ARTICLE IN PRESS

Orthodontic and orthopedic expansion

of the transverse dimension: A four
decade perspective
James A McNamara Jr, Lorenzo Franchi, and Laurie McNamara McClatchey

This paper describes four decades of research carried out at the University of
Michigan that has investigated the clinical alteration of the transverse
dimension of the face, with specific attention given to orthodontic and ortho-
pedic treatment of patients in the early mixed dentition. The results of a
series of clinical studies beginning in the late 1970s are described that con-
sider the etiology of dental crowding as well as treatment effects produced
by expansion in the late mixed/early permanent dentition and the early
mixed dentition. A treatment protocol for early treatment is described that
includes the lower Schwarz appliance, a bonded acrylic splint expander and
the placement of anterior brackets. A series of retrospective and prospective
studies are presented, including a study investigating the spontaneous
improvement of Class II malocclusion following increases in the transverse
dimension. The effect of maintaining or increasing anterior arch length on
subsequent mandibular second molar eruption is evaluated. The ideal timing
for rapid maxillary expansion is before puberty. An individual assessment of
the midpalatal suture using cone-beam computed tomography (CBCT) images
can be useful when making a clinical decision between conventional and sur-
gically assisted RME, especially for adolescent and young adult patients.
(Semin Orthod 2019; &:1–13) © 2019 Elsevier Inc. All rights reserved.

he focus of this paper is the alteration of the
T transverse dimension in patients treated at
various stages of dental development, with
emphasis on intervention in the early mixed den-
tition. Expansion treatment can be undertaken
for a variety of reasons, including correcting pos-
terior and/or anterior crossbite and increasing
available arch space to avoid extraction.1 Other
major goals for using this approach include cor-
recting Class III malocclusions with a facial mask
Department of Orthodontics and Pediatric Dentistry, School of
Dentistry, Department of Cell and Developmental Biology, School of
Medicine and Center for Human Growth and Development, The Uni-
versity of Michigan, Ann Arbor, MI, USA; Department of Experimen-
tal and Clinical Medicine, Section of Dentistry (Orthodontics), The
University of Florence, Florence, Italy; Department of Orthodontics
and Pediatric Dentistry, School of Dentistry, The University of Michi-
gan, Ann Arbor, MI, USA; Department of Orthodontics, The Univer-
sity of Michigan, Private practice of orthodontics, Ann Arbor, MI,
USA.
Corresponding author. E-mail: mcnamara@umich.edu
© 2019 Elsevier Inc. All rights reserved.
1073-8746/12/1801-$30.00/0
https://doi.org/10.1053/j.sodo.2019.02.002
combined with a bonded expander,2 facilitating
the eruption of impacted canines or incisors,3,4
encouraging spontaneous sagittal improvement
of Class II malocclusion,5 “broadening the
smile,”6 and enlarging the nasal airway.7
A major reason why expansion protocols initially
were of interest clinically was in the correction of
unilateral or bilateral posterior crossbite by divid-
ing the two parts of the maxilla orthopedically.8 A
less obvious but far more frequently observed
orthodontic problem related in part to the trans-
verse dimension is the discrepancy between tooth
size and the sizes of their bony bases. The most fre-
quently observed type of malocclusion in routine
orthodontic practice is dental crowding, an under-
lying imbalance between aggregate tooth size and
available bony arch perimeter. This relationship
occasionally may be expressed not as crowding but
as protrusion and flaring of the teeth relative to
their associated basal bone, particularly in the max-
illary incisor region.
Preparing such a paper for publication in a
themed issue of Seminars in Orthodontics has

Seminars in Orthodontics, Vol &, No &, 2019: pp 1
13 1

 ARTICLE IN PRESS
2 McNamara et al
allowed us to write an overview of our research
dealing with expansion that has been conducted
over the last four decades. Our research projects
have been undertaken in association with many
investigators, including colleagues at the Univer-
sity of Florence in Italy and Guarulhos University
in Guarulhos, Brazil, as well as with many former
orthodontic residents at the University of Michi-
gan who typically are listed as the lead author on
the projects that they conducted.
The ideas emerging from our initial clinical
experiences in a private practice setting have led
us to ask series of questions that range from the
etiology of dental crowding to the treatment
effects produced following expansion in the
mixed dentition by way of a bonded acrylic splint
expander, with or without prior orthodontic
expansion with a removable lower Schwarz appli-
ance. Further investigations led to the examina-
tion of spontaneous improvement of Class II
malocclusion during the post-expansion period
when the patient was wearing a removable palatal
plate to stabilize the treatment results achieved.
We also investigated whether the eruption of the
second molar is affected using a lower lingual
arch, a lower Schwarz appliance, or both during
the transition to the permanent dentition.
Overall, we estimate that at least 2500 patients
have been treated in our Ann Arbor practice
using our mixed dentition protocol that involves
a lower Schwarz expander (40% of patients), a
bonded acrylic splint expander (100% of
patients) and “temporary braces” on the maxil-
lary incisors (65% of patients); these are real
numbers based on a census of our patient popu-
lation. We have collected records prospectively
on all early-expansion patients treated in the
Ann Arbor practice beginning in 1982. Thus, our
comments in this paper are based both on our
clinical studies and our hands-on experiences.
