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Fixed versus Removable Appliance for Palatal Expansion; A 3D Analysis Using

the Finite Element Method

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 Original Article

Fixed versus Removable Appliance for Palatal Expansion;

A 3D Analysis Using the Finite Element Method

Allahyar Geramy1, Atefe Saffar Shahroudi2

1
Professor, Dental Research Center Dentistry Instituted, Orthodontics Department, Tehran University of Medical Sciences, Tehran, Iran
2
Assistant Professor, Orthodontics Department, Lorestan University of Medical Sciences, Khoram-abad, Iran

Abstract
Objective: Several appliances have been used for palatal expansion for treatment
of posterior cross bite. The purpose of this study was to evaluate the stress in-
duced in the apical and crestal alveolar bone and the pattern of tooth displacement
following expansion via removable expansion plates or fixed-banded palatal ex-
pander using the finite element method (FEM) analysis.
Materials and Methods: Two 3D FEM models were designed from a mesio-
distal slice of the maxilla containing the upper first molars, their periodontium and
alveolar bone. Two palatal expanders (removable and fixed) were modeled. The
models were designed in SolidWorks 2006 and then transferred to ANSYS Work-
bench. The appliance halves were displaced 0.1 mm laterally. The von Mises
stress in the apical, crestal, and PDL areas and also the vertical displacement of
the cusps (palatal and buccal) was were evaluated.
Results: The total PDL stress was 0.40003 MPa in the removable appliance (RA)
model and 4.88e-2 MPa in the fixed appliance (FA) model and the apical stress
was 9.9e-2 and 1.17e-2 MPa, respectively. The crestal stress was 2.99e-1 MPa in
RA and 7.62e-2 MPa in the FA. The stress in the cortical bone crest was 0.30327
and 7.9244e-2 MPa for RA and FA, respectively and 3.7271 and 7.4373e-2 MPa
in crestal area of spongy bone, respectively. The vertical displacement of the buc-
 Corresponding author: cal cusp and palatal cusp was 1.64e-2 and 5.90e-2 mm in RA and 1.05e-4 and
A. Saffar Shahroudi,
Orthodontics Department,
1.7e-4 mm in FA, respectively.
Lorestan University of Medi- Conclusion: The overall stress as well as apical and crestal stress in periodontium
cal Sciences, Khoram-abad, of anchor teeth was higher in RA than FA; RA elicited higher stress in both cor-
Iran
tical and spongy bone. The vertical displacement of molar cusps was more in re-
[email protected] movable than fixed palatal expander model.
B.
Received: 25 July 2013
Key Words: Orthodontics; Palatal Expansion Technique; Finite Element Method
Accepted: 21 December 2013 Journal of Dentistry, Tehran University of Medical Sciences, Tehran, Iran (2014; Vol. 11, No. 1)

INTRODUCTION maxillary and mandibular dental arches. Max-

One of the most prevalent occlusal discrepan- illary constriction can be skeletal, dental or a
cies is posterior crossbite which is a conse- combination of both. The prevalence of post-
quence of transverse discrepancy between erior crossbite in primary and mixed dentitions

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Journal of Dentistry, Tehran University of Medical Sciences Geramy & Saffar Shahroudi

has been reported to be 8 to 23 % [1]. This Accordingly, it is important to understand the

