PEDIATRICDENTISTRY/Copyright© 1990 by

The AmericanAcademy
of Pediatric Dentistry
Volume 12, Number2

Two-point rapid palatal expansion: an alternate

approach to traditional treatment
Erle Schneidman, DDS, MS Stephen Wilson, MA, DMD, PhD
Ronald Erkis, DDS

Abstract
Rapid palatal expansion (RPE)causes separation of the the buccinator muscle, due to the buccal movementof
lateral halves of the palate and traditionally has used four the maxillary teeth, would have less of a confinement
maxillaryteeth as anchorage.The purposeof this study wasto effect on the mandibular molars. The changes in the
introduce a rapid palatal expanderthat requires only two position of the mandibular teeth are neither pro-
anchor teeth (two-point RPEe)and to comparethe expansion nounced nor predictable (Gryson 1977).
obtained with that from a Hyrax® appliance. This study Haas (1980) reported a minimumof five indications
involved two groups of 25 children aged 7 to 15 years who for RPE:
were treated in a private orthodontist’s office with either a 1. Real and relative maxillary deficiency
Hyrax appliance or a two-point RPEe. Dental casts and 2. Class III malocclusion
occlusal radiographswere madebefore treatment and at least 3. Nasal stenosis
three monthsafler stabilization of the appliance.Pairedt-tests 4. Mature cleft palate patients
were performedto identify significant intragroup changes, 5. Selected arch length problems in Class I skeletal
and independentt-tests were performedto determine inter- patterns.
group differences. The findings showedthe two-point RPEe
was as efficient as the Hyraxin obtaining dental expansionof Several types of rapid palatal expanders (RPEe) have
been developed to prevent or correct malocclusions in
the maxillary posterior teeth w#hless effect on the maxillary
the child. The Arnold appliance and the Minne ex-
anterior and mandibularteeth. Therefore, the two-point RPEe
pander are RPEesthat are cemented to four anchor teeth
maybe useful in certain clinical situations.
(Biederman 1973). The anchor teeth usually are the
maxillary first permanent molars and either the maxil-
Introduction
lary first premolars or the maxillary first deciduous
Rapid palatal expansion is an orthodontic procedure molars. Both appliances are activated by turning an
designed to induce a physical separation of the lateral adjustment screw that compresses a coil spring. The
halves of the bony palate. Manyeffects are evident as the Hyrax® (OIS Orthodontics, 65 CommerceDr., Aston,
midpalatal suture opens (Haas 1961; Haas 1965; Haas PA, USA) appliance (Biederman 1973) also is an RPEe
1970). One of the most obvious initial changes is the which is anchored similarly, but is activated by means of
diastema crea ted betweenthe maxillary central incisors. a centrally located jackscrew (Fig la, next page). The
However,the incisors converge as a result of the tension Haas appliance (Haas 1961) is similar to the Hyrax
in the transeptal fibers during retention. construction and activation, but includes acrylic that
A changeoccurs in the direction of the long axis of the rests against the palatal soft tissues. An appliance that
maxillary posterior teeth during RPE. This change is includes an acrylic embeddedjackscrew is bonded di-
due to both palatal separation and tooth movement rectly to the posterior teeth (Cohen and Silverman 1973;
(Starnbach et al. 1966; Bishara 1987). The most frequent Howe 1982).
types of tooth movementare tipping and extrusion. RPEes have been used widely, but significant prob-
As the maxillary arch width increases, the mandibu- lems have been associated with their use. For instance,
lar posterior teeth tend to upright and tip buccally. Haas appliances containing acrylic may produce painful ul-
(1961) theorized that the change in orientation of the ceration of the palatal mucosaduring activation. Conse-
mandibular posterior teeth is due to the tongue being quently, it may be necessary to remove the RPEe and
forced downwardby the palatal appliance. In addition, delay treatment (Howe 1982). Also, anchor teeth have