Passive expansion with vestibular shields
Our first exposure to expansion during orthodon-
tic treatment other than that produced by fixed
appliances was the passive expansion of the dental
arches that occurs with Function Regulator (FR)
therapy developed by Rolf Fr€ankel.9 The unique
vestibular shields of the FR appliance are con-
structed so that the shields are fabricated 3 mm
away from the maxillary mucosa, allowing passive
expansion of the dental arches as well as
uprighting of the lower posterior teeth. The
forces produced by the adjacent soft tissues are
kept away from the developing dentition, allowing
for the passive widening and uprighting of these
teeth, especially in the maxilla.
The clinical results of FR treatment were
observed first hand by the lead author in 1975
and again in 1979 when he visited Fr€ankel’s
clinic in what was then the German Democratic
Republic (East Germany). Observing an esti-
mated 75 patients over the two visits and measur-
ing available serial dental casts indicated that
stable expansion of the dental arches was possi-
ble over the long-term.10 Subsequently, after con-
ducting two clinical studies of our own FR
patients,11,12 and with the simultaneous introduc-
tion of rapid maxillary expansion as a routine
clinical procedure,8,13 we began to explore the
possibility of orthodontic and orthopedic expan-
sion in growing individuals, focusing on the
short-term and long-term stability of expanded
dental arches.
Etiology of dental crowding
Before initiating a discussion of the treatment
effects produced by expansion treatment, we
asked a fundamental question as to the etiology of
the underlying tooth-size/arch-size relationship.
Is crowding caused by teeth that are too big,
arches that are too small, or some combination of
the two? One would assume that the last answer is
correct, but surprisingly in most instances it is not.
In one of the first clinical investigations by our
research group, Howe and co-workers14 com-
pared pretreatment dental casts of 50 patients
with erupted permanent second molars and
severe crowding to the dental casts of 54
untreated individuals from the University of Michi-
gan Growth Study15 who were classified as having
ideal or near-ideal occlusions. The study evalu-
ated both the sizes of the teeth and the dimen-
sions of the bony bases.
Tooth size
In the first part of our study, individual tooth
sizes were considered; the results were surprising.
In no instance was there a statistically significant
difference between the size of any given tooth
when the crowded and uncrowded dental arches
were compared. The mesiodistal sums of the
 ARTICLE IN PRESS
Long-term Transverse Adaptations
teeth in both arches then were determined, as
measured around the dental arches from the dis-
tal of the first molar to its antimere. Even though
there was a slight tendency (»1 mm) toward
larger teeth in the crowded cases, there was no
statistical difference in aggregate tooth size in
either arch between the two samples.14 Thus,
increased tooth size typically was not the cause of
the crowding, although there were some individ-
uals with larger than normal tooth size in the
crowded group.
A relatively simple clinical guideline that we
developed subsequently is based on the measure-
ment of one permanent maxillary central incisor.
If the upper central is wider than 10 .0mm, then
the teeth of the patient may be considered larger
than normal. The average mesiodistal diameter
of the maxillary central incisors in Caucasian
males and females is 8.9 § 0.6 mm and
8.7 § 0.6 mm, respectively.15 A central incisor
width greater than 10 mm is two standard devia-
tions larger than the norm; the possibility of
tooth extraction should be considered in these
patients.
Size of the bony bases
Significant differences were observed between
the arch dimension of the crowded and
uncrowded subjects. The crowded group had
smaller dental arch dimension, especially in
transpalatal widths and arch perimeter. For
example, transpalatal width measured between
the maxillary first molars was 37.4 mm in males
and 36.2 mm in females in the uncrowded sam-
ple.14 In contrast, the same measurement in the
crowded group was 31.3 mm in males and
30.8 mm in females. Thus, the differences
between the two groups was on average 5
6 mm
in the transverse dimension, indicating that
decreased transpalatal width was a characteristic
of dental crowding.
Significant differences were found in arch
perimeter measurements as well. In the non-
crowded group, the average mandibular arch
perimeter was 88.1 mm in males and 84.6 mm in
females.14 In contrast, in the crowded group, the
same measurement in males was 83.7 mm in
males and 79.6 mm in females, indication not
only the presence of sexual dimorphism but also
that there was at least 4.5 mm less arch perimeter
3
available in the crowded individuals in compari-
son to the normal occlusion group.
The conclusion that can be drawn from the
findings of this 1983 study14 is that a decreased
size of the bony bases, rather than large aggre-
gate tooth size is the primary factor in dental
crowding. Therefore, expansion of the dental
arches, particularly in the early mixed dentition,
may be indicated in individuals with tooth-size/
arch size discrepancies.
