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CASE REPORT
Year : 2014  |  Volume : 3  |  Issue : 5  |  Page : 51-54

Maxillary expansion by nickel titanium palatal expander in cleft palate patient


Department of Orthodontics, Institute of Dental Sciences, Bareilly, Uttar Pradesh, India

Date of Web Publication10-Mar-2014

Correspondence Address:
Parthasarathyraam Raju
Department of Orthodontics, Institute of Dental Sciences, Pilibhit by Pass Road, Bareilly - 243 006, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2277-8632.128491

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  Abstract 

Transverse expansion of the maxilla has been used by orthodontists for more than 100 years to correct maxillary anomalies. Rapid mechanical maxillary expansion procedures as presently employed, utilize large loads designed to produce a maximal skeletal repositioning with a minimum of individual tooth movement whereas tandem-loop nickel titanium NiTi, temperature-activated palatal expander with the ability to produce light, continuous pressure on the midpalatal suture. This case report describes the management of a 15-year-old girl with repaired cleft lip and palate, skeletal class III which exhibited mild maxillary deficiency. Dental examination revealed class I molar relation with reverse overjet, bilateral posterior crossbite, and constricted maxillary arch. A combination of various radiographs was used to diagnose and plan the treatment for maxillary expansion. The expander was assembled with bands as one unit and secured with elastic modules. During the 3 months study period, no other treatment was performed. An increase of 4 mm in intermolar width, 2 mm in intercanine width, and 4 mm in interpremolar width was achieved. The NiTi expander provides a viable alternative to rapid expansion for correction of transverse discrepancies.

Keywords: Cleft palate, expansion, maxillary expansion, NiTi palatal expander


How to cite this article:
Raju P, Bhattacharya P, Gupta A, Garg J, Agarwal D K. Maxillary expansion by nickel titanium palatal expander in cleft palate patient. J NTR Univ Health Sci 2014;3, Suppl S1:51-4

How to cite this URL:
Raju P, Bhattacharya P, Gupta A, Garg J, Agarwal D K. Maxillary expansion by nickel titanium palatal expander in cleft palate patient. J NTR Univ Health Sci [serial online] 2014 [cited 2019 Dec 13];3, Suppl S1:51-4. Available from: http://www.jdrntruhs.org/text.asp?2014/3/5/51/128491


  Introduction Top


Correction of a transverse discrepancy usually requires expansion of the palate by a combination of orthopedic and orthodontic tooth movements. Initially, transverse forces will tip the buccal segments laterally. [1] With proper appliance design, 3 rd -order moments will induce bodily translation. [2],[3],[4],[5] If the force is strong enough, separation occurs at the maxillary suture. The amount of orthopedic versus orthodontic change depends greatly on the patient's age. Normal palatal growth is nearly complete by age 6, and increasing interdigitation of the suture makes separation difficult to achieve after puberty. [6]

Unfortunately, conventional rapid palatal expansion (RPE) produces large forces at the sutural site over a short period of time. [7],[8] These heavy forces maximize skeletal separation of midpalatal suture by overwhelming the suture before any dental movement or physiological sutural adjustment can occur. However, traumatic separation of the midpalatal suture may induce patient discomfort. RPE appliance also requires patient or parent cooperation in appliance activation and labor-intensive laboratory procedures in fabrication of the appliance.

Orthodontic treatment can be challenging because of the drawbacks traditional appliances. The slow expansion appliances allow for more physiologic adjustment to sutural separation. This in turn, produces greater stability and less relapse potential. [9] Arndt, [10] developed tandem-loop nickel titanium (NiTi), temperature-activated palatal expander with the ability to produce light, continuous pressure on the midpalatal suture while simultaneously uprighting, rotating and distalizing the maxillary first molars. This fixed-removable appliance has adjustable stainless steel extension and is inserted into standard horizontal lingual sheaths that are spot welded to the molar bands.

At temperature below the transition temperature the interatomic forces weaker, making the metal much more flexible, above the transition temperature the interatomic forces bind the atoms tighter and the metal stiffens. The NiTi expander has a transition temperature of 94F. When it is chilled before insertion, it becomes flexible and can easily be bent to facilitate placement. As the mouth begins to warm the appliance, the metal stiffens, the shape memory is restored, and the expander begins to exert a light continuous force on the teeth and the midpalalal suture. This expander generate forces of 180-300 g. This appliance requires little patient cooperation and laboratory work.