92 RPE,AN ALTERNATE APPROACH: SCHNEIDMAN, WILSON, AND ERKIS

 Fig 1b. A two-point rapid palatal expander (RPEe).
Fig 1a. A Hyrax appliance.
either a skeletal Class III pattern based on cephalometric
been associated with marked pulpal and root resorptive analysis, an anterior or posterior crossbite, or mild to
damage (Timms and Moss 1971; Barber and Sims 1981; moderate dental crowding (> 4 mm), calculated by a
Langford and Sims 1982). Most significantly, mal- space analysis.
aligned or missing teeth may make parallel insertion of Orthodontic records were obtained for all patients
an RPEe on four or more anchor teeth difficult or impos- before any treatment (TO) including lateral cephalomet-
sible (Howe 1982). ric radiographs, study models, and standard intra- and
This paper presents a new appliance, a two-point extraoral photographs.
RPEe (Fig lb). It contains a centrally located jackscrew Activation of the appliances was initiated with two
similar to the Hyrax appliance (Fig. 1 a), but utilizes only turns of the jackscrew on the day of cementation (Tl).
two banded teeth as anchors, the first permanent max- Each turn represented .25 mm of separation to the screw
illary molars. If sufficient expansion can be obtained assembly. The patient's parent was instructed to turn
and maintained, the two-point RPEe will provide the the jackscrew one turn (.25 mm) in the morning and
practitioner with an effective appliance for the transi- again in the evening of each day of expansion treatment.
tional dentition that is simpler, less expensive, and The patient was examined on a weekly basis, and expan-
lessens the chances of potential damage to the teeth. sion terminated (T2) when the lingual cusp tips of the
The purposes of this study are to: maxillary first permanent molar were in contact with
1. Introduce a two-point RPEe the corresponding buccal cusp tips of the mandibular
2. Describe its dental changes first permanent molar. The number of days of active
3. Describe the dental changes obtained from a expansion was recorded, and the appliance was stabi-
Hyrax appliance (four-point RPEe) lized with acrylic placed in the screw area. Expansion
4. Compare the dental expansion obtained from the was retained with the appliance for a minimum of three
two-point RPEe to that of a Hyrax appliance. months (T3). After retention, the RPEe was removed
and study models were obtained.
Materials and Methods Occlusal radiographs were taken at Tl and T2 to
demonstrate the separation of the midpalatal suture
This prospective study involved 50 patients who and to record the configuration of separation. Follow-
were treated in a private orthodontist's office. Males up study models were taken when the RPEe was re-
and females who ranged in age from 7 to 15 years were moved at T3. The dental casts were evaluated at two
treated. Twenty-five children were treated with a two- stages of treatment (TO and T3) to determine the trans-
point RPEe (Group A) and 25 with a Hyrax appliance verse change in the maxillary arch width, the transverse
(Group B). The Hyrax appliance consisted of a Unitek change in the mandibular arch width, and the degree of
Expansion screw (Unitek/3M; Monrovia, CA), and tipping of the maxillary teeth. The following measure-
orthodontic bands cemented to maxillary first perma- ments were made by the primary investigator with
nent molars and either the maxillary first premolars or calipers (Boley Gauge) accurate to 0.1 mm (Fig. 2, next
maxillary first primary molars. The two-point RPEe had page):
bands that were cemented to maxillary first permanent
molars only and contained a similar jackscrew. RPE 1. Intermolar Cusp Tip Width — the distance be-
treatment was indicated for these children because of tween the mesiobuccal cusp tips of both maxillary