Expansion in the late mixed/early
permanent dentition
Before beginning a discussion of treatment
effects produced by expansion in the early mixed
dentition, it is appropriate to present data from a
study published by our group in 2003 that
involved patients treated with a Haas-type
expander followed by comprehensive edgewise
orthodontics in patients in the late mixed or
early permanent dentition.16 This unique treated
group consisted of 112 subjects, all of whom were
from the private practice of Drs. Robert and
Thomas Herberger of Elyria, Ohio, and who
were treated according to the RME protocol
developed by Dr. Andrew Haas.8 These records
were compared to those of 41 untreated subjects
from the University of Michigan Growth Study and
the University of Groningen Growth Study.
Dental changes
Serial dental casts were available at three differ-
ent intervals: pre-treatment (T1), after expansion
and fixed appliance therapy (T2), and at long-
term observation (T3). The mean duration of
the T1
T2 and T2
T3 periods for the treatment
group was 3 years 2 months, and 6 years 1 month,
respectively, with the last observation interval at
20 years of age.
Treatment by means of a Haas-type expander
followed by fixed appliances produced signifi-
cantly favorable long-term changes in almost all
the maxillary and mandibular arch measure-
ments. In comparison to controls, a net gain of
6.0 mm was achieved in the maxillary arch perim-
eter, whereas a net gain of 4.5 mm was found for
the mandibular arch perimeter of treated sub-
jects in the long term (about 20 years of age).
The net gain was determined by taking the
increase in each arch dimension of the RME
 ARTICLE IN PRESS
4 McNamara et al
group and subtracting the gain or loss of the
untreated group.16 Thus, at least in the samples
studied, clinically meaningful increases in arch
width and perimeter were observed in the
treated group in comparison to what occurred in
the untreated sample.
Skeletal changes
A companion lateral cephalometric study of the
long-term cephalometric effects of a subgroup of
patients treated with the same protocol17 revealed
that RME therapy used in the treatment of Class I
and Class II patients does not have a significant
long-term effect on either the vertical or the ante-
roposterior skeletal dimensions of the face when
compared to a matched group of patients treated
with fixed appliances alone or to untreated con-
trols. For example, there was no opening of the
mandibular plane angle and no forward or back-
ward movement of Point A over the long term.
Further, a related posteroanterior cephalometric
study on the same patient sample18 demonstrated
the long-term stability of the skeletal correction in
the transverse dimension, when the expanded
patients were »20 years of age.
A much larger cephalometric study on a
larger Herberger sample by Lineberger et al.19
was performed to evaluate the skeletal and den-
tal changes in the short and long-term in hyper-
divergent patients treated with rapid maxillary
expansion (RME) and fixed appliances. The
sample consisted of 143 patients who underwent
RME with a Haas-type expander followed by
edgewise therapy. Two groups were established:
a normal vertical dimension group (mandibular
plane angle [MPA] greater than 20° and smaller
than 27°; N = 52) and a hyperdivergent group
(MPA equal to or greater than 27°, N = 91). Lat-
eral cephalograms were taken before treatment
(T1, average age 11.5 years in both groups) and
after fixed appliance therapy (T2, average age
14.3 years for the two groups).
No significant differences in treatment effects
(T2
T1) were found in any of the sagittal or ver-
tical dentoskeletal variables examined. The long-
term evaluation of the patients at five or more
years post-treatment (T3
T2) showed no signifi-
cant skeletal changes. The results of this retro-
spective study indicate that rapid maxillary
expansion can be carried out successfully in
patients with increased vertical dimension
without detrimental effects on the vertical skele-
tal relationships. Thus, an increased mandibular
plane angle is not a contraindication to RME
therapy.
Expansion in the early mixed dentition
Early treatment protocol
Since 1982, we have used the following protocol
in the management of early mixed dentition
patients with crossbites and tooth-size/arch-size
discrepancies. The essential appliance is the
bonded acrylic splint expander2 (Fig. 1) that is
made from 3 mm Splint BiocrylTM , softened and
pressed on a stainless-steel wire framework using
a thermal-forming machine (BiostarTM ; Great
Lakes Orthodontic Products, Tonawanda NY).
Substituting cold-cure acrylic for Splint BiocrylTM
is not recommended because the former type of
acrylic is too rigid, making bonded expander
removal difficult.
Surprisingly, our protocol has not changed
much over the years, except for the addition of
the lower Schwarz appliance in 1986. We still use
ExcelTM adhesive (Reliance Orthodontic Prod-
ucts, Itasca, IL), a material specifically designed
to bond large acrylic appliances with adequate
working time. The bonded expander is activated
once-per-day for 28 days; then the number of
turns remaining is determined by the orthodon-
tist. After the completion of expansion, the appli-
ance is left in place for 5 additional months to
Figure 1. Bonded acrylic splint expander that is made
from 3 mm thick Splint Biocryl. Brackets also have been
placed on the maxillary incisors for alignment. Copy-
right Needham Press, used with permission.
 ARTICLE IN PRESS
Long-term Transverse Adaptations
Figure 2. Removable lower Schwarz appliance that is
activated once per week. Copyright Needham Press, used
with permission. A. Pre-expansion B. Post-expansion.
