Dental and Skeletal Changes in the

Transverse Dimension
Leslie A. Will and Zane E Muhl
Many methods are available for achieving maxillary expansion. Dental
expansion can be accomplished using a variety of appliances depending on
the amount of expansion desired and the age of the patient. Significant
skeletal expansion may be achieved with a fixed jackscrew expander, though
the amount of skeletal expansion and the stability of such expansion is
variable. No skeletal expansion should be expected in a patient who has
reached skeletal maturity. (Semin Orthod 2000;6:50-57.) Copyright 2000 by
W.B. Saunders Company

wide variety of modalities for orthodontic

treatment in the transverse dimension have
b e e n r e p o r t e d in the literature. These appliances include banded, bonded, and removable
appliances, as well as appliances not typically
used for expansion, such as h e a d g e a r and functional appliances. Patients f r o m 4 years of age
into their fifth decade of life are r e p o r t e d as
being effectively treated. W h e n evaluating the
efficacy of a given appliance, it is useful to
consider the following aspects: How m u c h dental
expansion is achieved with this appliance? Is
skeletal expansion desired, and how m u c h skeletal expansion is achieved relative to dental
expansion? How stable are b o t h the dental and
skeletal expansion obtained? Does unwanted
dental tipping occur c o n c o m i t a n t with expansion? At what ages is the appliance effective?

Treatment Modalities
Many studies have b e e n carried out to evaluate
the p e r f o r m a n c e of appliances in e x p a n d i n g the
maxillary dental arch a n d / o r the maxilla. It is
often difficult to c o m p a r e appliances, because
c o m p a r a b l e m e a s u r e m e n t s often do not exist.

F~vm the Department of Growth and Development, Harvard

School of Dental Medicine, Boston, MA, and the Department of
Orthodontics, University of IUinois Collegeof Dentistr); Chicago, IL.
Address correspondence to Dr. Zane E Muhl, UIC College of
Dentistry, Department of Orthodontics MC 841, 801 S. Paulina
St.~vet, Chicago, IL 60612.
Copyright 2000 by W.B. Saunders Company
1073-8746/00/0601-0006510. 00/0

50

Most often m e a s u r e m e n t s were taken from dental casts, but in a few instances, frontal cephalometric radiographs were available. For the purposes of this review, those studies that include a
long-term follow-up are of particular interest,
because stability of the e x p a n d e d arch is a
p r i m a r y concern.

JackscrewAppliances
Two general types of jackscrew appliances are
most often used to expand the maxilla. In
patients in w h o m growth has not ceased, skeletal
expansion is achieved along with dental expansion. Tooth-borne, or Hyrax, appliances are fixed
to the teeth only, either by orthodontic bands, or,
in the studies reported, by b o n d a b l e acrylic pads
that cover the occlusal surfaces of the buccal
segments and extend over the buccal and lingual
surfaces of the teeth. Tissue-borne appliances,
particularly the Haas-type appliance, include an
acrylic button, m o l d e d to the palate, in which
the jackscrew is e m b e d d e d and to which the
bands are attached. P r o p o n e n t s of the tissueb o r n e appliance claim that greater skeletal expansion is achieved with the Haas-type appliance
than the tooth-borne expander, because force is
transmitted m o r e directly to the palatal shelves.
The fixed jackscrew appliance can produce a
significant m o l a r e x p a n s i o n , with r e p o r t e d
amounts ranging from a m e a n of 4.69 m m 1 to 7.9
m m . 9 Skeletal expansion ranged f r o m 46% 3 to
58% 4 of dental expansion, though m a n y studies
did not measure this, and these authors evaluated this on dental casts. Assessing skeletal expan-