PEDIATRIC DENTISTRY: APRIL/MAY, 1990 ~ VOLUME 12, NUMBER 2 93

 significant intergroup differences with respect to pa-
tient characteristics (sex, age, number of crossbites, and
Fig 2. Themeasurements activation days) for the two groups (A and B).
obtainedfrom the dental Independent t-tests were performed to determine any
casts. significant intergroup differences of the mean changes
1. Maxillary Intermolar seen in the seven dental variables. The probability for
Width(IMmax) statistical significance effect or change was set at 0.05.
2. MandibularIntermolar
Width(IMmand) Results
3. Canine Arch Width Patient Characteristics
(AWc) Fifty children (23 males and27 females)7 to 15 years
4. Molar Arch Width of age wereinvolved in the study. Therewasno signifi-
(AWm) cant difference in the distribution of malesand females
5. Maxillary Intercanine betweenthe two groups. The average age of the children
Width(ICmax) was10.1 years (also was the average age of both males
6. Mandibular Intercanine and females). There wasno significant difference in the
Width(ICmand) distribution of age betweenthe two groups (Table 1).
Of the 50 children, 43 had crossbites. They were
evenlydistributed betweenanterior, right posterior, left
posterior, andbilateral crossbites. Nosignificant differ-
permanentfirst molars (IMmax)and the distance ences betweengroups were noted in the distribution of
between the mesiobuccal cusp tips of the two crossbites (Table2).
mandibular permanent first molars (IMmand) The average numberof activation days (T1 to T2)
2. Arch Width -- the transverse diameter of the the RPEewas15 days, with a range of 6 to 36 days. There
palate measuredat the free gingival marginof the wasno significant difference in the distribution of acti-
maxillary canines at their most lingual aspect vation days between the two groups.
(AWc),and at the free gingival margin of the Reliability of Measurement
maxillary first permanentmolars at their most The Pearson Product MomentCorrelation Coeffi-
lingual aspect (AWm) cients relating the two independent measurementsof
3. Intercanine Width -- the distance between the the dental variables were found to be greater than 0.96
cusp tips of the two mazillary canines (ICmax) for all variables.
and the distance betweenthe cusp tips of both Two-point RPEe(Group A)
mandibular canines (ICmand), depending on the
canine present at the time of treatment. Paired t-tests were performed on variables within
GroupA that comparedpre- and postexpansion values
The amountof maxillary first permanentmolar tip- (T0-T3). The two-point RPEewas retained for an aver-
ping (Mtip) wasdefined as the changein the distance be- age of 180 days, and changes obtained can be seen in
tween their mesiobuccal cusp tips (IMmax)minus the Table 3. There wasa significant increase in the distance
changein the distance betweenthe transverse diameter between the maxillary first permanent molars (AWm
of the palate measuredat the free gingival marginof the 5.5 ram), and maxillary cuspids (AWc= 2.2 ram). There
first molars (AWm). also was a significant increase in the distance between
To determine reliability of the measurements,25 the mandibular cuspids (ICmand -- 0.8 ram), but
modelswere remeasuredwithout reference to initial significant decrease in the distance was observed be-
measurements by the primary investigator. These tween the mandibular first permanent molars (IMmand
measurementswere comparedto the original data, and
a Pearson Product MomentCorrelation Coefficient was TAI~LE
1. SexandAge(Years)Distribution
PerGroup.
used to determine the degree of association between
measurements. Males Females Total
Paired t-tests were performedto determineany sig- Group # Age # Age # Age
nificant intragroup changes that occurred betweenthe
A(two-pointRPEe) 15 10.8 10 10.1 25 10.5
pretreatment and posttreatment measures(5 variables B (four-pointRPEe) 8 9.3 17 10.1 25 9.7
associated with the study models) for both groups.
Total 23 10.1 27 10.1 50 10.1
Independent t-tests were performedto determine any