Figure 3. Acrylic maintenance plate with ball clasps,
oblique view. Copyright Needham Press, used with
permission.
5
Figure 4. Transpalatal arch made from 0.03600 stain-
less steel wire. Copyright Needham Press, used with
permission.
allow for reorganization of the maxillary sutures
to occur.
If an increase in lower anterior arch perimeter
or an uprighting of lingually inclined lower pos-
terior teeth is desired, a removable lower
Schwarz appliance (Fig. 2) can be used for man-
dibular “dental decompensation”.1 The appli-
ance is worn nearly full-time by the patient,
including during eating and sleeping as well as
during most other activities. The appliance is
activated once quarter turn per week for
5 months, and then the lower appliance serves as
a retainer during the subsequent RME phase.
The maxillary expander is removed after 6
7
months; usually the Schwarz appliance is discon-
tinued at that time as well. The expanded maxilla
is stabilized by having the patient wear a remov-
able maintenance plate (Fig. 3) on a full-time
basis for at least a year, after which it is worn on a
full-time or part-time basis or discontinued.
In about two-thirds of the patients, pread-
justed brackets (referred to as “temporary
braces” in contrast to the full fixed appliances
used in Phase II) also are placed on the upper
anterior teeth for about 6 months to achieve inci-
sor alignment (Fig. 1). The total treatment time
for RME plus anterior brackets is 9 months; if a
Schwarz appliance is added to the protocol, the
total active treatment time is extended to
14 months.
Before the loss of the maxillary deciduous
molars, a transpalatal arch (Fig. 4) is used to
rotate and deliver torque to the maxillary first
permanent molars as needed. Because of the
 ARTICLE IN PRESS
6 McNamara et al
Figure 5. Lower lingual arch made from 0.03600 stain-
less steel wire. Copyright Needham Press, used with
permission.
differences in the sizes of the second deciduous
molars and the second premolars, simply placing
a transpalatal arch to prevent the forward move-
ment of the permanent maxillary first molar can
save 2.0 mm of “leeway space” bilaterally.15 Simi-
larly, a lower lingual arch (Fig. 5) can be used to
prevent forward permanent molar movement in
the mandible, resulting in a net gain in arch
perimeter of 2.5 mm on each side.15 Phase II
consists of full preadjusted edgewise appliances
to optimize the occlusion, with an average treat-
ment time of about 18 months.
Studies on treatment effects
The first investigation using this unique early
expansion sample was published in the inaugu-
ral issue of the Seminars in Orthodontics in 1995
by Spillane and McNamara.20 This study pre-
sented the findings of 162 patients who under-
went RME during the early mixed dentition.
Arch dimensions were measured pre-expansion,
post-expansion and at yearly intervals until the
eruption of the first premolars. One significant
finding of this study was that 22% of the sample
has a unilateral crossbite and 4% had a bilateral
crossbite before treatment; nearly three quar-
ters (74%) of the sample had no crossbite prior
to treatment.
In this initial sample of patients, the typical
increase in transpalatal width was 5
6 mm. During
the post-expansion period, most of the arch width
increases were maintained. Over 90% of the
achieved increase in transpalatal width measured
between the upper first molars remained after the
first year, with slightly less (80%) of the overall
expansion maintained at the end of the observa-
tion period (2.4 years post-appliance removal).
Interestingly, maxillary arches that initially were
narrow maintained more expansion than maxillae
with initially wider arch dimensions. In addition,
maxillae with initially more lingually-inclined
molars tended to retain more expansion than
maxillae with more upright molars.
A second study by Brust and McNamara21 was
larger in scope. It involved a prospective study of
146 patients treated with the acrylic splint
expander and an additional 36 patients who also
wore a removable lower Schwarz expander for
5 months as an active orthodontic expander.
Then the Schwarz appliance was worn fulltime as
a passive retainer until the acrylic splint expander
was discontinued. Changes in the arch dimen-
sions of these patients were compared to those
changes occurring in a comparable control group
of 50 untreated subjects.
The Brust and McNamara study21 evaluated
arch dimensional changes pretreatment, imme-
diately following the removal of the expander,
after the eruption of the maxillary first premo-
lars, and at Phase II records obtained before
fixed appliance therapy. A significant amount of
stable expansion was achieved in the maxillary
arch, with at least 74% of the initial expansion
maintained at the time of Phase II records. Max-
illary arch perimeter increased by 3.1 mm in the
RME only group and 3.6 mm in the RME/
Schwarz group. The control group underwent a
change of 0.4 mm during the same interval.
Increases in mandibular arch perimeter were
more modest at the time of Phase II records.
The RME/Schwarz group had a 1.3 increase in
arch perimeter, whereas the control group had a
decrease of 1.8 mm; the net difference, there-
fore, was 3.1 mm between the two groups.
