CASE REPORT

A 22-year follow-up of the nonsurgical expansion

of maxillary and mandibular arches in a young
adult: Are the outcomes stable, relapsed, or
unstable with aging?

Valladares-Neto,a Karine Evangelista,b Hianne Miranda de Torres,b Matheus Melo Pithon,c and
Jose
Maria Alves Garcia Santos Silvad
Goi^ania, Goi
as, and Jequi
e, Bahia, Brazil
Adult maxillary and mandible arch expansion without a surgical approach can be uncertain when long-term stability is considered. This case report describes the treatment of a 19-year-old woman with an Angle Class I
malocclusion with constricted maxillary and mandibular arches. The patient's main complaint was mandibular
anterior crowding. The treatment plan included expansion of the mandibular arch concurrent with semirapid
maxillary expansion. An edgewise appliance was used to adjust the nal occlusion. Smile esthetics and dental
alignment were improved without straightening the prole. This outcome was followed up with serial dental casts
for 22 years after treatment. At the end of that period, the occlusion and tooth alignment were clinically satisfactory, further supported by mandibular xed retention. However, the transverse widths were continuously and
gradually reduced over time, superposing orthodontic transverse relapse and natural arch constriction caused
by aging. (Am J Orthod Dentofacial Orthop 2016;150:521-32)

uccessful orthodontic treatment is also referred to

as long-term stability. However, orthodontic
relapse and physiologic changes with age can produce dental arch instability. Longitudinal studies have
shown that tooth position can be physiologically
changed with aging in untreated subjects because of
progressive arch constriction.1-3 These 2 phenomena
are probably superposed in treated subjects during the
postretention period.4

a
Adjunct professor, Division of Orthodontics, School of Dentistry, Federal University of Goi
as, Goi^ania, Goi
as, Brazil.
b
Postgraduate student (PhD), School of Dentistry, Federal University of Goi
as,
Goi^ania, Goi
as, Brazil.
c
Professor, Department of Orthodontics, School of Dentistry, Southwest Bahia
State University, Jequi
e, Bahia, Brazil.
d
Professor, Department of Stomatologic Sciences, School of Dentistry, Federal
University of Goi
as, Goi^ania, Goi
as, Brazil.
All authors have completed and submitted the ICMJE Form for Disclosure of
Potential Conicts of Interest, and none were reported.
Address correspondence to: Jos
e Valladares-Neto, Division of Orthodontics,
Federal University of Goi
as, Avenida Universit
aria esquina com 1a Avenida, s/n,
Setor Universit
ario, CEP: 74.605-220, Goi^ania, Goi
as, Brazil; e-mail,
jvalladares@uol.com.br.
Submitted, May 2015; revised and accepted, October 2015.
0889-5406/$36.00
2016 by the American Association of Orthodontists. All rights reserved.
http://dx.doi.org/10.1016/j.ajodo.2015.10.030

As regards the transverse dimension, constricted arch

problems have been solved through expansion, and
increments in arch dimensions have been clearly
demonstrated.5,6 However, most studies on maxillary
and mandibular arch expansion have dealt with subjects
in the mixed and early permanent dentitions, and only a
few authors have studied long-term results.5,7-9 In
young adults, the prognoses for rapid maxillary
expansion and semirapid maxillary expansion (SRME) in
terms of palatal suture opening are uncertain due to the
rigidity of the skeletal components with advancing
maturity.10 This prevents or limits the extent of suture
opening and results in a greater dentoalveolar than a
skeletal response, with an unpredictable long-term
outcome.11 On the other hand, the response of mandibular arch expansion is only dentoalveolar, and it has
been recommended in the case of a constricted arch.6,8
Nevertheless, the changes in mandibular arch form have
controversial results and could adversely affect longterm stability and treatment outcomes.12 In contrast,
other studies have shown that mandibular arch forms
can be successfully expanded in the early stages.5,8,9
Because dental and skeletal long-term stability is a key
objective in orthodontics, and the tendency toward
relapse is a real problem superposed by changes caused
521