94 RPF, AN ALTERNATE APPROACH: SCHNEIDMAN, WILSON, AND ERKIS

TABLI~
2. Distribution
of Typesof Crossbites
PerGroup. the two-point RPEetipped toward the lingual an aver-
Rt Lt Bilat age of 0.5 ram, while those of the four-point RPEetipped
Group Ant Post Post Post None Total toward the buccal 0.3 mm.
A (two-point RPEe) 6 6 4 4 5 25
B (four-point RPEe) 5 Discussion
5 8 5 2 25
Total 11 11 12 9 7 50 No significant difference was noted between the two
groups with respect to the following patient character-
istics: distribution of sex, age, crossbites, and days of
TABLE 3. GroupA vs. GroupB. activation (Tables 1 and 2). This suggests that the two
groups were homogenous.
Variable* Group A Group B T value d.f. P value
The even distribution between groups of males and
AWrn 5.5 mm 5.3 mm 0.35 48 .728 females in this study reflects a normal population of
AWc 2.2 mm 3.4 mm 2.23 29 .033 orthodontic patients. The mean age of patients (10.1
IM- -0.8 mm 0.8 mm 2.77 46 .008 years) is characteristic of the transitional dentition.
mand
During this period of arch and dental development,
ICmand 0.8 mm 0.6 mm 0.37 38 .714 using a two-point RPEe may be more advantageous
Mtip -0.5 mm 0.3 mm 2.88 48 .006
compared to a four-point RPEebecause of the need for
AWm = Intermaxillary molar width. AWc= intermaxillary ca- only two anchor teeth. The four-point RPEe requires
nine width. IMmand = Intermandibular molar width. 1Cmand four anchor teeth that are reasonably parallel to facili-
= Intermandibularcanine width. Mtip= Tippingof maxillary
molar. tate a path of insertion of the appliance. Also, in clinical
cases that need orthopedic corrections (e.g.: skeletal
= -0.8 mm). There was a significant degree of lingual crossbites), an orthodontic appliance, such as a quad
tipping of the maxillary first permanent molar (Mtip helix, maynot produce the desired effects.
0.5 mm). The average number of activation days for both
Four-Point RPEe(Group B) appliances was 15 days. Hypothetically, this would
represent 30 turns of the activator jackscrew (two turns
Paired t-tests were performed on variables within
per day) and 7.5 mmof activation (.25 mmper turn).
Group B that compared pre- and postexpansion values
the appliance is 100%efficient, 7.5 mmof expansion of
(T0-T3). The four-point RPEewas retained for an aver-
the maxillary posterior teeth wouldbe expected. The av-
age of 210 days, and the changes obtained can be seen in
Table 3. There was a significant increase in the distance erage expansion overall was 5.5 ram. This discrepancy
between the ideal and actual expansion may be due to
between the maxillary first permanent molars (AWm
poor patient compliance, activation of the screw assem-
5.3 mm)and that of the maxillary canines (AWc= 3.4
mm). There was no significant increase in the distance bly, compression of the periodontal ligament, and dif-
ferent effects on craniofacial sutures other than the
between the mandibular canines, and no significant
midpalatal suture (Haas 1961). There was no significant
change was seen in the distance across the mandibular
difference between appliances in terms of posterior ex-
molars. The maxillary first permanent molar tipped
pansion. Therefore, the two-point RPEeis as efficient as
toward the buccal an average of 0.3 mm,but this change
a Hyrax appliance in obtaining dental expansion.
was not significant.
Occlusal radiographs obtained when the RPEes were
Group A vs. Group B stabilized (T2) showed a similar triangular configura-
Independent t-tests were performed to compare tion of palatal separation. As described by Bell (1982),
changes obtained from the two-point RPEeto those of the greatest opening of the midpalatal suture was fou~nd
the f6ur-point RPEe(Table 3). There was no significant anteriorly in the incisor region, with progressively less
difference in the average number of days of retention separation toward the molar area. The pattern of
between the two RPEes. There was no significant differ- midpalatal suture separation was similar for both appli-
ence between the two RPEes with respect to change in ances. However, the radiographs that were taken to
distance across the maxillary first permanent molars document palatal separation were not standardized
and across the mandibular canines. There was, how- with respect to operator and angulation, and no meas-
ever, a significant difference with respect to change in urements were made.
distance across the maxillary canines and across the According to Bishara et al. (1987), the maxillary
mandibular molars. There was significantly less change posterior teeth should extrude and tip laterally before
in both of these measurementswith the two-point RPEe. palatal separation occurs. After the midpalatal suture
A significant difference also was observed in the tipping splits, the maxillary posterior teeth movebodily along
of the maxillary first permanent molar. The molars in with the palatal halves. Both the two-point RPEeand