RME alone
We have completed two prospective clinical
investigations of the long-term effects of two
expansion protocol (without and with a lower
Schwarz appliance). The first study by Geran and
co-workers22 examined the treatment effects of
the acrylic splint RME appliance when used
alone in the early mixed dentition. The dental
casts of 51 consecutively treated expansion
 ARTICLE IN PRESS
Long-term Transverse Adaptations
patients were compared with those of 41
untreated controls at three different intervals:
pre-treatment (T1), after expansion and fixed
appliance therapy (T2), and at long-term obser-
vation (T3). The mean ages for treatment group
were 8 years 10 months at T1, 13 years 10 months
at T2, and 19 years 9 months at T3.
Treatment by means of an acrylic splint
expander followed by a second phase with full
fixed appliances produced significantly favorable
long-term changes in almost all the maxillary and
mandibular arch measurements.22 The amount
of change in both maxillary and mandibular inter-
molar and intercanine widths fully corrected the
initial discrepancies. Approximately 4 mm of
long-term relative increase in maxillary arch
perimeter, and 2.5 mm additional maintenance
of mandibular arch perimeter were observed in
patients when compared to untreated subjects
(Note: It should be remembered that these
patients were judged not to need active expansion
of the lower dental arch at the beginning of treat-
ment). These results suggest that this treatment
protocol is effective and stable for the manage-
ment of constricted maxillary arches, while it can
relieve modest deficiencies in arch perimeter.
Schwarz/RME combination
In about 40% of patients undergoing early ortho-
pedic expansion, we choose to expand the lower
arch orthodontically prior to RME because of
anterior crowding and/or lingually-inclined
lower posterior teeth (RME-Sz group). The lower
Schwarz appliance is activated once per week in
an effort to create a modest amount of arch
length anteriorly and upright the lower posterior
dentition prior to RME.1
O’Grady and co-workers23 considered two
groups of patients, one treated with RME alone
and one with the Schwarz/RME sequence. Both
groups were matched longitudinally to untreated
controls. The dental casts of 27 RME-only patients
were compared with those of 23 RME-Schwarz
patients and with those of 16 untreated controls
with constricted maxillary arches at four different
intervals: pre-treatment (T1), after expansion/
before fixed appliance therapy (T2), after fixed
appliance therapy (T3), and at long-term observa-
tion (T4). The mean ages for the treated groups
were approximately 9 years at T1, 12 years at T2,
14 years at T3, and 20 years of age at T4.
7
Treatment by way of an acrylic splint RME
alone and in combination with a lower Schwarz
appliance followed by fixed appliances produced
significant long-term increases in maxillary arch
widths over controls. The use of the lower
Schwarz expander prior to RME led to signifi-
cantly more favorable results when compared to
the RME-only protocol: Significantly greater
increase in the transverse width of the lower arch
and in mandibular arch perimeter occurred as
did an uprighting of the lower posterior teeth
buccally, thus allowing for an amount of maxil-
lary expansion that was effective clinically for cor-
recting tooth-size/arch-size discrepancies of a
moderate amount.
During the overall observation interval, the
significant increases in maxillary and mandibular
arch perimeters in the RME-Sz group were
respectively 3.8 mm and 3.7 mm when compared
with the matched control group.18 The RME-
only protocol produced modest long-term
increases in maxillary arch perimeter (2.6 mm);
the average long-term increase in mandibular
arch perimeter (2.0 mm) in the RME-only group
was not statistically significant.
Spontaneous improvement of Class II
relationships
The major focus of the discussion thus far has
been the resolution of tooth-size/arch-size dis-
crepancy problems. There is another phenome-
non, however, that has been a serendipitous
finding, that being the so-called “spontaneous
improvement” of Class II malocclusions in
patients with maxillary constriction, perhaps as a
manifestation of “maxillary deficiency syn-
drome.”24 A most interesting (and somewhat sur-
prising) observation following our initial efforts to
expand Class II patients in the early mixed denti-
tion was the occurrence of a spontaneous
improvement of the Class II malocclusion during
the retention period. Such patients either had an
end-to-end or full cusp Class II molar relationship
at the start of treatment. Generally, these patients
did not have severe skeletal imbalances, but typi-
cally were characterized clinically as having either
mild-to-moderate mandibular skeletal retrusion
or an orthognathic facial profile.
As per our protocol, these patients inten-
tionally were overexpanded slightly (with a ten-
dency toward a buccal crossbite) relative to the
 ARTICLE IN PRESS
8 McNamara et al
lower arch, with only the lingual cusps of the
upper posterior teeth contacting the buccal
cusps of the lower posterior teeth. Following
expander removal, a maxillary maintenance
plate (Fig. 5) was used for stabilization. Six to 12
months later, the tendency toward a buccal cross-
bite often disappeared, and some of the patients
now had a solid Class I occlusal relationship. It
should be noted that the shift in molar relation-
ship in these patients typically occurred before
the transition from the lower second deciduous
molars to the lower second premolars, the point
at which an improvement in Angle classification
sometimes occurs in untreated subjects due to
the forward movement of the permanent lower
first molars into the leeway space.