Valladares-Neto et al

522

Fig 1. Pretreatment photographs.

by aging, information on patients monitored over a long

period could be valuable and help to clarify this issue. We
present the treatment of an adult with a Class I malocclusion and constricted maxillary and mandibular arches.
The outcome of the expanded mandibular arch concurrent with SRME was followed for 22 years after treatment.
DIAGNOSIS AND ETIOLOGY

A 19-year-old woman, complaining mainly of tooth

crowding, came for orthodontic treatment at a private
ofce. She reported being satised with her facial
appearance and had no serious medical impairment. A
facial analysis showed a well-balanced face, a mesocephalic growth pattern, and a straight prole. The ratio
of lower to upper facial heights was normal. The patient
had competent lips and the nasolabial angle was within
the normal range, but considering her slightly hooked
nose and retruded upper lip, the mentolabial sulcus

September 2016  Vol 150  Issue 3

was somewhat deep, and her lower lip was slightly

thicker than the upper lip although it did not impair
the relationship between them. She had a high smile,
exposing more than 2 mm of gingivae, and increased
buccal corridors.
An intraoral evaluation showed a Class I molar relationship with maxillary and mandibular atresic dental
arches. A crowding discrepancy of 5.0 mm was present
in the anterior segment of the mandibular arch and was
responsible for the irregular gingival alignment. The
maxillary anterior teeth showed a buccal proclination
with a slight midline diastema because of the central
incisor divergence. On the right side, the canine had a
Class II relationship. A single dental crossbite was
present between the second premolars on the left side.
A deep overbite was detected, with the maxillary incisors
covering 60% of the mandibular incisors, and overjet
was 6 mm (Figs 1-3). No intermaxillary tooth-size
discrepancy was found before treatment.

American Journal of Orthodontics and Dentofacial Orthopedics

Valladares-Neto et al

523

Fig 2. Pretreatment dental casts.

Fig 3. Pretreatment radiographs: A, panoramic; B, lateral cephalometric; C, cephalometric tracing.

American Journal of Orthodontics and Dentofacial Orthopedics

September 2016  Vol 150  Issue 3

Valladares-Neto et al

524

Table. Cephalometric measurements

Variable
Skeletal ( )
ANB
SNA
SNB
SN.GoGn
FMA
Dental
1.NA ( )
1-NA (mm)
1.NB ( )
1-NB (mm)
IMPA ( )
Overjet (mm)
Overbite (mm)
Prole (mm)
S-Ls
S-Li

Norm

Pretreatment
19 y 11 mo (T1)

Posttreatment
22 y 11 mo (T2)

Postretention
44 y 9 mo (T4)

2.0
82.0
80.0
32.0
25.0

2.0
80.0
78.0
34.0
25.0

2.0
82.5
79.5
31.5
26.0

2.5
80.0
77.5
33.5
25.0

22
4
25
4
90
2-3
2-3

31.0
8.0
21.5
5.0
90.5
6.0
5.0

24.5
6.5
35.5
8.0
110.5
2.0
2.0

24.0
6
33.0
6
102.5
3.0
3.0

0
0

4.0
1.0

3.0
0.5

3.0
1.0

Fig 4. Progress photographs: slow maxillary expansion and mandibular dentoalveolar expansion
treatments.

Most of these morphologic changes were probably

related to her oral breathing developed with the increase
in upper airway resistance during infancy. The Table
shows the patient's cephalometric measurements.
TREATMENT OBJECTIVES

The aims of the treatment were to expand the maxillary and mandibular arches, resolve the mandibular
crowding, correct the dental crossbite, and obtain
normal overjet, overbite, and incisor inclinations.
TREATMENT ALTERNATIVES

In view of the treatment objectives, the following

treatment alternatives were presented to the patient:
(1) SRME with mandibular dentoalveolar expansion followed by an orthodontic xed appliance, (2) surgically
assisted rapid maxillary expansion and mandibular dentoalveolar expansion followed by an orthodontic xed

September 2016  Vol 150  Issue 3

appliance, (3) dental slice and xed appliance, and (4)

extraction of 4 premolars.
The rst option was selected because of the principal
problems and the patient's wishes.