PEDIATRIC
DENTISTRY:
APRIL/MAY, 1990- VOLUME
12, NUMBER
2 95
 four-point RPEedisplayed a buccal expansion of the the primary indication for a two-point RPEemay be for
maxillary first permanent molar (Table 3). However, the correction of a posterior crossbite in a patient during
major difference occurred with respect to the angulation the late mixed dentition when the number of stable
of the tooth. With the four-point RPEe, the maxillary anchor teeth are limited, or if there is a difficult path of
first permanent molar tipped buccally as expected. On insertion for a four-point RPEe.
the contrary, the maxillary first molars tipped lingually There maybe other clinical indications for the two-
with the use of the two-point RPEe(Table 3). The reason point RPEeif it can be established that this appliance
for this finding is unclear; however, it seems reasonable produces skeletal changes different from the four-point
to expect that the two-point RPEehad a different distri- RPEe. Preliminary data from a secondary study sug-
bution of forces on the dentition and associated gests that the two appliances do cause different re-
craniofacial suture sites than that of the four-point sponses in the palatal plane angle. Further rigorous
RPEe. For instance, the two-point RPEe may have im- study is needed to determine the extent of skeletal
posed a significantly greater and more concentrated influence associated with these appliances.
effect on palatal and other craniofacial sutures, the
dentition, and on the appliance. It maybe hypothesized Conclusions
that the major vector of force associated with the two- A significant amount of dental expansion was ob-
point RPEeis more apically directed. This would be tained from a two-point RPEe, especially of the maxil-
manifested primarily as a lingual tipping of the crown. lary posterior teeth. The expansion obtained from the
Onthe other hand, the major vector of force of the four- Hyrax appliance in this study was similar to that re-
point RPEemay be more coronal, which would cause a ported in previous studies. Compared to the Hyrax
buccal tipping of the crown. appliance, the two-point RPEehas less effect on the
There was an increase in the distance between the maxillary anterior teeth and on the mandibular teeth.
maxillary canines with both RPEes (Table 3). However, Therefore, the two-point RPEeis indicated and recom-
the four-point RPEeshowed a significantly greater in- mendedin certain clinical situations:
crease in the distance between the canines when com-
1. During the late mixed dentition, when only two
pared to the two-point RPEe. This probably was due to stable anchor teeth are present
the four-point RPEehaving a greater effect on the ante- 2. In patients with malaligned dentition and a diffi-
rior portion of the maxilla as comparedto that of the
cult path of insertion for a conventional four-point
two-point RPEe. Here again, this finding is congruent
RPEe(e.g.: cleft palate patient)
with the hypothesized difference in the distribution of
3. Whenthe desired effect of RPEeis expansion of the
forces between the two RPEeappliances.
posterior maxilla without an effect on the anterior
The distance between the mandibular posterior teeth maxilla or on the mandibular teeth (e.g.: skeletal
is expected to increase as they upright and tip buccally Class II malocclusion with a posterior crossbite).
(Haas 1961). The mandibular first permanent molars
treated with a four-point RPEebehaved in this fashion, Dr. Schneidman is in private practice in Montreal, Quebec, Canada;
but those of the two-point RPEedid not (Table 3). In the Dr. Wilson is assistant professor, dept. of pediatric dentistry, Ohio
latter cases, the distance decreased between the me- State University, Columbus,OH;and Dr. Erkis is in private practice in
Columbus, OH.
siobuccal cusp tips of the mandibular first permanent
molars. This finding is consistent with the different Barber AF, Sims MR: Rapid maxillary expansion and external root
effects of the two appliances observed in the maxillary resorption. AmJ Orthod 70:630-52, 1981.
arch (viz., the forces associated with the lingually di- Bell RA: A review of maxillary expansion in relation to the rate of
rected maxillary molars of the two-point RPEe would expansion and patient’s age. AmJ Orthod 81:32-37, 1982.
tend to tip the mandibular molars more lingually and
vice versa with the four-point RPEe). Biederman W: Rapid correction of Class II1 malocclusion by
midpalatal expansion. AmJ Ortho 63:47-55, 1973.
RPEes may cause degenerative pulpal and/or peri-
odontal responses in anchor teeth (Timms and Moss Bishara SE, Staley RN: Maxillary expansion: clinical implications. Am
1971; Barber and Sims 1981). In this study, no attempt J Orthod Dentofacial Orthop 91:3-14, 1987.
was made to evaluate soft tissue responses to the two
CohenM, Silverman E: A new and simple palate splitting device. J Clin
RPEes. Nonetheless, there were no patient symptomsor Orthod 7:368-69, 1973.
clinical signs of any soft tissue or pulpal problemsnoted
throughout this study. Gryson JA: Changes in rnandibular interdental distance concurrent
Of the 25 children treated with a two-point RPEe, 14 with rapid maxillary expansion. Angle Orthod 47:186-92, 1977.
had a posterior crossbite (Table 2). All of these crossbites Haas AJ: Rapid expansion of the maxillary dental arch and nasal
were corrected with a two-point RPEe. Consequently, cavity by opening the midpalatal suture. Angle Orthod 31:73-90,
1961.