We addressed the concept of the spontaneous
improvement of Class II malocclusion by conduct-
ing two related investigations.5,25 From an initial
sample of 1137 consecutively-treated patients
from our private practice, McNamara and col-
leagues assembled the cephalometric records of
500 patients who had undergone acrylic splint
RME therapy during the early mixed dentition.25
Cephalometric films were available at the begin-
ning of treatment (T1) and at the beginning of
Phase II (T2). For comparison, we used records
from 188 untreated subjects from the Michigan,
Bolton-Brush, and Denver Child Growth Studies,
on whom longitudinal cephalometric films were
available at the same time points. This study
included both Class I and Class II patients. Due to
the length of the above article, results of this study
will be not discussed here.
From the above data base, we narrowed the
focus of a second study,5 which was a prospective
clinical investigation conducted by Guest and co-
workers that focused only on patients who had
Class II malocclusion. These patients were com-
pared to a matched untreated Class II control
group.
The treatment sample consisted of fifty
patients with Class II malocclusion (19 males, 31
females) treated with the rapid maxillary expan-
sion (RME) protocol described earlier. Some
patients had a removable lower Schwarz appli-
ance and/or maxillary incisor bracketing as
part of their treatment protocol. Post-expan-
sion, the patients were stabilized with a remov-
able maintenance plate and/or a transpalatal
arch. The mean age at the start of treatment of
the RME group was 8.8 years (T1), with a pre-
Phase II treatment cephalogram (T2) taken
3.7 years later. The control sample, derived
from the records of three longitudinal growth
studies mentioned earlier, consisted of the
cephalometric records of fifty Class II individu-
als (28 males; 22 females). The mean age of ini-
tial observation for the control group was
8.9 years, and the mean interval of observation
was 3.9 years. All subjects in both groups were
pre-pubertal at T1 and showed comparable prev-
alence rates for pre-pubertal or post-pubertal
stages at T2.
The treatment group demonstrated slight but
statistically significant increases in mandibular
length and a slight advancement of pogonion rel-
ative to the nasion perpendicular. The acrylic
splint RME had significant effects on the antero-
posterior relationship of the maxilla and mandi-
ble, as shown by the improvements toward Class
I in the maxillomandibular differential value, the
Wits appraisal value, and the ANB angle.
Patients treated with the bonded RME showed
the greatest effects of therapy at the occlusal level,
demonstrating highly significant improvement of
Class II molar relationship and a decrease in over-
jet (Fig. 6). The change in sagittal molar relation-
ship between Time 1 (initial) and Time 2 (pre-
Phase II) as observed cephalometrically was com-
pared to the same measurement in the untreated
Class II sample. During the 4-year treatment/
observation interval, the average change in the
untreated group was 0.0 § 0.8 mm. In contrast,
the average movement toward Class I was
1.8 § 1.0 mm in the expander group.
Looking at the comparison between the two
groups in more detail (Fig. 6), 18% of the con-
trols had a negative change toward Class II, while
none of the Class II treated worsened (¡1 mm or
more negative). The molar relationship of 62%
of the control sample did not change, while only
8% of the treated sample remained unchanged.
Molar relationship improved slightly (maximum
1.5 mm) in 20% of the controls, whereas the
molar relationship improved in 92% of the
treated Class II sample. Further, a change in
molar relationship toward Class I of 2 mm or
greater was not observed in the controls, while
48% of the treated group had at least 2 mm
(maximum 4 mm). Treatment with the acrylic
splint RME had no sustainable effects on the skel-
etal vertical dimension, maxillary skeletal posi-
tion, or maxillary dentoalveolar dimensions.
 ARTICLE IN PRESS
Long-term Transverse Adaptations
Figure 6. Change in molar relationship from T1 to T2,
an interval of 4 years. In the untreated Class II group,
the molar relationship on average did not change. In
the expansion group, however, the molar relationship
improved in 92% of the sample, with 48% improving
2 mm or more. Adapted from Guest et al., 2010.5
The results of this study suggest that the pro-
tocol described, including treatment with a
bonded rapid maxillary expander used in the
early mixed dentition in Class II, division
1 patients can help to improve the Class II mal-
occlusion as a side-effect, both skeletally and
dentally. Evidence for this phenomenon was
based previously on anecdotal data; the results
of this study show that the improvements in
Class II patients are far more pervasive than
anticipated.
Impaction of second molars
Thus far we have been considering ways of gain-
ing arch perimeter anteriorly, particularly with
the lower Schwarz expander. In effort to treat
patients without the removal of permanent teeth,
the Schwarz appliance often is followed by a
lower lingual arch (LLA) to preserve the
“E-space.” The LLA prevents the mesial migra-
tion of the mandibular first molars that naturally
occurs because of the size difference between
the mandibular deciduous second molars and
the second premolars. The benefit of this style of
lingual arch is that the appliance preserves the
leeway space and ultimately allows this arch space
to be used to resolve anterior crowding, on aver-
age about 2.5 mm per side. The question then
arises, “Does the use of these appliances have the
9
unwanted side effect of increasing the probabil-
ity of impacting the lower second molars?”