TREATMENT PROGRESS

In the expansion phase, the patient was treated with a

Haas appliance and had her lingual arch expanded
(Fig 4). She was advised to activate the screw by 2 quarter
turns per day for the rst week, followed by a 1 quarter
turn every other day, characterizing the SRME. After
16 days, she showed a low orthopedic response observed
by a minimal median maxillary diastema and suspicions
of a buccal alveolar fracture in the left rst premolar.
Two-dimensional radiographic images have limited access to any vestibular fracture, and no action was taken.
The screw was then stabilized for retention. The 0.9-mm
lingual arch of stainless steel wire was expanded 3 times

American Journal of Orthodontics and Dentofacial Orthopedics

Valladares-Neto et al

525

Fig 5. Immediately posttreatment photographs.

during the SRME retention. For the activation, the

lingual arch was rst removed, the bands were labially
torqued with a Weingart pliers, the lingual archwire
was symmetrically expanded by 3 to 4 mm each time,
and recemented. The aim of the active lingual arch
was to correct the collapsed mandibular arch until the
posterior teeth became upright, and thus contribute to
improving the morphology of the mandibular dental
arch. When both the Haas and the lingual arch expanders
were removed after 5 months, there had been gains in
the perimeters of the arches.
The xed appliance was bonded using a 0.022-in
edgewise prescription. The alignment phase included a
binary movement of the left second premolar to solve
the tooth rotation and dental crossbite problems. Alignment and leveling of the teeth took place over 8 months.
After we used rectangular wires, the maxillary anterior
proclination was corrected using lingual torque and
adding Class II elastics. The appliance was debonded
after 14 months of treatment.

The patient used a wraparound retainer in the maxillary jaw throughout the day over the rst 6 months and
only at night during sleep for the next 6 months. The
mandibular xed retainer from canine to canine has
been maintained up to the present.
TREATMENT RESULTS

The treatment resulted in signicant improvements

in dental alignment and smile, without straightening
the prole. A proper morphologic occlusion, with normal
overbite and overjet, and a good occlusal relationship
between the posterior teeth, were achieved with treatment, and both the maxillary and mandibular arches
were expanded. The expansion effect included proclination of the mandibular incisors, by increasing the IMPA
(initial, 90.5 ; nal, 110.5 ). The extent of gingival
recession after treatment was only what was adequate
for tooth alignment. Anterior and lateral occlusal guidances were also checked at the end of treatment. No

American Journal of Orthodontics and Dentofacial Orthopedics

September 2016  Vol 150  Issue 3

Valladares-Neto et al

526

Fig 6. Immediately posttreatment dental casts.

Fig 7. Final treatment radiographs: A, panoramic; B, lateral cephalometric; C, cephalometric tracing.

September 2016  Vol 150  Issue 3

American Journal of Orthodontics and Dentofacial Orthopedics

Valladares-Neto et al

527

Fig 8. Photographs 6 years after treatment.

Fig 9. Dental casts 6 years after treatment.

American Journal of Orthodontics and Dentofacial Orthopedics

September 2016  Vol 150  Issue 3

Valladares-Neto et al

528

Fig 10. Photographs 22 years after treatment.

Fig 11. Dental casts 22 years after treatment.