Seminars in Orlhodonlics, Vol 6, No 1 (March), 2000: pp 50-57

MaxiUary Expansion

sion f r o m d e n t a l casts is p r o b l e m a t i c , b e c a u s e
even if t h e a p p r o p r i a t e l a n d m a r k s a r e r e g i s t e r e d
o n t h e casts, t h e overlying soft tissue o b s c u r e s t h e
u n d e r l y i n g b o n y s t r u c t u r e s , a n d is n e c e s s a r i l y
i n c l u d e d in t h e m e a s u r e m e n t . N o n e o f t h e
studies e m p l o y i n g a f i x e d j a c k s c r e w a p p l i a n c e
m e a s u r e d skeletal e x p a n s i o n d i r e c t l y f r o m f r o n tal r a d i o g r a p h s , even t h o u g h this a p p l i a n c e t h e o retically s h o u l d b e t h e m o s t effective f o r p r o d u c i n g skeletal as well as d e n t a l c h a n g e . A s u m m a r y
o f d e n t a l a n d skeletal e x p a n s i o n a n d r e l a p s e
r e p o r t e d f o r t h e two types o f f i x e d j a c k s c r e w
a p p l i a n c e s is s h o w n in T a b l e 1.
A significant side effect o f m a x i l l a r y o r t h o p e dic e x p a n s i o n has b e e n d o w n w a r d d i s p l a c e m e n t
o f t h e maxilla. This is c a u s e d by t i p p i n g o f t h e
p o s t e r i o r t e e t h as t h e two halves o f t h e m a x i l l a
s e p a r a t e . This bite o p e n i n g can b e f a v o r a b l e
w h e n t h e p a t i e n t has a Class II! skeletal p a t t e r n ,
b u t is m o r e f r e q u e n t l y u n d e s i r a b l e b e c a u s e Class
II p a t t e r n s p r e d o m i n a t e . It has b e e n h y p o t h esized t h a t b o n d e d j a c k s c r e w a p p l i a n c e s p r e v e n t
this b i t e o p e n i n g for two r e a s o n s . First, it is a
m o r e r i g i d a p p l i a n c e a n d is t h o u g h t to p r e v e n t
d e n t a l t i p p i n g . I n a d d i t i o n , its t h i c k n e s s i n t r u d e s
o n t h e freeway space, t u r n i n g t h e e x p a n d e r i n t o
a f u n c t i o n a l a p p l i a n c e . As t h e p a t i e n t bites o n
t h e occlusal acrylic, m u s c l e f o r c e s will p r e v e n t
the maxilla from being inferiorly displaced.
S a r v e r a n d J o h n s o n 17 e v a l u a t e d t h e skeletal
c h a n g e s t h a t o c c u r r e d in 20 a d o l e s c e n t s d u r i n g

51

r a p i d p a l a t a l e x p a n s i o n with a b o n d e d H y r a x
a p p l i a n c e . T h e y c o m p a r e d t h e s e c h a n g e s with
t h o s e r e p o r t e d by Wertz, 8 w h o u s e d s i m i l a r
m e a s u r e m e n t s to e v a l u a t e skeletal c h a n g e s with
a banded jackscrew appliance. Sarver and
J o h n s o n 17 f o u n d t h a t vertical d i s p l a c e m e n t o f
t h e m a x i l l a , as m e a s u r e d by t h e d i s t a n c e b e t w e e n
t h e SN p l a n e a n d PNS, was significantly less in
those patients who had the bonded appliance.
O t h e r i n d i c a t i o n s o f vertical c h a n g e , such as t h e
mandibular plane angle and the distance from
SN to ANS, w e r e n o t significantly d i f f e r e n t .
However, t h e y c o n c l u d e d t h a t t h e d o w n w a r d a n d
anterior displacement of the maxilla may be
m i n i m i z e d o r n e g a t e d with t h e use o f t h e b o n d e d
a p p l i a n c e . 17
A s a n z a et al 7 also c o m p a r e d t h e effect o f a
b o n d e d H y r a x a p p l i a n c e with t h a t o f a b a n d e d
Hyrax, s t u d y i n g 14 a d o l e s c e n t s . T h e y f o u n d t h a t
t h e b o n d e d g r o u p d i s p l a y e d less i n c r e a s e in t h e
total facial h e i g h t as m e a s u r e d b e t w e e n A N S a n d
m e n t o n , as well as less i n f e r i o r m a x i l l a r y displacem e n t at p o s t e r i o r nasal spine. It a p p e a r s t h a t t h e
b o n d e d a p p l i a n c e d o e s t e n d to m i n i m i z e infer i o r m o v e m e n t o f t h e maxilla, b u t results a r e n o t
u n i v e r s a l l y significant.
T h e r e d o n o t s e e m to b e a n y c o n s i s t e n t t r e n d s
in e i t h e r stability o r in t h e p r o p o r t i o n o f skeletal
e x p a n s i o n a m o n g t h e studies r e p o r t e d . This is
p r o b a b l y t h e r e s u l t o f a l a r g e n u m b e r o f variables
b e t w e e n t h e studies, such as r e t e n t i o n p r e -