Rubin and co-workers26 conducted a longitu-
dinal study that compared the prevalence of
mandibular second molar eruption difficulties in
patients treated with appliances used to maintain
mandibular arch perimeter. Three hundred and
one patients/subjects were divided into four
groups: patients treated with a Schwarz appli-
ance, patients treated with a lower lingual arch,
patients treated with a combination of both
appliances, and subjects who received no treat-
ment.
All patients also had a bonded expander as
part of their treatment protocol. Panoramic
radiographs were analyzed at two intervals—
prior to any treatment (T1) and after treatment
(T2). The T1 radiograph was evaluated for the
angulation of the lower second molars as well as
the space available for these unerupted teeth.
The T2 radiograph was used to determine the
incidence of lower second molar eruption diffi-
culty.
The results of this study indicated that all
three treatment groups (Schwarz, LLA, and
Schwarz/LLA) demonstrated a higher incidence
of lower second molar eruption difficulty when
compared to untreated controls, with the
increased prevalence being significant for the
protocols incorporating the Schwarz appliance.26
Initial molar angulation, space width ratio, age
and gender of the patient were not significant
predictors of disturbance in the eruption pattern
of the lower second molars. Thus, orthodontic
appliances aimed to maintain lower arch perime-
ter in the mixed dentition increase the probabil-
ity of eruption disturbances of the lower second
molars. Clinicians should monitor these patients
carefully to prevent impaction of the second
molars and to refer patients with second molar
eruption problems for surgical exposure and lux-
ation when appropriate.
Treatment timing for RME
The Herberger sample discussed previously also
was used to assess ideal treatment timing for
orthopedic maxillary expansion.27 This study by
Baccetti and coworkers evaluated treatment out-
comes before and after the peak in skeletal matu-
ration, based on the cervical vertebral maturation
(CVM) method,28 in a sample of 42 patients
 ARTICLE IN PRESS
10 McNamara et al
compared to a control sample of 20 untreated
subjects from the University of Michigan Growth
Study.29 Posteroanterior cephalograms were avail-
able for both treated patients and control subjects
before treatment and at a long-term observation.
Treated and control samples were divided into 2
groups according to individual skeletal matura-
tion.
The early-treated and early-control groups
had not reached the pubertal peak at T1 (cervi-
cal stage, CS 1 to 3), whereas the late-treated and
late-control groups were during or slightly after
the peak at T1 (CS 4 to 6).27 In the long-term,
maxillary skeletal width, maxillary intermolar
width, lateral nasal width, and lateral orbital
width were significantly greater in the early-
treated group. The late-treated group exhibited
significant increases in lateral nasal width and in
maxillary and mandibular intermolar widths.
Patients treated before puberty exhibit signifi-
cant and more effective long-term changes at the
skeletal level in both maxillary and circummaxil-
lary structures. When RME treatment is per-
formed after the pubertal growth spurt,
maxillary adaptations to expansion therapy shift
from the skeletal level to the dentoalveolar level.
In 2013, Angelieri et al.30 proposed a novel
classification method for the individual assess-
ment of midpalatal suture morphology (Fig. 7)
using cone-beam computed tomography
(CBCT) images that can be helpful when making
a clinical decision between conventional and sur-
gically assisted RME especially for adolescent
and young adult patients. CBCT images from
140 subjects (ages ranged from 6 to 58 years)
were examined to define the radiographic stages
of midpalatal suture maturation.
Five stages of maturation of the midpalatal
suture were identified and defined (Fig 7): stage
A, straight high-density sutural line, with no or lit-
tle interdigitation; stage B, scalloped appearance
of the high-density sutural line; stage C, 2 paral-
lel, scalloped, high-density lines that were close
to each other, separated in some areas by small
low-density spaces; stage D, fusion completed in
the palatine bone, with no evidence of a suture,
while in the maxillary portion of the suture still
can be visualized as 2 high-density lines separated
by small low-density spaces; and stage E, fusion in
the maxilla.
Based on our proposed staging methodology,
we speculated that at stages A and B, a
conventional RME approach would have less
resistant forces and probably more skeletal
effects than at stage C when there are many ini-
tial ossification areas along the midpalatal suture.
Patients in stages D and E might be better treated
by surgically assisted RME because fusion of the
midpalatal suture already has occurred partially
or totally, hampering the RME forces from open-
ing the suture. Interestingly, adults (older than
18 years) showed great variability in sutural matu-
ration. We found that 53% of the adults were in
stage E, 31% were in stage D, 13% were in stage
C, and 1 subject (3%) was in stage B. Therefore,
16% of the adult subjects showing more imma-
ture stages, potentially could be treated with con-
ventional RME procedures.
In another study31 that correlated the stages
of maturation of the midpalatal suture with the
CVM method, we found that the most immature
stages A and B are typical of the prepubertal
phases of development (CS 1 and CS 2 in CVM)
while stage C occurs at the pubertal peak (CS 3
in CVM). The stages D and E describing partial
or total fusion of the midpalatal suture, respec-
tively, are associated with a post-pubertal stage of
development (CS 5). However, for postpubertal
patients (CS4 and CS5), an individual assessment
of the midpalatal suture with CBCT can be indi-
cated, since 14% of patients at CS5 show a stage
C in midpalatal suture maturation and, presum-
ably, could be treated with conventional RME.