September 2016  Vol 150  Issue 3

American Journal of Orthodontics and Dentofacial Orthopedics

Valladares-Neto et al

529

Fig 12. Radiographs 22 years after treatment: A, panoramic; B, lateral cephalometric; C, cephalometric tracing.

signicant root resorption was observed, and root parallelism was well established (Figs 5-7). The 6-year and
22-year follow-up evaluations showed stable alignment
and occlusion, with normal radiograph images
(Figs 8-12).
Serial dental casts made on 4 occasions were available: pretreatment (T1), after expansion and xed appliance therapy (T2), and at the long-term observations
after 6 (T3) and 22 years (T4) posttreatment. Increases
in intercanine, interpremolar, and intermolar widths
were noted due to treatment in both arches. In the
maxillary jaw, the intercanine, interpremolar, and intermolar widths increased by 2.47, 4.09, and 3.75 mm,
respectively, after treatment. The mandibular arch
increased by 3.35, 3.05, and 3.65 mm, respectively, for
the same groups of teeth. During the evaluation at
6 years after treatment, a slight decrease in the transverse dimension was observed, and this tendency was

gradually maintained until the evaluation at 22 years after treatment, without returning to the initial width. The
maxillary width decreased by 0.42, 1.30, and 0.37 mm
after 6 years, respectively, for the intercanine, interpremolar, and intermolar widths; and by 0.97, 1.7, and
1.03 mm from 6 to 22 years after treatment, respectively.
The mandibular widths decreased by 0.0, 0.25, and
0.5 mm after 6 years, and by 0.0, 0.43, and 1.49 mm
after 22 years, respectively.
The cephalometric superimpositions showed no
change in the vertical dimension, and overjet was corrected because of maxillary retrusion concomitant to
mandibular protrusion (Fig 13). Overbite was basically
corrected by mandibular incisor protrusion. The longterm outcome showed a slight movement of these teeth
in the direction of the pretreatment position (Table). Our
case report showed increases in the transverse dimensions that remained clinically stable for 22 years after

American Journal of Orthodontics and Dentofacial Orthopedics

September 2016  Vol 150  Issue 3

Valladares-Neto et al

530

Fig 13. Cephalometric superimpositions: A, effect of treatment (pretreatment, black lines; nal treatment, red lines); B, effect of long-term outcomes (nal treatment, red lines; 22 years posttreatment,
green lines). Total (on the sella-nasion plane at sella), maxillary (on the palatal anterior curve), and
mandibular (on the mandibular plane at internal cortical symphysis) superimpositions.

Fig 14. Maxillary and mandibular arch widths at the canines (A), rst premolars (B), and rst molars
(C) during the 4 stages: pretreament (T1), immediately after treatment (T2), 6 years (T3), and 22 years
(T4) posttreatment.

treatment. However, as shown in Figure 14, a reduction

in the transverse width was detected in the long term,
without resulting in clinical disarrangement.
DISCUSSION

Although this case report is not unusual and

represents a perplexing clinical situation, it presents a
serious issue. It deals with the outcome of the treatment
of an adult, who simultaneously had maxillary and
mandibular nonsurgical expansions followed by a xed
edgewise appliance and who was followed for 22 years
posttreatment. This issue makes this report unique and
interesting.
A posterior crossbite is not an essential clinical
condition for undertaking maxillary expansion. In the

September 2016  Vol 150  Issue 3

case of simultaneous arch constrictions, a maxillary

and mandibular expansion phase is recommended to
improve the transverse dental arch dimensions before
or during xed appliance treatment.8 The nonextraction
treatment of a crowded and constricted dental arch
requires an increase in arch perimeter to allow for arch
alignment and leveling. Ricketts et al13 proposed that
1 mm of incisor advancement produces 2 mm of arch
length, and 1 mm of canine expansion produces 1 mm
of arch length, whereas 1 mm of molar expansion results
in an increase of 0.25 mm in arch length.
Our case report showed that maxillary and
mandibular arch expansion followed by a xed
orthodontic appliance led to increases in arch widths
from 3 to 4 mm in an adult patient. McNamara et al8
found similar results for maxillary arch expansion in