Table 1. Expansion and Stability of FixedJackscrewAppliances

Expansion (ram)
Author
Tooth-borne appliances
Sandikqio~lu and Hazar5
Akkaya et al6
Asanza et al7
Berger et al I
Linder-Aaronsen and Lindgren~
Unspecified type of fixed appliances
Wertz8
Battagel and Ryan9
Tissue-borne appliances
Chang et al l
Ladner and Muhl 3
S/irnas et a111
Spillane and McNamara lz
Moussa et a113
Handelman TM
da Silva Filho et a115
Krebs 16
Abbreviation: NO, not observed.

Relapse (mm)

Sample Size

Dental

Skeletal

Dental

Skeletal

10
12
7
7
24
?

6.2
9.05
6.01 (banded)
5.94 (bonded)
4.7
7.9

2.7
NO
NO

0.8
0.22
NO

0.1
NO
NO

3.6
NO

0.3
4.34

0.69
NO

56
?

6.5
4.0

2.58
NO

1.88
1.0

0.56
NO

25
30
1
?
55
5
32
23

4.8
6.0
7.2
6.0
6.9
6.3
5.5
6.0

NO
3.0
2.1
NO
NO
NO
2.8
2.3

0.2
NO
6.0
1.2
1.2
0.64
NO
0

NO
NO
0.8
NO
NO
NO
NO
0.5

59

Will and M u h l

scribed and worn, expansion protocol, timing of

records relative to expansion, and length of
follow-up. Thus, it is impossible based on this
review to accurately compare tissue-borne and
tooth-borne appliances with regard to stability or
efficacy in p r o d u c i n g skeletal expansion. In general, skeletal expansion seems to be approximately 30% to 50% of the a m o u n t of dental
expansion, although the figure reported by
Berger et aP is significantly higher.
No study has reported on the a m o u n t of arch
length or perimeter gained in palatal expansion.
However, Nimkarn et al is compared several methods of evaluating the a m o u n t of arch width
n e e d e d to alleviate crowding in the maxillary
arch (Pont's index, Schwarz' analysis, and McNamara's molar width). They f o u n d that Schwarz'
analysis came closest to predicting the actual
a m o u n t of required arch expansion. Pont's index and McNamara's width overestimated the
a m o u n t of n e e d e d arch expansion 2.5 m m to 4.7
m m and 2.7 m m to 3.7 Inln, respectively. According to Nimkarn et al) s McNamara gives a single
value for the "ideal" molar width in males (37.4
mm) and females (36.2 mm), whereas the two
indices involve a calculation that requires measurement of the sum of the incisor widths.
Nimkarn et aP s also pointed out that it makes a
difference where the expansion takes place (molars v premolars) as to how m u c h expansion will
suffice, but they caution that in their study, a
large a m o u n t of variation in arch crowding was
not explained by arch width.