Non-extraction vs extraction decision
Rapid maxillary expansion been shown to be a
predictable way of widening the transverse
dimension in patients in the early mixed, later
mixed and early permanent dentition. It is
much more than an appliance used in the cor-
rection of unilateral and bilateral posterior
crossbites. Our long-term research indicates
that patients with mild to moderate crowding
can be managed effectively with RME, especially
in those patients whose lower posterior teeth
initially are tipped lingually. In such patients,
the removable lower Schwarz appliance is effec-
tive in uprighting lingually tipped posterior
teeth as well as creating a modest amount of the
arch length anteriorly. More severe crowding,
however, must be managed through the
removal of permanent teeth.
 ARTICLE IN PRESS

Long-term Transverse Adaptations 11

Figure 7. Stages of maturation of the midpalatal suture as observed with CBCT images. Stage A is seen in this
patient as a relatively straight high-density line at the midline. Stage B is observed as one scalloped, high density
line at the midline. Stage C is visualized as two parallel, scalloped, high density lines that are close to each other
and separated in some areas by small low-density spaces. Stage D is visualized as two scalloped, high-density lines at
the midline on the maxillary portion of the palate, while the midpalatal suture cannot be visualized in palatine
bone. At stage E, sutural fusion has occurred in the maxilla. From Angelieri et al., 2013.25

It should be noted that when the outcomes of
520 consecutively treated patients from our prac-
tice who underwent RME in the early mixed denti-
tion were analyzed, 52 patients ultimately
underwent the removal of permanent teeth, not
considering the third molars.32 The teeth removed
typically were maxillary first premolars or four pre-
molars, leading to a 10% extraction rate in this
prospective treatment sample. The need for extrac-
tion was based primarily on profile considerations
that were evident at the beginning of Phase II.
Final remarks
Expansion of the transverse dimension has many
indications. As this article has described previ-
ously, orthopedic expansion with RME is indi-
cated in patients with constricted maxillae, as
manifested by a narrow transpalatal width, as
measured from the closest point on the lingual
surface of the maxillary permanent first molar to
its antimere. Orthopedic expansion is beneficial
in eliminating posterior crossbites, anterior
crossbites (in conjunction with a facial mask)
and improving tooth size/arch size discrepan-
cies. When applied in the appropriate patient,
RME alone or in combination with a removable
lower Schwarz appliance has been shown to pro-
vide clinically significant increases in available
arch width in comparison to matched untreated
controls. Other benefits of orthopedic expansion
include improvement in smile esthetics, the crea-
tion of space to aid in the eruption of impacted
canines or incisors, and enlarging the nasal air-
way, subjects not covered in this discussion.
An additional treatment effect of early interven-
tion in the transverse dimension is that it may lead
to a spontaneous improvement in molar relation-
ship in some Class II patients during the transition
to the permanent dentition. The bonded RME had
its greatest effects at the occlusal level, specifically
producing highly significant improvement of Class
II molar relationship and a decrease in overjet. The
Class II molar relationship remained virtually
unchanged in the control group, while the RME
group showed an improved molar relationship of
 ARTICLE IN PRESS
12 McNamara et al
over 1 mm in 92% of the expansion patients, and
over 2 mm in almost 50% of them.
Yet even with well-timed early intervention,
individual responsiveness to treatment must be
expected, and in some cases, definitive sagittal
correction techniques (e.g., functional jaw ortho-
pedics) or an extraction protocol may by indi-
cated as a part of the second phase treatment.
Ideal timing for RME is during the prepuber-
tal phases of development. In the postpubertal
period, however, an assessment of the midpalatal
suture maturation using CBCT images may be
indicated in deciding between conventional
rapid maxillary expansion and surgically-assisted
rapid maxillary expansion.
Acknowledgments
We acknowledge the contributions of many peo-
ple in this overall research effort. First, we must
mention our good friend Tiziano Baccetti who
worked on numerous research projects from
1994 to 2011, when he died tragically from a fall.
His presence is everywhere; we miss him greatly.
We also must acknowledge the many Univer-
sity of Michigan orthodontic residents who
worked on projects related to the transverse
dimension as part of their Master’s thesis. These
include Larry Spillane, Eric Brust, Joyce Chang,
Chris Cameron, Susie Guest, Renee Geran, Paul
O’Grady, Matt Lineberger, Rebecca Lash Rubin,
and Lainie Shapiro as well as Paul McDougall
from the University of Detroit. Dental students
who were major contributors include Lauren
Sigler Busch, Heidi Novak, and Jared Little.
We thank Fernanda Angelieri from Guarulhos
University in Brazil and Lucia Cevidanes from
The University of Michigan. Both researchers
have helped expand our horizons into CBCT
imaging. Finally, we thank Bob and Tom Her-
berger, the father-and-son orthodontic team who
systematically gathered long-term records on
their expansion patients. Their contributions to
our work are obvious.
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