Type 1, an acrylic cap splint-type expansion appli-
ance covering all dentition except the incisors and the
canine on the shifted side, was constructed and applied
(Fig 1, B). The patients were asked to open the screw
once every 12 hours (twice a day). After a week of
expansion, the patients were checked, and the opening
of the midline diastema was recorded, both clinically
and radiologically (Fig 1, C). When enough expansion
was achieved, the screw was fixed with a ligature
wire and left in the mouth as a retainer. During 4
months of retention, the incisors on the shifted side
moved toward the midline diastema, whereas the
incisors in the opposite side were kept in place by the
acrylic cap (Fig 1, D).
Type 2, an acrylic cap splint-type expansion appli-
ance covering only the posterior teeth, starting from the
first premolars, was constructed and applied (Fig 2, B).
The same expansion protocol was followed until the
expansion phase was finished. When sufficient expan-
sion was achieved, brackets were placed on the central
and lateral incisors and the canine on the noncrowded
side. The acrylic shield on the vestibular part of first
premolar was removed to place a bracket. The brackets
were tied together with a ligature wire to prevent the
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 130, Number 5
Fig 3. A, Before expansion; B, buccal nonocclusion after removal of RME appliance; C, end of
treatment.
incisors from moving toward the diastema. Thus, the
midline space could be closed only by movement of the
incisors on the opposite side (Fig 2, D).
RESULTS
The mean duration of expansion was 25.6 days, and
the mean amount of median diastema was 6.7 mm.
After 4 months of retention, the incisors on the
shifted side moved toward the midline aided by the
transseptal fibers in both groups.
The clinical and radiological examinations showed
that (1) expansion with appliance type 1 resulted in an
asymmetric arch shape; (2) the incisors covered by the
acrylic cap in appliance type 1 moved laterally and
downward; (3) the relapse tendency of the incisors was
so high that, in 3 subjects with type 1 appliances, the
central incisors returned to their initial overlapping posi-
tions after the relapse period; (4) in 3 subjects, overex-
pansion was needed to correct the midline, and the
expansions resulted in buccal nonocclusion; and (5) in
both groups, the midline diastemas were closed only by
the movement of the shifted incisors, and the midline
shifts were corrected without active orthodontic forces,
by only physiologic tooth movements.
DISCUSSION
Anterior crowding caused by the constriction of the
maxilla can be either symmetric or asymmetric. If the
crowding is asymmetric, the upper midline is shifted
to 1 side, and either the canine or the incisors are
malpositioned. Then treatment strategy can be RME
and appropriate orthodontic mechanics.
The treatment protocols in this study are indicated
only for patients with constricted maxillae, anterior
crowding on 1 side, and upper midline shifts. The
treatment protocols for symmetric anterior crowding
without dental midline or functional shift of the man-
dible will not be discussed here.
The total activation time of the expansion procedure
was determined according to 2 main criteria: until the
crossbite was corrected and until 1 maxillary incisor
Alcan and Ceylanoglu 673
coincided with the lower midline and the midface. In 3
patients, expansion resulted in buccal nonocclusion
because of overexpansion to obtain the midline correc-
tion. Thus, after the midline diastema was closed and
the midline was corrected, the posterior teeth were left
free to relapse in the transverse direction (Fig 3).
Relapse of the posterior dental expansion was accept-
able because skeletal expansion was used in the cor-
rection of the midline shift.
In the first group with appliance type 1, the forces
produced by the tension of the transseptal fibers moved
the free incisors toward the midline diastema after expan-
sion, whereas the other incisors were held by the acrylic
cap. With this appliance, there is no need for extra work
because the incisors are held by the appliance itself, and it
is an advantage from the point of chair time.
Both groups included bilateral maxillary constric-
tion patients; symmetrical expansion was needed. How-
ever, expansion in the first group (type 1) resulted in
asymmetric arch shapes, because the appliances cov-
ered all the teeth on 1 side, creating more anchorage,
but only the posterior teeth on the other side. Therefore,
this type of appliance might be more indicated for
unilateral crossbite patients (Fig 4).
Another disadvantage of appliance type 1 was the
greater lateral and downward movement of the capped
incisors than the incisors on the other side. This was a
result of dental expansion because those incisors were
included in the acrylic cap. The incisors on the opposite
side did not move dentally. They were translated
laterally with the maxillary half during expansion. This
side effect can be corrected after the expansion proce-
dure, but, until that time, it causes an esthetic problem.
Also, most of the patients complained about the asym-
metric appearance of the appliance in spite of the
transparent acrylic and cement (Fig 5).
In 3 patients with appliance type 1, the central
incisors overlapped before expansion. After expansion,
the incisors on 1 side were left for relapse. It was
observed that the central incisors overlapped again just
as they were at the beginning. This situation shows how
674 Alcan and Ceylanoglu
Fig 4. Asymmetric arch shape with type 1 appliance: A, before expansion; B, end of retention;
C, after removal of appliance.
Fig 5. Lateral and downward movement of incisors: A, before treatment; B, before expansion;
C, after expansion.
strong the transseptal fibers are and their tendency to
relapse. In similar cases, it would be advantageous to
use type 2 appliances because the overlapped incisors
could be controlled by the brackets.
The expansion appliance used in the second group
(type 2) covered only the posterior teeth from the first
premolars on both sides (Fig 2, B). It is a symmetric
appliance from the point of appearance and anchorage.
Hence, expansion resulted in a symmetric arch form,
and the incisors remained at the same level. How-
ever, if the incisors on both sides are left free after
expansion, they start moving toward the midline
diastema. To hold the incisors on the noncrowded
side, brackets should be placed immediately, and the
incisors and the canine should be ligated to the first
premolar and consequently to the acrylic cap. This
procedure needs extra chair time and good timing,
because the incisors can move quickly and close the
acquired space for the midline correction. Two pa-
tients did not come to their appointments immediately
after expansion, and the midline diastemas were closed
reciprocally without midline correction. These patients
were excluded from the study.
As another disadvantage of appliance type 2, the
patients complained about the asymmetric appearance of
the brackets in 1 quadrant. To solve this problem, braces
can also be placed on the other side without ligation.
Haas3 stated that the incisors separate as the maxilla
American Journal of Orthodontics and Dentofacial Orthopedics
November 2006
expands; then they come into contact again with the aid
of the transseptal fibers; this cycle takes about 4
months. In this study, the retention period of RME was
planned as 4 months. The expansion appliance was kept
in the mouth as a retainer, although it was bulky and
unhygienic. However, the acrylic cap of the appliance
was a great anchorage unit and also served as the
posterior bite plane during the leveling process of palatally
or infrapositioned anterior teeth. In some cases, palatally
positioned lateral incisors moved buccally because of
spontaneous pressure of the tongue (Fig 2).
CONCLUSIONS
With both types of appliance, midline shift and
anterior crowding caused by the bilateral constriction of
the maxilla were treated successfully because of the
physiologic forces produced by the transseptal fibers
during expansion. Appliance type 2 was found to be
more esthetic and hygienic than appliance type 1. On
the other hand, appliance type 1 was more advanta-
geous in less cooperative patients than appliance type 2.
In this study, we show that residual or unwanted forces
produced during RME can be used to benefit treatment
and shorten chair time.
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Volume 130, Number 5

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3. Haas AJ. Palatal expansion. Just the beginning of dentofacial
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4. Timms DJ. Rapid maxillary expansion. Chicago: Quintessence;
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5. Starnbach H, Cleall J. The effects of splitting the mid palatal
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