Removable Expanders
Several investigators used removable jackscrew
appliances to expand the maxilla, goysen 19placed
in 17 children, aged 6 years 4 months to 10 years
9 months (with a mean of 8 years 6 months), an
appliance with acrylic covering the posterior
maxillary occlusal surfaces to disarticulate the
occlusion. The screw was activated twice per
week for a total weekly expansion of 0.5 ram.
Basal expansion with this appliance was f o u n d to
be less than that resulting from the quad-helix.
Sandlk1o~lu and Hazar 5 included a treatment
group of 10 children with removable appliances
in their study reported above. The molar expansion with this appliance was 4.0 ram, and the
skeletal expansion was 1.5 mm. No relapse was

measured. Brin et al 2 f o u n d dental expansion of

3.3 m m and skeletal expansion of 6.0 mm, which
is very unusual. No amounts of relapse were
reported.

Nonscrew Expanders
A n o t h e r type of appliance widely used for maxillary expansion is the palatal arch (Table 2).
Made of .036- or .038-inch wire, it is attached to
the palatal aspect of the first molar bands, and is
activated by expansion before cementation. Lateral forces delivered by the wires against the
teeth serve to expand the dental arch. The
quad-helix incorporates four helices in the palatal arch, and is used primarily for y o u n g e r
children for dental expansion.
It is noteworthy that Boysen et a119 f o u n d
more basal expansion with the quad-helix than
with a removable jackscrew appliance. However,
it is not known how m u c h dental expansion was
attempted, because each type of appliance was
activated merely until the crossbite, and accompanying lateral shifts were corrected. It should also
be noted that Adkins et al z2 reported that buccal
teeth tipped an average of 7.3 as the mean
expansion of 6.5 m m was achieved.
Most of the patients who received treatment
with the quad-helix appliance were in the deciduous or mixed dentition, and none were older, on
average, than approximately 12 years. Although
several studies did report skeletal change, either
sutural opening or increased maxillary width on
posteroanterior (PA) radiographs, there was little
in the way of posttreatment follow-up, so it is not
possible to determine how m u c h of the skeletal
expansion p r o d u c e d by this appliance is maintained in the long term.
The transpalatal arch is also used for dental
expansion. Ingervall et a124used this appliance to

Table 2. Expansion and Stability of Palatal Arches

Sample Expansion (mm)
Size

Bell and Le
Compte2l
Adkins et a122

10
?

5.7
6.5

17

5.6

yes
30%-40%
yes
?
yes
(ratio)
?

10

5.3

1.9

1.1

0.4

11

yes

yes

Boysen et a119
Sandikcioglu
and Hazar5
Haberson and
Myers23:
W arch

Dental Skeletal

Relapse (mm)

Au~or

Dental

Skeletal

?
?
?

Maxillary Expansion

correct unilateral crossbites in 35 children from

6 years, 8 months to 15 years, 11 months. With 20
children, buccal root torque was added to the
molar not in crossbite, and both molars were
expanded equally. Crossbite correction occurred
in both groups a mean of 91 days after insertion
of the appliance. The group that had one molar
with buccal root torque demonstrated more
sutural opening, although both values were less
than 1 mm, and the torqued molar did not move
significantly.
Thus, it seems clear that although palatal
arches can open the maxillary suture, sutural
expansion is minimal, and palatal arches are best
used for dental expansion in children with primary or mixed dentition.