American Journal of Orthodontics and Dentofacial Orthopedics

Valladares-Neto et al

children, whereas Handelman et al11 found the

amounts to be 4.5 to 5.5 mm for adults. In the mandibular arch, the sample of McNamara et al increased by
only 1 to 2 mm. This comparison must take the
difference in methodologic measurement into account,
since we measured from the tip of the canines, whereas
McNamara et al used lingual landmarks. This gain was
sufcient to increase the arch perimeter, correct the
enlarged overjet, and solve the mandibular crowding
problem in our patient.
Adult nonsurgical expansion has always been
contentious, and several adverse side effects have been
reported. Our patient reported the suspicion of a
painless buccal alveolar fracture in the left rst premolar
at the end of screw activation, but no gingival recession
developed afterward. Unfortunately, few well-designed,
long-term studies have addressed stability with adult
nonsurgical expansion. Handelman et al11 found a
signicant reduction (0.5-0.6 mm) in maxillary posterior
arch width 5 years after retention. In our patient's
follow-up register of 6 years after treatment, the
reduction in maxillary width ranged from 0.25 to
1.3 mm.
We observed a clinically favorable occlusion and
esthetic gain in our patient even at 22 years after treatment. However, as previously mentioned, the transverse
dimension was not mathematically stable, except in the
mandibular intercanine width that was permanently
retained. Permanent mandibular retention was opted
for because of the strong tendency toward arch width
relapse described in the literature.12,14 In addition,
mandibular crowding was the patient's main complaint
before treatment. But in general, the dental arch width
gradually decreased, between 14% and 40%, after
22 years of follow-up. These changes were due to the
superposition of the orthodontic relapse and the natural
arch constriction as a result of aging. The orthodontic
relapse probably superposed to the aging effect up to
T3; from then on, the changes were attributed to the
effect of aging alone (Fig 14). In general, natural
changes in dental arch dimensions have been reported
to be small (\1.0 mm) from the third to the fth
decades of life, with no difference between the sexes
or patients with a high vs a low mandibular plane
angle.3,15,16
Our patient showed an improvement in the gingival
leveling of the mandibular incisors because of
orthodontic alignment and protrusion, and no gingival
recession was detected in the long term. In the literature,
gingival recession associated with orthodontic treatment
is a controversial issue. Recently, Renkema et al17 found
no association between proclined teeth and gingival
recession after a 5-year follow-up. Gingival recession

531

could also be inuenced by gingival phenotype. The authors of a study found that where there is thickness of
more than 0.5 mm in the attached gingiva, the risk of
gingival recession is reduced.18
Overall, simultaneous maxillary and mandibular arch
expansion using a nonsurgical approach is a viable
procedure for young adults; in selected cases, it can offer
a clinically favorable result in the long term. First,
preference should be given to SRME because of
problems arising from rapid maxillary expansion in
adults. The rapid rate of expansion can cause pain and
discomfort.19 Second, a clear atresia of the mandibular
arch should be a morphologic condition that needs
expansion. In addition, the muscular balance should
also contribute to better stability. Our case report
showed a mathematical reduction in the transverse
dimension in a patient from 23 to 45 years of age,
with no clinical signicance, except at the mandibular
intercanine distance, which maintained its stability. No
periodontal disease occurred in this patient with good
oral hygiene.
CONCLUSIONS

1.

2.

Maxillary and mandibular dental arch expansion

followed by the use of a xed orthodontic appliance
increased the arch widths by 3 to 4 mm and
resulted in a clinically favorable occlusion in the
long term.
However, the transverse dimension gradually
reduced throughout the maximum follow-up period
of 22 years, except in the mandibular intercanine
width, which remained stable because of the
permanent retention. The later changes were
considered the superposition of the orthodontic
relapse, and the natural arch constriction was due
to aging.