Successful cleft lip and cleft palate rehabilitation requires a multidisciplinary approach employing the skills of plastic surgeons, speech therapists, pediatric dentists, and orthodontists. Although early surgical intervention improves the patients' quality of life, lip repair and closure of palatal cleft also tends to reduce the intercanine width and intermolar width and contributes to anterior and posterior crossbites. The temperature-activated Arndt NiTi palatal expander is a good choice for cleft palate applications because it creates transverse maxillary expansion, uprights, and rotates the maxillary molars.


  Case Report Top


A 15-year-old girl with a repaired cleft lip and palate presented with moderate skeletal class III malocclusion. The patients profile was concave. The lower lip was prominent and the lips were competent. Vertical facial proportions were normal and there were no significant asymmetries. A full complement of permanent teeth was present except left upper canine. Peg-shaped lateral incisor in the first quadrant, class I molar relation with reverse overjet and overbite and bilateral posterior crossbite with constricted maxillary arch.

Alginate impressions of the maxillary and mandibular dental arches were taken for fabrication of study models. Maxillary occlusal radiographs and intraoral radiographs of the maxillary were taken prior to insertion of the appliance. Extraoral and intraoral pretreatment photographs of the subjects were taken for record purpose [Figure 1]. The periodontal status of the teeth were clinically examined and evaluated and rectified if the need arose.
Figure 1: Preexpansion intraoral photographs; (a) Frontal (b) Right lateral (c) Occlusal

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The distance from the maxillary 1 st left molar palatal surface to the right 1 st molar surface (SITES of lingual sheaths) was measured. In accordance with the specification of the manufacturer, 4 mm was added to the measured inter molar distance to choose the appropriate nitanium palatal expander [Figure 2].
Figure 2: Different sizes of nickel titanium expander

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The molars were separated with elastic modules or brass wire. Molar bands of 180 × 0.005 inch width were fitted and festooned on to which 0.036 inch lingual sheaths were welded. The expander was assembled with bands as one unit and secured with elastic modules [Figure 3]. Zinc phosphate cement was mixed according to manufacturer's specification for luting. The teeth were dried and isolated with cotton rolls and the bands were cemented. The center bands of the nitanium wires were sprayed with the ICE spray (tetraflouroethane refrigerator spray) to make the appliance dead soft for placement [Figure 3].
Figure 3: Size 38 expander selected for maxillary intermolar width of 34 mm, plus 4 mm for overexpansion

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Optional methods if ice spray is not available

  1. Keep the blue ice pack in freezer and remove it when needed. Place nickel titanium palatal expander (NPE) on frozen pack for 3-5 min before insertion.
  2. Place the NPE in freezer prior to application for 3-5 min.


One band was seated and held in position and then the other band was seated and cotton rolls were placed on the teeth asking the patient to bite for the setting if the cement. Care was taken to make sure that the bands were completely seated before the excess cement was wiped off. Oral hygiene instructions were given and were asked to be strictly adhered to, before the patient was disposed. The patient was asked to report once in 15 days for review to make sure the appliance is seated properly and oral hygiene is maintained to satisfactory levels [Figure 4].
Figure 4: Various methods used to cool nickel titanium component below its transition temperature

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After 2 months of treatment, the appliance was activated by expanding the anterior wire for bicuspid expansion and the distal wire for molar expansion [Figure 5].
Figure 5: Preexpansion occlusal photograph with appliance

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After an interval of 3 months, the appliance was removed and alginate impressions of the maxillary dental arches were taken for comparative study [Figure 6]. The same appliance was cemented back in the maxillary arch for 3 months for retention purpose [Figure 7].
Figure 6: Postexpansion occlusal photograph

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Figure 7: Pre- and postexpansion occlusal X-ray view

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  Result Top


After 3-4 months of expansion treatment, we were able to achieve of 4 mm increase in intermolar width, 2 mm increase in intercanine width, and 4 mm increase in interpremolar width. The appliance was left in place as a retainer for 3 months, in the duration of time fixed appliance treatment was started for aligning of both the arches.


