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ORIGINAL ARTICLE

Inuence of the expansion screw height on


the dental effects of the hyrax expander:
A study with nite elements
nes Landre, Jr,b Diana de Lourdes Almeida Silva,c Wellington Pacheco,d
Rafael Marques de Sousa Araugio,a Ja
e
Matheus Melo Pithon, and Dauro Douglas Oliveiraf
Belo Horizonte, Minas Gerais, and Jequie, Bahia, Brazil

Introduction: Our objective was to evaluate the inuence of the expansion screw height of a hyrax expander on
the degree of dental inclination during rapid maxillary expansion by using the nite element method. Methods:
mes,
The hyrax expander and the maxillary arch were modeled by using Solidworks software (Dassault Syste
Paris, France). Three distinct nite element method models were created by simulating different screw heights
relative to the plane that intersected the center of resistance of the maxillary rst molars. These 3 relative positions were 10 mm below the maxillary rst molars center of resistance, at the same level as the maxillary rst
molars center of resistance, and 10 mm above the maxillary rst molars center of resistance. The initial activation of the expanders was simulated, and tooth displacements for each nite element method model were registered in the buccolingual, corono-apical, and mesiodistal directions. Results: The simulations tested showed
that the 3 hyrax screw heights had different dental tipping tendencies. When the screw was simulated below the
maxillary rst molars center of resistance, buccal tipping of the crowns and lingual tipping of the roots were registered. This tendency decreased when the screw was simulated at the same level as the maxillary rst molars
center of resistance. However, when the screw was simulated above the maxillary rst molars center of resistance, the tipping tendency was inverted, with the crowns displaying lingual tipping and the roots displaying buccal tipping. Conclusions: These ndings might explain the importance of carefully planning the height of the
hyrax expander screw, since, depending on this position, different tooth movements can be achieved. From
an orthopedic perspective, the ideal screw position might be slightly above the maxillary rst molars center of
resistance; this would generate less dental tipping. (Am J Orthod Dentofacial Orthop 2013;143:221-7)

tudies performed since the 1950s have proven the


viability of rapid maxillary expansion (RME) and its
capacity to aid in the treatment of posterior cross-

a
Private practice, and former orthodontic resident, Pontical Catholic University
of Minas Gerais, Belo Horizonte, Brazil.
b
Associate professor, School of Engineering, Pontical Catholic University of
Minas Gerais, Belo Horizonte, Minas Gerais, Brazil.
c
Former undergraduate student, Mechanical Engineer, School of Engineering,
Pontical Catholic University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil.
d
Adjunct professor, Department of Orthodontics, Pontical Catholic University of
Minas Gerais, Belo Horizonte, Minas Gerais, Brazil.
e
Professor, Department of Orthodontics, Southwest Bahia State University, Jequie,
Bahia, Brazil.
f
Program director, Department of Orthodontics, Pontical Catholic University of
Minas Gerais, Belo Horizonte, Minas Gerais, Brazil.
The authors report no commercial, proprietary, or nancial interest in the products or companies described in this article.
Correspondence to: Dauro Douglas Oliveira, P
os-graduac~ao em Odontologia,
Pontifcia Universidade Cat
olica de Minas Gerais, Avenida Dom Jose Gaspar,
500, Predio 46, sala 106, Belo Horizonte, MG 30535-610, Brazil; e-mail,
dauro.bhe@gmail.com.
Submitted, June 2012; revised and accepted, September 2012.
0889-5406/$36.00
Copyright 2013 by the American Association of Orthodontists.
http://dx.doi.org/10.1016/j.ajodo.2012.09.016

bites, especially in patients with maxillary arch constriction.1-5 Various studies have analyzed the effects of RME
on the maxilla and its adjacent structures,1-4,6,7 as well as
the forces exerted by the rapid maxillary expanders.8,9
Several authors have stressed the importance of optimizing the orthopedic effects of RME. Buccal inclination
of the posterior teeth is an undesired side effect that
might limit the amount of orthopedic expansion obtained.7,10 Sometimes, RME must be prematurely
interrupted to prevent a posterior buccal crossbite
without achieving adequate orthopedic correction of
the transverse deciency. Although RME has been
widely used in orthodontics for several decades, we
still need to better understand its effects and to
improve the control of its undesired side effects.
The use of the nite element method is an established
and important research tool in dentistry. The nite element method has recently been used to analyze the effects of RME on the teeth and craniofacial bones.11-13
Undoubtedly, a major advantage of this research
method in the health care eld is the possibility of
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Araugio et al