discrepancy can cause functional shifting pattern of stress distribution along the maxil-
which affects jaw growth and increases the lary sutures as well as throughout the alveolar
risk of facial asymmetry and cranio- bone induced by palatal expanders. It is also
mandibular disorders [2-4]. Additionally, imperative to know the pattern of tooth
maxillary constriction leads to space deficien- movement, improve the appliance design and
cy in the dental arch that results in crowding, minimize the adverse effects. Clinical studies
increases the risk of tooth impaction or aggra- have some limitations in illustrating the bio-
vates occlusal disharmony [5, 6]. Various mechanical effects of palatal expansion; con-
treatment modalities have been proposed and ventional methods such as photoelastic and
used for correction of posterior crossbite via strain gauges cannot identify the exact sites of
orthodontic or orthopedic maxillary expan- stress concentration in the orthopedic response
sion. These protocols are generally divided [15, 16].
into rapid maxillary expansion (RME) and The finite element method (FEM) has been
slow maxillary expansion (SME) based on the successfully applied for the biomechanical
activation intervals and force exerted by the study of stress and strain response to foreign
appliances [1, 7]. Several appliances are used forces in living structures [17]. This method
as palatal expanders. Fixed appliances such as has proven its efficiency in answering a wide
Haas and Hyrax with jackscrews can be used range of questions from basic to clinical [18-
for both SME and RME [8, 9]; while, remova- 23]. With regard to the issue of orthopedic pa-
ble expansion plates and quad helix are de- latal expansion there are few FEM studies that
signed for SME [10]. According to two syste- address stress distribution in RME along the
matic reviews, the available evidence on the midpalatal and craniofacial sutures [15, 24,
advantages of one treatment over the other one 25]. However, none of them compare different
is insufficient now and more studies are expander appliances and the patterns of tooth
needed [11, 12]. In RME treatment, the expan- movement during expansion. This finite ele-
sion screw is activated one or two times a day ment study was done to evaluate the stress in-
which is 0.25 – 0.5 mm expansion by about duced in the apical and crestal alveolar bone
100 N force [13]. SME appliances with screws following the same amount of displacement
are activated once or twice a week; which ex- induced by removable expansion plates and
ert about a 20 N force [8]. Thus, SME can eli- fixed appliances.
cit more efficient skeletal changes and more
stable results by allowing more time for adap- MATERIALS AND METHODS
tation [8]. The bone of the mid-palatal suture Three dimensional finite element method (3D
responds to compressive and tensile forces. FEM) was selected for the analysis. Two 3D
However, since the expansive force is directed FEM models were designed from a mesio-
to the teeth, dental movement and alterations distal slice of the maxilla containing the upper
in tooth inclination relative to the supporting first molars. The first model consisted of the
bone structure is inevitable. Although the most left and right first molars, their PDL, a palatal
desirable type of tooth movement is bodily expander and a mesio-distal slice of the maxil-
movement, palatal expansion leads to some lae. The difference between the two models
extent of molar tipping [14]. It is believed that was the design of the expander. In the first
the skeletal-to-dental movement ratios vary model, the expander was a removable ap-
according to type of expander appliance and pliance and the other model contained a fixed
the protocol of activation [13]. appliance.

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Geramy & Saffar Shahroudi Fixed versus Removable Appliance for Palatal Expansion…

Fig1. The meshed models: fixed appliance model (left), removable appliance model (right)

Contact elements were defined so that the con- 129,570 elements in the removable expansion
tact point of the removable appliance with the model and 530,806 nodes and 325,159 ele-
palatal side of the molars was inseparable, si- ments in the fixed palatal expansion model
mulating the contact of an Adam’s clasp to the (Figure 1). The anterior and posterior surfaces
palatal surface of the molar crown. of each model were restrained. The mechani-
The models were designed in SolidWorks cal properties of the materials used are pre-
2006 (Concord, Massachusetts, USA) and then sented in Table 1. The appliance halves were
transferred to ANSYS Workbench Ver. displaced 0.1 mm laterally. The von Mises
11(Canonsburg PA, USA) for the analysis. stress in the apical, crestal, and PDL and also
Meshing was done by the Workbench meshing the vertical displacement of the cusps (palatal
program. and buccal) of the first maxillary molars were
Meshed models contained 260,551 nodes and evaluated.

Table 1. Mechanical properties of the materials used in models

Young’s Modulus (MPa) Poisson’s Ratio
Tooth 20300 0.26
PDL 0.667 0.49
Spongy Bone 13400 0.38
Cortical Bone 34000 0.26
Stainless Steel 200000 0.3
Acrylic 23000 0.4

Table 2. Levels of stress induced in models with removable and fixed palatal expanders in MPa.
Removable appliance (e-2) Fixed appliance (e-2)
In crestal region of PDL 29.9 7.62
In apical region of PDL 9.90 1.17
Overall PDL 40.00 4.88
In cortical bone 30.327 7.4373
In spongy bone 372.71 7.4373

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Journal of Dentistry, Tehran University of Medical Sciences Geramy & Saffar Shahroudi

Fig 2. Displacement manner in the fixed appliance model (top); the removable appliance model (bottom).

RESULTS
Numeric findings are shown in Tables 2 and 3. The crestal stress was 2.99e-1 MPa in the re-
movable appliance model and 7.62e-2 MPa in
Stress: the fixed model (Table 2). Crestal stress was
The von Mises stress in the PDL was 0.40003 0.30327 MPa in the cortical crest bone in re-
MPa in the model with the removable ap- movable appliance and 7.9244e-2 MPa in the
pliance and 4.88e-2 MPa in the fixed ap- fixed appliance. These findings were 3.7271
pliance model. The apical stress was 9.9e-2 MPa in the removable and 7.4373e-2 MPa in
MPa in the removable model and 1.17e-2 MPa the fixed appliance when measured in the
in the fixed one. spongy bone area of the crest.