REFERENCES
1. Sinclair PM, Little RM. Maturation of untreated normal occlusions.
Am J Orthod 1983;83:114-23.
2. Tibana RH, Palagi LM, Miguel JA. Changes in dental arch measurements of young adults with normal occlusiona longitudinal
study. Angle Orthod 2004;74:618-23.
3. Carter GA, McNamara JA Jr. Longitudinal dental arch changes in
adults. Am J Orthod Dentofacial Orthop 1998;114:88-99.
4. Thilander B. Orthodontic relapse versus natural development. Am J
Orthod Dentofacial Orthop 2000;117:562-3.
5. Ferris T, Alexander RG, Boley J, Buschang PH. Long-term stability
of combined rapid palatal expansion-lip bumper therapy followed
by full xed appliances. Am J Orthod Dentofacial Orthop 2005;
128:310-25.
6. Vargo J, Buschang PH, Boley JC, English JD, Behrents RG,
Owen AH 3rd. Treatment effects and short-term relapse of

American Journal of Orthodontics and Dentofacial Orthopedics

September 2016  Vol 150  Issue 3

Valladares-Neto et al

532

7.

8.

9.

10.
11.

12.

maxillomandibular expansion during the early to mid mixed

dentition. Am J Orthod Dentofacial Orthop 2007;131:456-63.
Gurel HG, Memili B, Erkan M, Sukurica Y. Long-term effects of
rapid maxillary expansion followed by xed appliances. Angle
Orthod 2010;80:5-9.
McNamara JA Jr, Baccetti T, Franchi L, Herberger TA. Rapid maxillary
expansion followed by xed appliances: a long-term evaluation of
changes in arch dimensions. Angle Orthod 2003;73:344-53.
O'Grady PW, McNamara JA Jr, Baccetti T, Franchi L. A long-term
evaluation of the mandibular Schwarz appliance and the acrylic
splint expander in early mixed dentition patients. Am J Orthod
Dentofacial Orthop 2006;130:202-13.
Melsen B. Palatal growth studied on human autopsy material. A
histologic microradiographic study. Am J Orthod 1975;68:42-54.
Handelman CS, Wang L, BeGole EA, Haas AJ. Nonsurgical rapid
maxillary expansion in adults: report on 47 cases using the Haas
expander. Angle Orthod 2000;70:129-44.
Burke SP, Silveira AM, Goldsmith LJ, Yancey JM, Van
Stewart A, Scarfe WC. A meta-analysis of mandibular intercanine width in treatment and postretention. Angle Orthod
1998;68:53-60.

September 2016  Vol 150  Issue 3

13. Ricketts RM, Roth RH, Chaconas SJ, Schulhof RJ, Engel GA.
Orthodontic diagnosis and planning. Denver, Colo: Rocky
Mountain Orthodontics; 1982.
14. Kahl-Nieke B, Fischbach H, Schwarze CW. Treatment and
postretention changes in dental arch width dimensionsa
long-term evaluation of inuencing cofactors. Am J Orthod
Dentofacial Orthop 1996;109:368-78.
15. Bondevik O. Changes in occlusion between 23 and 34 years. Angle
Orthod 1998;68:75-80.
16. Bondevik O, Espeland L, Stenvik A. Dental arch changes from 22
to 43 years of age: are they different in individuals with high versus
low mandibular plane angle? Eur J Orthod 2015;37:367-72.
17. Renkema AM, Navratilova Z, Mazurova K, Katsaros C, Fudalej PS.
Gingival labial recessions and the post-treatment proclination of
mandibular incisors. Eur J Orthod 2015;37:508-13.
18. Yared KF, Zenobio EG, Pacheco W. Periodontal status of
mandibular central incisors after orthodontic proclination in
adults. Am J Orthod Dentofacial Orthop 2006;130:e1-8.
19. Capelozza Filho L, Cardoso Neto J, da Silva Filho OG, Ursi WJ.
Non-surgically assisted rapid maxillary expansion in adults. Int J
Adult Orthod Orthognath Surg 1996;11:57-66.

American Journal of Orthodontics and Dentofacial Orthopedics