Slow Expansion
An alternative to traditional rapid palatal expansion, slow expansion uses lower, orthopedic forces
and takes months instead of weeks to accomplish
the same a m o u n t of expansion. Its p r o p o n e n t s
consider that with lower forces, there is less
sutural trauma and less dental tipping. A Minne
expander ( O r m c o Corporation, Glendora, CA)
is usually used for slow expansion, although a
traditional jackscrew appliance can also be used
and turned less frequently. The Minne expander
consists of a spring-loaded jackscrew attached to
four orthodontic bands. The jackscrew is turned
to compress the spring, which slowly expands
while delivering continuous force. Lower force
levels are possible because the jackscrew can be
activated in small increments.
Hicks 25 evaluated the stability of slow expansion in 5 subjects, aged 10 to 15 years. Dental
expansion ranged from 3.8 to 8.7 mm, with
skeletal expansion comprising 24% to 30% of
the dental expansion in the 10- to 11-years olds,
but only 16% in the 15-year-old. Mossaz-Joelson
and Mossaz z6 c o m p a r e d b o n d e d and b a n d e d
Minne expanders and f o u n d no difference in the
a m o u n t of dental and skeletal expansion or
relapse. Skeletal expansion comprised about half
of the dental expansion. Finally, Akkaya et al 6
compared arch changes in a group with a b o n d e d
Hyrax appliance with those from a group using a
b o n d e d Minne expander. Molar expansion was
not significantly different between the 2 groups,
with the slow-expansion group exhibiting 9.81
m m of expansion and 0.2 m m of relapse. No
skeletal changes were measured.

53

Functional Appliances
Several studies have reported that significant
dental expansion can be achieved with various
functional appliances, and in several instances,
significant skeletal expansion was achieved as
well (Table 3). Although relapse data were incomplete at best, it appeared that dental relapse
could be significant, ranging from 19% to 100%.
In fact, Owen 3~ noted that while transverse increases gained with the Frankel appliance could
alleviate arch-length deficiencies, it could not
correct a crossbite.
BeGole et aP 2 reported on the a m o u n t of
molar expansion normally occurring during fixed
edgewise therapy. They f o u n d that in nonextraction cases, the maxillary molar width increased
by 2.96 mm, and in extraction therapy, the
molars narrowed by 0.22 mm. After treatment,
the nonextraction patients demonstrated 0.52
m m of relapse, while extraction patients showed
an additional expansion of 0.67 mm. Kirjavainen
et aP a reported on expansion achieved with a
Kloehn-type cervical headgear. Dental expansion ranging from 2.8 m m to 5.1 m m was
reported, but no skeletal expansion or anaounts
of relapse were reported.

Timing of Expansion
To discuss the optimal timing for maxillary
expansion, it is useful to review the transverse
growth of the maxilla and the face. Bj6rk and
Skieller 34 reported in 1974 on their study of nine
boys. Frontal cephalometric radiographs were
Table 3. Expansion and Stability of Functional
Appliances
Author

Ffratli and l]lgen27:

FR3 appliance
Gibbs and Hunt2S:
Andresen
appliance
Bionator
appliance
Frankel appliance
Hime and OwenS9:
FR2 appliance
McDougal et a13:
FR1 and FR2
appliance
Owen31:
FR 1 and FR2
appliance

Sample Expansion (mm) Relapse(mm)

Size Dental Skeletal Dental Skeletal

2.0

1.2

NO

NO

2.3

NO

0.9

NO

?
?