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Geramy & Saffar Shahroudi Fixed versus Removable Appliance for Palatal Expansion…

Fig 3. Total displacement produced in the fixed appliance model (top); the removable appliance model (bottom).

Displacement:
The vertical displacement measured at the (Table 3). This displacement in the palatal
buccal cusp of the first molar (inferior- cusp was 5.90e-2 mm in the removable and
superiorly) was 1.64e-2 mm in the removable 1.7e-4 mm in the fixed appliance model (Fig-
and 1.05e-4 mm in the fixed appliance model ures 2 and 3).

Table 3. Vertical displacement of various points in the crown of a modeled tooth in a model under expansion
by a removable and fixed appliance (in mm).
Removable appliance (e-2) Fixed appliance (e-4)
Buccal cusp 1.64 1.05
Palatal cusp 5.90 1.7

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Journal of Dentistry, Tehran University of Medical Sciences Geramy & Saffar Shahroudi

DISCUSSION after expansion and Chung stated that 4.3% of

With regard to the amount of expansion- inter-molar expansion after treatment by the
induced stress in the apical region of the anc- Haas appliance was due to buccal crown tip-
hor tooth, the results obtained from this FEM ping [29]. The degree of tipping depends on
study indicated that expansion via a removable various factors; some studies compared tooth-
appliance (RA) produced excessive stress at born appliances (hyrax) and tooth-tissue born
the apical and crestal regions while the stress (Haas) appliances and observed tipping in
was relatively low in fixed appliances (FA, both types but more in banded relative to
Table 2). With regard to the hypothesis that bonded ones; albeit the difference was not sig-
more molar tipping occurs by RA, this high nificant in some studies [26, 30]. With regard
apical stress can be attributed to apical dis- to RA, it can be speculated that the force deli-
placement of the root in uncontrolled tipping vered to teeth by acrylic plate cannot produce
type of tooth movement. A high degree of tip- a force necessary for bodily movement be-
ping is more obvious when the vertical move- cause there is no constant contact between the
ment of buccal and palatal cusps were com- acrylic plate and tooth surface. The acrylic
pared in removable and fixed models. As can plate can slide on the tooth and the location of
be seen in Table 3, buccal cusps of the molars force exertion varies with time. The pattern of
were displaced about 162.95 e-4mm more in contact depends on the amount of adaptation
RA using FA in the apico-coronal direction. of the acrylic plate and tooth surface. Howev-
Similarly, the palatal cusp moved about er, in FA, the bands have a wrap-around effect
588.30e-4 mm more in the same direction us- on the anchor teeth. The manner of tooth-band
ing RA. Moreover, the arrows which were rep- contact which is provided by the cement layer
resentative of displacement (Figure 2) de- and the rigid type of band-appliance connec-
picted a harmonious pattern and parallel direc- tion neutralizes the tipping induced by the
tions throughout the teeth in FA; while in RA screw - wire force application. From another
the inclination of the arrows changed smooth- point of view, the buccal tipping of anchor
ly from buccal to palatal cusps of the tooth. tooth can lead to lingual tipping as a conse-
Two scopes can be extrapolated from these quence of relapse after retention time. For ex-
results: the type of tooth movement during ex- ample McNamara et al. [27] reported 5° lin-
pansion (bodily vs. tipping) and direction or gual tipping in the crown of upper molars and
vertical tooth movement. According to finite 6° in lower molars in long term observation
element analysis of this study, more buccal after expansion phase. With regard to the re-
tipping occurs in molars undergoing expansion sults of vertical dimension, both buccal and
with RA while banded expanders induced lingual cusps showed vertical displacement in
more bodily buccal movement of molars. Al- the same directions. It can be concluded that
though the most desirable tooth movement palatal expansion induced extrusive force on
during palatal expansion is bodily movement, anchor teeth and the extrusion is more promi-
previous studies on this issue stated some de- nent in RA than FA. The importance of this
grees of buccal crown tipping of anchor teeth issue is more obvious in patients with vertical
during expansion [6, 26-28]. This tipping is growth patterns and opens bite tendency in
inevitable since the expansive force is deli- which the preservation of the bite is more cru-
vered to the crowns of the teeth away from cial [31, 32]. Considering the total stress dis-
center of resistance. The reported amount of tribution throughout the periodontium, the re-
tipping is various. Handelman et al. [28] re- sults of this study revealed that higher levels
ported 5.1° of maxillary molar buccal tipping of stress were induced in periodontium of anc-