  Discussion Top


Increases in arch width with slow expansion appliances such as a quadhelix and Porter arch type of expansion appliance are thought to result from buccal tipping of the maxillary molars. By contrast with RPE appliance, 400-600 g of force is generated, which may not be sufficient to separate the median palatal sutures. [11] However, clinical studies with slow expansion appliances in young patients with primary or early mixed dentition show that skeletal contribution to maxillary expansion ranges from 16% to 64%. [12],[13] In the West Virginia University Study, radiographic analysis of occlusal films taken 2 weeks after expansion with tandem-loop NiTi expansion appliance showed sutural separation in 85% of the cases. These results suggest that NiTi expansion appliances are effective for transverse expansion in young patients with primary or early mixed dentition.

Another group of patients that can be benefited from this type of appliance is the cleft lip and palate patients. [14] Early surgical soft tissue repair of the palate often creates constriction of the maxillary arch and contributes to posterior crossbite. Maxillary expansion is needed around mixed dentition period to approximate the anterior and posterior alveolar segments in preparation for the alveolar bone graft. Due to the presence of an alveolar and palatal cleft, low level of force is actually desirable for maxillary expansion so as not to tear the repaired soft palate.

Finally, the tandem-loop NiTi expansion appliances do not require laboratory fabrication. The prefabricated appliances eliminate the necessity to take another maxillary impression and save chair time.


  Conclusion Top


The NiTi expander provides a viable alternative to rapid expansion for correction of transverse discrepancies. Incorporation into an existing fixed appliance eliminates a separate laboratory phase and extra appointments for delivery, impressions, adjustments, and rebanding of the molars after removal. The buccal molar attachments are free for use with intrusion arches, utility arches, wire segments, extraoral appliances, and comprehensive fixed appliances. The expander is not cumbersome or uncomfortable and thus can be kept in place for retention and anchorage, even while other procedures are being performed.

 
  References Top

1.Majourau A, Nanda R. Biomechanical basis of vertical dimension control during rapid palatal expansion therapy. Am J Orthod Dentofacial Orthop 1994;106:322-8.  Back to cited text no. 1
    
2.Cleall JF, Bayne DI, Posen JM, Subtelny JD. Expansion of the mid-palatal suture in the monkey. Am J Orthod Dentofacial Orthop 1965;35:23-35.  Back to cited text no. 2
    
3.Starnebach H, Bayne D, Cleall J, Subtelny JD. Facioskeletal and dental changes resulting from rapid maxillary expansion. Angle Orthod 1966;36:152-64.  Back to cited text no. 3
    
4.Murray JM, Cleall JF. Early tissue response to rapid maxillary expansion in the midpalatal suture of the rhesus monkey. J Dent Res 1971;50:1654.  Back to cited text no. 4
    
5.Storey E. Tissue response to the movement of bones. Am J Orthod 1973;64:229-47.  Back to cited text no. 5
    
6.Moyers RE. Standards of human occlusal development. Center for Human Growth and Development. University of Michigan, 1976.  Back to cited text no. 6
    
7.Issacson RJ, Ingram AH. Forces produced by rapid maxillary expansion. II. Forces present during treatment. Angle Orthod 1964;34:261-70.8.  Back to cited text no. 7
    
8.Wertz RA. Skeletal and dental changes accompanying rapid midpalatal suture opening. Am J Orthod 1970;58:41-66.  Back to cited text no. 8
    
9.Kurol J, Berglund L. Longitudinal study and cost-benefit analysis of the effect of early treatment of posterior cross-bites in the primary dentition. Eur J Orthod 1992;14:173-9.  Back to cited text no. 9
    
10.Arndt WV. Nickel titanium palatal expander. J Clin Orthod 1993;27:129-37.  Back to cited text no. 10
    
11.Haas AJ. Rapid expansion of the maxillary dental arch and nasal cavity by opening the mid-palatal suture. Angle Orthod 1961;31:73-90.  Back to cited text no. 11
    
12.Bell RA, LaCompte EJ. The effects of maxillary expansion using a quad-helix appliance during the deciduous and mixed dentitions. Am J Orthod 1981;79:156-61.  Back to cited text no. 12
    
13.Harberson VA, Myers DR. Midpalatal suture opening during functional posterior cross-bite correction. Am J Orthod 1978;74:310-3.  Back to cited text no. 13
    
14.Abdoney MO. Use of the Arndt nickel titanium palatal expander in cleft palate cases. J Clin Orthod 1995;29:496-9.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]


This article has been cited by
1 A Programmable Expander for Patients With Cleft Lip and Palate
Ana Torres,Ibtesam AlYazeedy,Stephen Yen
The Cleft Palate-Craniofacial Journal. 2019; 56(6): 837
[Pubmed] | [DOI]



 

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