1.9
3.6

NO
NO

0.6
0.7

NO
NO

0.45

NO

0.45

NO

3.9

4.4

NO

NO

3.3

3.7

NO

NO

54

Will and Muhl

taken annually f r o m age 4 up to age 20 in some

of the boys. Metallic implants were placed in the
infrazygomatic crests, on the palate on either
side of the midpalatal suture, and in the anterior
maxilla. These served as registration points for
superimposition of the films. Bjork and Skieller s4
f o u n d that the transverse growth of the maxilla
followed distance and velocity curves similar to
those for body height, with similar times of
growth spurt and growth completion. In addition, they f o u n d that while posterior growth was
three times that of the anterior maxilla, the
dental arch width showed only one quarter the
increase of that of the basal maxilla. In 1990,
Korn and B a u m r i n d 35 used a similar technique
to study the growth of 31 children f r o m 8.5 to
15.5 years of age. They f o u n d an average annual
rate of transverse growth of 0.43 -+ 0.18 m m p e r
year, and c o n f i r m e d that posterior growth was
greater than anterior growth.
In the last decade, several investigators have
published n o r m s of transverse craniofacial parameters. Examined together, they provide significant information a b o u t transverse facial growth.
In 1992, Athanasiou et a136 published the n o r m s
he obtained in a cross-sectional study of 588
Austrian schoolchildren, aged 6 to 15 years.
Eight linear distances (6 skeletal, 2 dental), 10
ratios a m o n g these widths, and two angular
m e a s u r e m e n t s f o r m e d his analysis. Because of
conclusions reached in an earlier work, Athanasiou et a136 did not separate his sample by gender.
All linear m e a s u r e m e n t s showed progressive increases, with several widths (inner orbital, nasal
cavity, maxillary skeletal base, m a n d i b u l a r intergonial) increasing relative to the interorbital
width, indicating some differentiation in transverse growth a m o n g structures. F u r t h e r m o r e ,
they n o t e d that the maxillary intermolar width
did not increase between 9 and 12 years of age,
and the m a n d i b u l a r i n t e r m o l a r width showed no
significant change over the entire course of
study. It should, however, be n o t e d that the
maxillary basal width showed a lack of change
between 11 and 13 years of age, similar to the
maxillary molar, and n o n e of the growth changes
presented were tested for significance. Athanasiou et a136 restated the conclusion first m a d e by
K r o g m a n that transverse jaw growth is affected
minimally by adolescent growth changes, and
the small, steady increases Athanasiou r e p o r t e d
seem to b e a r this out. However, the superimposi-

tion of 70 to 90 individual growth curves for each

year of age will tend to flatten out any individual
growth peaks. In addition, lumping females and
males together would further obliterate any overall growth peaks. However, the inclusion of ratios
is a welcome innovation given the sensitivity of
cephalometric n o r m s to individual variation and
technique-related problems such as magnification and h e a d position.
Snodell et a137 separated their sample by
g e n d e r in their longitudinal study published in
1993. Twenty-five males and 25 females f r o m the
University of Colorado growth sample were included in the study, with annual films starting at
age 4 and ending at age 20 for females and 95 for
males. All subjects h a d Class I skeletal and dental
patterns. Snodell et al ~7 used five skeletal and
four dental transverse measurements, and added
five vertical m e a s u r e m e n t s with which to compare the magnitude of growth. As o p p o s e d to
Athanasiou et al, 36 gonion rather than antegonial notch was used for the l a n d m a r k for mandibular width, and cranial and bizygomatic widths
were included instead of any orbital measurements. Snodell et al ~7 also f o u n d a progressive
increase in all parameters, although the increases cannot be directly c o m p a r e d to Athanasiou et al's 36 results as a result of the latter's lack
of g e n d e r separation. Snodell et a137 did find
significant g e n d e r differences at 6 years of age
that increased at 12 and 18 years. At 6 years of
age, only cranial width, facial width, and maxillary width were significantly different between
males and females. At 18 years of age, only
m a n d i b u l a r first-molar width was not significantly different. Snodell's 37 study also determ i n e d the percentage of adult size that the
6-year-old m e a s u r e m e n t represented, and established the age at which growth was complete and
adult size was reached. At 6 years of age, females
had reached a higher percentage of adult size
than males for all parameters, with values ranging f r o m 80% for adult nasal width to 103% for
adult lower second-molar width. Male values
ranged f r o m 75% to 109% for the same measurements being represented at the extremes. In
contrast, only 71% to 84% of the adult value was
reached for vertical parameters by age 6. Once
again, females h a d r e a c h e d a higher percentage
of adult values than males. Females were similarly quicker to complete growth, with all growth
ceasing by age 17, while males showed continued

