20A Reader's forum

American Journal of Orthodontics and Dentofacial Orthopedics

Reply to Dr. Berg

First, I thank Prof. Berg for his

generous comments regarding the
case I presented in the April issue
of the AJO/DO.
I routinely use palatal arches
with auxiliary springs in the treatment of palatally impacted maxillary canines and in a fair number of
cases where maxillary canines are
located buccally. The decision
whether to use a palatal arch when
the teeth are impacted in a buccal
position depends on the crown tip
location and the direction of force
required for optimal tooth movement.
In this case, a palatal arch with
an auxiliary spring was positioned
before surgery in case palatal force
systems were required. As I
explained in the case presentation,
success depended on the absence
of ankylosis and whether the maxillary canines could be moved past

the root apex of the maxillary lateral incisors. For this reason, I did not
want to remove the deciduous
canines before the maxillary
canines had been brought down a
certain distance. Consequently,
because of the occlusion, it was not
possible to pass an auxiliary spring
across the arch.
In this case, I decided to bond
before surgery, because a buccal
approach was likely. The surgeon
could then pass the ligature from
the lingual button through the flap
and hook it over the arch wire, thus
reducing the amount of pain associated with initial activation.
If no brackets had been present
at surgery, the surgeon would have
had to fix this wire to either the lateral incisor or the first premolar.
During initial activation, the wire
from the button would be straightened out and consequently cut

through soft tissue, leading to

patient discomfort.
In my early days as an orthodontist, I did use a high labial arch with
auxiliary springs in a certain number
of cases with buccally impacted
maxillary canines. However, I found
that it was difficult to control such a
high labial arch in some cases and
abandoned this practice many years
ago.
Whenever a palatal arch with
auxiliary spring can be used, I agree
with Dr. Berg that initial harmonization of the impacted canines without
bonded teeth is an advantage for
the reason he mentions, and normally I postpone bonding in such
cases to a time when the impacted
tooth is near eruption.

Jan ~degaard
Madlaveien 9
4008 Stavanger
Norway

In favor of semirapid expansion

I would like to congratulate Drs.
Sandikgio-lu and Hazar I on their
recent article. It is the first scientific
presentation I have seen that compares slow, semirapid, and rapid
expansion. Slow expansion is usually defined as approximately one
third mm per week, semirapid as 1
mm per week, and rapid is approximately 3 mm per week. Although
many firm opinions are expressed
by clinicians to justify their preferred
rate, there has been little firm evidence available. Critics of slow
expansion dislike the pain, the tissue damage, and the box-shaped
arch form that often results. I discussed these issues in 19772 when
I first recommended a simirapid rate
of 1 mm per week.
Story 3 showed that rapid expansion was followed by poor tissue
repair, as the capillary network can
hardly keep up with the separation

of the suture. Many clinicians feel

that in the long term, expansion
relapses to an extent that renders it
valueless, whereas others use it
routinely in their practice. The
relapse does seem highly variable,
but several studies 4,5 have shown
that the widening of the vault is stable and it is the alveolus that tends
to relapse. This would suggest that it
is advantageous to separate the
suture.
Sandikio-lu and Hazar appear
to have had some difficulties in gaining cooperation with the patients
who wore the semirapid appliances
that were removable. I note from
their figures that although the
patients were asked to open at 1
mm per week, the effective rate over
the 5.5 months was less than a fifth
of a millimeter per week. In my clinical experience, that is too slow to
open the suture and is not really

semirapid. This study could possibly

be misleading in this respect. My
own research 6 suggests that semirapid expansion is very stable.
I could perhaps offer the authors
some advice in gaining an effective
rate of 1 mm per week. First, insist
that the patients wear the appliance
while eating. This may be impossible to start with, but children will
hardly notice it in their mouth within
10 days. Second, open one eighth
of a turn each day, not one quarter
every other day. The periodontal
membrane is approximately an
eighth of a millimeter thick and so an
eighth of a turn, distributed between
the two sides, will only reduce it by
half, not crush it. Also it is easier to
remember something you do every
day. Third, check the amount of
opening at each visit, because if the
rate of opening slows much below 1
mm per week, the suture will not
separate and most of the widening

American Journal of Orthodontics and Dentofacial Orthopedics

Volume 112, No 4

will be alveolar and liable to greater

relapse. I personally use an adapted
form of Crozat clasp that can be
adjusted so firmly that the child
needs the assistance of their parents
to remove the appliance. Little is
achieved by adjusting loose removable appliances.
One final point in favor of the
semirapid rate is that it can be relied
on to separate adult sutures in 75%
of cases, whereas rapid expansion
fails in almost the same proportion

(R. Scavo, 1986 unpublished clinical

trial). This is of major significance in
presurgical cases, and it is a shame
that this knowledge is not more
widespread.
John Mew
Heathfield, Sussex, U. K.
Tel~fax 01435 862045

Reader's forum

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REFERENCES
1. Sandikqio-lu M, Hazar S. Skeletal and dental

6.

21A

changes after maxillary expansion in mixed

dentition. Am J Orthod Dentofac Orthop
1997;111:321-7.
Mew JRC. Relapse following maxillary
expansion. Br Dent J 1977;143:301-6.
Story E. Tissue response to the movement of
bones. Am J Orthod 1973;64:229.
Labret LML. Expansion with labiolingual and
removable appliances. Am J Orthod
1964;50:786-7.
Skiener V. Expansion of the midpalatal suture
by removable plates studies by the implant
method. Trans Eur Orthod Soc; 1964. p.14358.
Mew JRC. Relapse following maxillary
expansion. Am J Orthod 1983;83:56-61.