222

simulating different treatment approaches without


exposing animals or humans to any adverse effects of
experimental ideas and procedures.14
Hyrax and Haas appliances are the 2 rapid maxillary
expanders mostly used in orthodontics. Although both
expanders generate similar orthopedic effects, many orthodontists prefer to use the hyrax expander because it
facilitates the patients oral hygiene compared with the
Haas expander.9,15
Various studies have analyzed the stresses and strains
imposed on the craniofacial complex by RME.11-13
However, at present, no studies in the literature have
researched the inuence of the position of the
expansion screw on the orthodontic and orthopedic
responses to RME. Therefore, the purposes of this study
were to use the nite element method to simulate
different hyrax screw heights and to evaluate their
inuence over posterior tooth inclination during RME.
MATERIAL AND METHODS

The construction of the 3-dimensional nite element


method model was initiated by using 2-mm sections of
a multiplanar computerized tomography scan of a young
adult with a complete permanent dentition, except for
the third molars. Our research protocol was approved
by the ethics research committee of the Pontical Catholic University of Minas Gerais in Brazil.
A total of 195 computerized tomography images (2dimensional) were stacked with the computer design
software Solidworks with the Simulation package (Dassault Systemes, Paris, France) to accurately develop the
3-dimensional model. During the development of this
model, the maxilla and the teeth were built independently and considered to be independent parts with uniform mechanical properties. The maxillary graphic
reproduction was made without considering the maxillary sinus because its anatomic variations would significantly increase the drawing complexity. In addition, the
maxilla was drawn up to an upper horizontal limit dened by a plane passing through the anterior nasal spine
and the external acoustic meatus on both sides. After all
bony structures were graphically represented, each of the
14 teeth was drawn separately, with no differentiation
between enamel, dentin, or pulp, and with each tooth
considered an independent part.
Once the maxilla and the teeth were created, the hyrax expansion screw was modeled in Solidworks based
on the measurements of the Palex Mini-12 expansion
screw (Dentaurum, Newtown, Pa). The modeled apparatus featured an expansion screw and 2 segments of steel
wire that were 0.9 mm in diameter, following the lingual
contour of the crowns of the maxillary rst and second
premolars and the rst and second molars (Fig 1).

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Fig 1. Hyrax expander closely t to the molars and premolars, simulating the horizontal restriction of the movement that would be imposed by bands on the rst molars.

Three distinct nite element method models were


created, with different heights of the screw relative to
the plane that intersected the center of resistance of
the maxillary rst molars dened by the furcal region
of these 2 teeth (Fig 2). The rst model (FEM 1) had
the screw positioned in a plane parallel to the occlusal
plane that intersected the crowns of the maxillary teeth
in the center of their crown, 10 mm below the maxillary
rst molars center of resistance. The second model (FEM
2) had the screw simulated at a higher and intermediate
position that was coincident with the plane that intersected the maxillary rst molars center of resistance.
The nal model (FEM 3) simulated the screw closer to
the palate, 10 mm above the maxillary rst molars center of resistance (Fig 2).
The frame of the expansion screw was substituted for
a frame with a rectangular section. Since a goal of this
study was to evaluate the inclinations of the premolars
and molars, soft elements were incorporated into the
buccal surfaces of the roots of these teeth.
For all 3 models, the materials of both the teeth and
the expander were dened. The teeth were considered to
have isotropic properties, with an elastic modulus of
21,400 MPa and a Poisson coefcient of 0.31. The expander was dened with the properties of AISI 304 steel
from the database of the SolidWorks software, with an
elastic modulus of 190,000 MPa and a Poisson coefcient of 0.29. Elastic supports were incorporated into
the buccal surfaces of the roots of the teeth, with an
elastic constant of 1 3 106 (N/m)/m2. A force of 1 N
was applied in a direction normal to the medial surface
of the body of the apparatus. The values used for the
elastic and force constants were standardized across all
3 congurations.
The elastic constant is a way of simulating the resistance to the displacement caused by the labial bone
plate. Because there is no value for this resistance in
the literature, a standard value was arbitrarily selected.

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223

RESULTS

Fig 2. Expander apparatus: A, lowest position, screw


simulated in a plane parallel to the occlusal plane at the
center of the maxillary teeth and 10 mm below the maxillary rst molars center of resistance; B, intermediate position, screw parallel to the occlusal plane at the same
level as the maxillary rst molars center of resistance;
C, the highest position, with the screw closest to the palate, 10 mm above the maxillary rst molars center of resistance.

Since this value was not real, the magnitude of the force
is relatively unimportant, because this magnitude has
been standardized based on our assumed resistance
value. Therefore, for the 3 models, meshes were generated with elements measuring 2 mm with a tolerance
of 0.1 mm. Static studies were performed, and the tooth
displacements for each of the 3 models were registered
in the buccolingual (x-axis), corono-apical (y-axis),
and mesiodistal (z-axis) directions.