MaxiUaryExpansion

growth beyond 18 years for all parameters except

maxillary width. Snodell et a137 reported declining rates of maxillary growth from 6 to 14 years
of age with acceleration at age 14 to 15 years,
although the annual rates were not reported.
This decrease in growth velocity is in agreement
with Athanasiou et alY Snodell et aP 7 also
reported that increases in maxillary first-molar
width were highly correlated with maxillary
growth, which also confirmed Athanasiou et
al's a6 report.
Cortella et aP s evaluated 36 subjects from the
Bolton-Brush Growth Study in 1997, but limited
their analysis to the basal maxilla and mandible.
They used landmarks from Ricketts analysis that
were the same as in Athanasiou et al's ~a study.
Longitudinal films were traced and measured,
although some subjects did not have a film for
each year between ages 5 and 18 years. These
examiners also adjusted for magnification. All
values from Cortello et al's ~s study were smaller
than those reported by Athanasiou et al, ~6 even
without correction for magnification. The ratio
between maxillary and mandibular width was
similar and showed a gradual decrease. However,
the values from Cortella et al as were generally
greater. Intraexaminer error was 1.03 mm.
This lack of agreement between two sets of
published norms highlights the technical difficulties in establishing firm norms, and reinforces
the advisability of using ratios rather than absolute linear measurements.
Studies regarding the growth and maturation
of the intermaxillary suture are a n o t h e r source
of information relating to the optimal time to
expand the maxilla. These studies by necessity
nmst be histological examinations on normal
sutures, and samples are thus difficult to obtain.
In two studies published in the 1970s, Melsen ~9,4
used autopsy material to histologically examine
the maturation of the midpalatal suture. The
sample for the first study included 33 boys and 27
girls, aged 0 to 18 years of age, who had died
"without prior illness." Microradiography enabled the localization of growth activity. Melsen ~9
divided sutural maturation into three stages
based on its morphology. In the infantile stage,
the suture was broad and smooth, but by approximately 10 years of age had developed into a more
typical squamous suture with overlapping sections. Melsen 39 called this stage the 'juvenile"
stage. Finally, the "adolescent" phase was seen at

55

ages 13 to 14 years, where the suture was more

wavy with increasing interdigitation. These interdigitations could not be separated without fracturing them. Melsen's categories were extended
in a 1982 study, 4 which evaluated the sutures
from 30 individuals, aged newborn to 27 years.
The suture in the oldest individuals was classified
as "adult," t h o u g h no specific ages were given to
distinguish this category. Adult sutures demonstrated n u m e r o u s bony bridge formations across
the suture, and n u m e r o u s synostoses were noted.
In a n o t h e r study, Persson and Thilander 4~
quantified suture closure by evaluating the degree of obliteration in the suture. The sample for
this study was a group of 14 males and 10 females
who had died suddenly. The earliest closure seen
in any portion of the suture was in a 15-year-old
female, but no closure was seen in 4 of the 7
individuals less than 20 years of age. O n e 27-yearold female had no sutural obliteration. Although
a marked degree of closure is rarely f o u n d until
the third decade, sutural obliteration progresses
rapidly during that time. The authors concluded
that midpalatal suture closure is highly variable.
From these studies, it is suggested that patients who have passed their pubertal growth
spurt may have difficulty in u n d e r g o i n g traditional orthopedic maxillary expansion. The increased interdigitation of the suture may require
excessive force to separate. However, the literature is not conclusive on this topic, and factors
other than age and sutural fusion are important
in the ability to orthopedically expand the maxilla.

Conclusion
Many treatment modalities are available for
achieving expansion. Significant skeletal expansion may be achieved with a fixed jackscrew
expander, though the a m o u n t of skeletal expansion achieved and the stability of such expansion
is variable. Dental expansion can be achieved
using a variety of appliances d e p e n d i n g on the
a m o u n t of expansion desired and the age of the
patient. No skeletal expansion should be expected in a patient who has reached skeletal
maturity.

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