96 RPE, AN ALTERNATE
APPROACH:
SCHNEIDMAN,
WILSON,AND[~RKIS
Haas AJ: The treatment of maxillary deficiency by opening the LangfordBD,SimsMR:Root surface resorption, repair and periodon-
midpalatal suture. AngleOrthod35:200-217,1965. tal attachment following rapid maxillary expansionin man.AmJ
Orthod81:108-15,1982.
HaasAJ: Palatal expansion:Just the beginningof dentofacialorthope-
dics. AmJ Orthod57:219-55,1970. StarnbachH, BoynerD, Cleall J, SubtelnyJD: Facro-skeletalaod dental
changesresulting from rapid maxillary expansion. AngleOrthod
Haas AJ: Longterm treatment of rapid palatal expansion. Angle 36:152-64,1966.
Orthod50:189-218,1980.
TimmsDJ, MossJP: A histological investigation into the effects of
HoweRP: Palatal expansionusing a bondedappliance. AmJ Orthod rapid maxillary expansion on the teeth and their supporting
82:464-68,1982. tissues. Trans Eur OrthodSoc 47:263-7l, 1971.

Dentists willing to treat AIDS patients

A Chicago survey contradicts the notion that few dentists are willing to treat patients who have
AIDS or who are carriers of the human immunodeficiency virus (HIV).
Writing in the March/April 1989 issue of General Dentistry, journal of the Academy of General
Dentistry, Robert J. Moretti, PhD, William A. Ayer, DDS, PhD, and Alix Derelinko, of Northwestern
University’s medical and dental schools, report that in their survey of 500 Chicago dentists, more
than 60% of respondents said they would treat asymptomatic HIV carriers. Forty per cent said they
were willing to treat patients who had progressed to AIDS or to AIDS-related complex (ARC), and
20% said they had treated known HIV carriers.
Most of these dentists, however, were unwilling to accept referrals of known HIV carriers or
AIDS/ARCpatients from outside their practices: only 16% of the survey group were willing to treat
such referred patients.
Many respondents who said they would not treat HIV-infected persons said they believed that
exposure to such patients would place them at risk of contracting the AIDS virus. The researchers
report that this fear is greater among dentists who have never treated AIDS patients than among
those whose patient population includes them.
Moretti and his colleagues write that dentists’ fears in this regard are not based on scientific
knowledge and reflect a poor understanding of HIV and the actual risk involved in treating HIV
patients. The authors note that risks to dentists and their staff members can be reduced greatly by
adherence to infection control procedures defined by the Centers for Disease Control and the
American Dental Association.
One surprising finding was that few dentists in the sample even wore fresh gloves routinely
with each patient. Even fewer reported wearing face masks and protective eye wear.
The researchers conclude that much additional continuing education is needed for dentists in
the matter of infection control procedures.

PEDIATRIC DENTISTRY: APRIL/MAY, 1990 ~ VOLUME 12, NUMBER 2 97