The number of elements and nodes of the mesh for


each nite element method model differed because of
the different lengths of the screw arms. The model
with the lowest conguration (FEM 1) contained
11,378 elements and 19,299 nodes. The model with
the intermediate screw position (FEM 2) generated
11,417 elements and 19,414 nodes. The expander simulated with the highest screw position (FEM 3) had a mesh
with 11,616 elements and 19,761 nodes.
In FEM 1, the crowns of the premolars and molars
showed buccal displacements that gradually decreased
in the apical-cervical direction. The roots exhibited lingual displacements.
In FEM 2, the crowns of the 4 teeth had displacements in the buccal direction that gradually decreased
in the apical-cervical direction. Only the apices of the
roots had lingual displacements. The tooth displacements from this conguration were smaller than those
registered in FEM 1.
In FEM 3, the tooth crowns displayed displacements
in the lingual direction that gradually decreased in the
apical-cervical direction. All roots exhibited buccal displacements (Fig 3).
In FEM 1, displacement in the apical-cervical direction was identied for the 4 teeth examined, indicating
a tendency toward intrusion.
In FEM 2, there were displacements in the apicalcervical direction of the 4 teeth, indicating a tendency
toward intrusion. However, the magnitude of this intrusion tendency was smaller than that registered in FEM 1.
Conversely, in FEM 3, displacement in the coronal
direction was identied in the 4 teeth, indicating a tendency toward extrusion (Fig 4).
In FEM 1, the crowns of the 4 teeth had displacements in the mesial direction that gradually decreased
in the apical-cervical direction. The roots exhibited distal
displacements.
In FEM 2, the crowns of the 4 teeth showed mesial
displacements that gradually decreased in the apicalcervical direction. The roots exhibited distal displacements. The magnitude of these displacements was
smaller than those noted in FEM 1.
In FEM 3, the crowns of the 4 teeth had displacements in the distal direction that gradually decreased
in the apical-cervical direction. The roots exhibited
mesial displacements (Fig 5).
To better visualize the differences in the displacements for each of the 3 hyrax expander congurations,
a Sonda tool (Dassault Systemes) was used to mark points
along the edges of each tooth in each nite element
method model. Thus, points were marked on the buccal

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224

Fig 3. Displacement in the buccolingual direction. In


each image of this gure, positive values are represented
by warm colors and indicate displacement in the buccal
direction; negative values are represented by cold colors
and indicate displacements in the lingual direction. However, the scale of displacement magnitudes varies between the different images, as does the relative position
and color of zero displacement. A, In FEM 1, zero displacement is represented by green; B, in FEM 2, zero is
rendered in blue, close to the apices of the roots; C, in
FEM 3, zero displacement is represented by green.

sides of the premolars and molars, and along the edges


that had previously been dened along the long axes
of these elements. For each point, or node, the Sonda
tool provided the corresponding displacement. After
obtaining these points, comparative graphs of displacement were generated in the buccolingual direction of
each tooth for the nite element method model (Fig 6).
The graphs of the 4 teeth illustrate the tendency toward crown tipping in the buccal direction for FEM 1
and FEM 2, and in the lingual direction for FEM 3.

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Fig 4. Displacement in the corono-apical direction. In


each image of this gure, positive values are represented
by warm colors and indicate displacement in the apical direction; negative values are represented by cold colors
and indicate displacements in the occlusal direction.
However, the scale of displacement magnitudes varies
greatly between the various images. A, FEM 1; B, FEM
2; C, FEM 3.

However, FEM 2 had a tendency toward homogenous


displacement, indicating that constructing the hyrax expander with the screw positioned slightly higher than the
maxillary rst molars center of resistance might minimize dental tipping.
DISCUSSION

Although the viability of RME has been proven and its


effects have been studied over the last decades, the search
for ways to improve RME efciency continues. The nite
element method has been successfully used to evaluate
the forces and deformations imposed on teeth and

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Fig 5. Displacement in the mesiodistal direction. In each


image of this gure, positive values are represented by
warm colors and indicate displacements in the mesial direction; negative values are represented by cool colors
and indicate displacements in the distal direction. However, the scale of displacement magnitudes varies greatly
between the various images. A zero value is represented
by green for all parts of this gure, although the precise
tint of this shade varies among the different gure parts.
A, FEM 1; B, FEM 2; C, FEM 3.

craniofacial bones when RME is performed.11,13,16,17


However, no study in the literature has examined the
inuence of the expansion screws position on the
orthodontic and orthopedic responses of RME.
The simulations we performed in this study evaluated
the initial effects of RME with the hyrax expander. The
inuence of the hyrax screws height relative to the palate was evaluated by assessing the displacements on the
maxillary teeth used to anchor the expander.
This study proposal is validated by the importance to
try to improve current RME appliances to maximize their