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Geramy & Saffar Shahroudi Fixed versus Removable Appliance for Palatal Expansion…

hor teeth in RA than in PDL of anchor teeth of increase as much as tooth-born expanders.
FA with the same expansion force (Table 2). They also reported reduction in the level of
The difference in supporting structures of alveolar crest in buccal region of first molar
these appliances is worth consideration. With and first premolars especially in mesiobuccal
the same amount of expansion produced by region of first molar; which is thinner than
RA and FA, the entire force is applied to the central and distal areas. There has been a
anchor tooth (molar) in FA but it is not the strong correlation between excessive tooth
same in RA despite the presence of a wide movement and alveolar bone dehiscence re-
area of acrylic-palatal tissue contact. Howev- ported in the literature [38, 39] and an in-
er, the amount of force even in RA was not creased rate of dehiscence following RME has
above the PDL level of stress under routine been observed in various animal studies [40-
orthodontic forces [33]. Previous studies ex- 42]. This issue is more debatable when com-
plained the force exerted by palatal expanders paring RME and SME because of different
produced compression areas in PDL of sup- magnitudes of force and activation intervals.
porting teeth. Subsequently, alveolar bone re- However, in comparison of FA and RA, it can
sorption occurred on the buccal side; which in be extrapolated that the expander with a higher
turn led to tooth movement in the same direc- level of stress in the crestal region (which was
tion [34]. Odenrick et al. [35] confirmed that RA in this study) makes the alveolar bone
tooth-born palatal expanders were more iatro- more susceptible to resorption and dehiscence.
genic from the periodontal health standpoint From a more clinical point of view, several
and caused more root resorption in the anchor issues can be disputed. Fixed appliances are
teeth. Comparing the stress induced in cortical not dependent on patient compliance and
and spongy bone in the crestal region, our re- therefore their results are more predictable
sults indicated that RA exerted a higher level [43]. However oral hygiene may be impaired
of stress in both bone types than FA. Although by fixed appliances and banding can make the
in the FA model the amount of stress in both tooth more prone to demineralization [44]. On
types was approximately similar, in RA, the the other hand, when other minor tooth
stress of spongy bone was nearly ten times movements such as buccal movement of a lin-
more than that of cortical bone. Excessive gually placed lateral incisor is required, it can
tooth movement in the buccal direction puts be done simultaneously with a removable ex-
high stress on the buccal plate of alveolar pander by inserting a Z spring in the acrylic
bone, especially in the crestal region and de- plate. With regard to applying finite element
creased buccal bone plate thickness has been method to analyze maxillary expansion, lseri
reported following RME with banded and et al. evaluated the biomechanical effect of
bonded expanders [36] as well as after SME RME on the craniofacial complex and meas-
[37]. These findings were observed only in ured the stress induced and the amount of wi-
anchor teeth (for example in the first molar dening in circum-maxillary structures [25].
and first premolar not in canine or second They concluded that the highest stress concen-
premolar). This reduction was more prominent trated at the pterygoid plates of the sphenoid
in tooth-born (hyrax) relative to tooth and tis- bone in the region close to the cranial base. In
sue-born (Haas) appliances. Garib et al. [36] another FEM study, Gautam et al. demonstrat-
believed that the lingual bone plate may in- ed downward displacement and backward ro-
crease in thickness after expansion. However, tation of the maxilla and high stresses along
since tooth and tissue-born appliances elicited the deep structures and the various sutures of
compression-induced resorption in palatal the craniofacial skeleton following RME [15].
plate, the lingual bone plate resorption did not Lee et al. compared stress pattern distribution

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Journal of Dentistry, Tehran University of Medical Sciences Geramy & Saffar Shahroudi

between two FEM models with and without 3- Andrade Ada S, Gameiro GH, Derossi M,
patent palatal suture and concluded different Gaviao MB. Posterior crossbite and functional
patterns of stress distribution in circum- changes. A systematic review. Angle Orthod.
maxillary sutures [45]. However, it should be 2009;79:380-6.
mentioned that in our study, the orthopedic 4- Petren S, Bondemark L. Correction of
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modeled and evaluated since we concentrated Orthod Dentofacial Orthop. 2008;133:790 e7-
on the stress distribution pattern in anchored 13.
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