225

orthopedic effects and minimize their undesired side


effects, such as buccal crown tipping, a long-standing
concern found in the dental literature.7,10 An
important limiting factor of RME is the transverse
relationship between the posterior maxillary and
mandibular teeth. The activation of the expansion
screw must be interrupted before a posterior buccal
crossbite occurs.15 Thus, the greater the dental tipping,
the smaller the orthopedic gain obtained from the separation of the midpalatal suture.
During RME, there is a tendency toward buccal crown
tipping of the premolars and molars18,19 and alveolar
bone folding also in the buccal direction.20 Bassarelli
et al19 found a positive correlation between the amount
of palatal expansion and the magnitude of buccal
crown tipping of the posterior teeth. These ndings
are reinforced by the results of our study for the model
simulating the hyrax screw below the maxillary rst
molars center of resistance (FEM 1). However, the results of the intermediate (FEM 2) and higher (FEM 3)
congurations indicated that it might be possible to reduce the dental tipping tendency when the height of the
hyrax expansion screw is properly chosen.
Bassarelli et al19 did not identify an increase in the
height of the crowns of the maxillary teeth during
RME. Reed et al,21 however, reported extrusion of the
molars with banded and bonded expanders. In our study,
tooth displacements in the corono-apical direction were
also evaluated to observe intrusion or extrusion tendencies with the different hyrax screw heights tested. An
extrusion tendency of the molars and premolars was registered in FEM 3. It might be due to the upward tendency
of deformation registered in the central portion of the
expander, which generated a reactive tendency to deform and displace the lateral portions of the expander
and the adjacent teeth in the opposite direction, thus
downward. Conversely, in FEM 1 and FEM 2, a downward tendency of deformation was observed in the central portion of the hyrax screw. Therefore, a reactive and
upward deformation tendency was registered in the
expander extremities, thus generating the intrusion tendencies for both premolars and molars. The results of
these simulations cannot be directly extrapolated to
the clinical setting. They represent mechanical tendencies, since some degree of approximation is a limitation
of nite element method studies; our ndings must be
conrmed in vivo before they are clinically applied.
There is a tendency toward deformation of the medial
portion of the apparatus in the mesial direction for all 3
apparatus congurations. This observation indicates
a force component in the anterior direction. For the
low and middle screw congurations, this force occurs
below the center of resistance of the teeth, resulting in

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Fig 6. Displacement in the buccolingual direction for the rst premolar, second premolar, rst molar,
and second molar. Positive values indicate displacements in the buccal direction; negative values indicate displacements in the lingual direction.

mesial movement for their crowns and distal movement


for their roots. In the highest screw conguration, the
opposite occurs: the force component in the anterior direction is above the center of resistance of the teeth. As
with the previous deformations discussed, these effects
are likely reduced when both halves of the apparatus
are considered.
When the mesiodistal displacements were evaluated,
a mesially directed deformation tendency of the hyrax
central portion was registered in all nite element
methods tested. This tendency indicated that an anterior
force component acting on the extremities of the expander and over the supporting teeth. In FEM 1 and
FEM 2, the anterior force component was located below

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the centers of resistance of the teeth, indicating mesial


crown and distal root tipping. Inversely, in FEM 3, the resultant anterior force vector was observed above the
centers of resistance of the teeth. However, these displacements are unlikely to be observed clinically because
of the bony and dental structures that were not simulated in the nite element method models tested.
The results of this study indicated that the construction of the hyrax expander apparatus with the screw below the maxillary rst molars center of resistance
generated an increased tendency toward buccal tipping
of the crown. The closer the screw is positioned to the
maxillary rst molar, the less the dental tipping tendencies. However, when the screw is located above the

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maxillary rst molars center of resistance, the crown


tends to tip in the lingual direction. When the screw
was tested far from the maxillary rst molars center of
resistance (FEM 1 and FEM 3), the apices were displaced
in the opposite direction from the crowns. This could
generate undesired compression in the root apices, especially in the premolars. The intermediate conguration
(FEM 2) appears to be close to ideal, producing nearly
homogenous displacements. The likely ideal position
for this evaluated situation would be slightly above the
maxillary rst molars center of resistance; this would
generate bodily displacement in the buccal direction
for the 8 teeth, optimizing the orthopedic effects of RME.

227

7.

8.

9.

10.

CONCLUSIONS

The results of the nite element method simulations


tested in this study indicated the following.
1.

2.

3.

Greater amounts of buccal crown tipping were registered when the hyrax screw was positioned closer
to the occlusal plane.
There were extrusive tendencies when the screw was
simulated above the center of resistance of the
teeth.
There were mesial displacement tendencies when
the screw was simulated below the center of resistance of the teeth and distal displacements when
it was above the maxillary rst molars center of resistance.

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