Contemporary Orthodontics & Dentofacial Orthopedics
Board Certified Treatment for Children, Teens and Adults
My child needs a Palatal Expander, what is it
and what can I expect?
I have discussed the rationale for and the various types of expanders in previous articles so I will limit this discussion to the types of expanders and what to expect when your child comes home for the first week.
First of all, remember that expanders should only be placed on the upper arch since they are meant to move bones; the upper arch (maxilla) is formed from several pieces that do not fuse together until the mid to late teens. The lower jaw pieces fuse around birth so you cannot “expand” the lower jaw; an expander on the lower jaw will push the lower teeth out of the bone leading to relapse as well as a significant risk of recession.
“The lower jaw fuses at or around birth so you cannot “expand” the lower jaw: and expander on the lower jaw will push the lower teeth out of the bone leading to relapse as well as a significant risk of recession.”
Expanders are made up of a hyrax screw and some type of anchorage system to attach the screw to the upper teeth (they will use erupted teeth as anchorage). The screw is fairly universal, all expanders will have a similar mechanism where a “key” is used to turn the screw which then expands the two sides of the expander apart.
These are the three types of expanders; note the screw is the same in each.
The Removable Expander is generally not used by specialists since it has been shown to only tip teeth and not truly expand the bone. Besides the obvious problems associated with all removable appliances (compliance and loss being the two most common), any “expansion” from a removable expander will be mostly dental and not skeletal and is therefore going to cause extrusion of molars, tipping of the back teeth outward and opening of the bite which will lengthen the face and have a tendency to open the bite.
The Banded Expander is the most common expander used though it also will cause tipping in most cases, especially when used in younger patients with a mix of primary teeth and only the permanent molars. As in the case above, note that the screw is already turned but the front of the arch remains narrow and tapered. When you look closely you will that only the molars where the expander is attached have moved out but the bone remains narrow. This expander also can allow molars to tip outward which in turn leads to relapse and can open the bite and the bands are difficult to clean around leaving areas that can become decayed if oral hygiene is not stellar.
The Bonded Expander is the most specialized and efficient of the three expanders. It includes a clear acrylic plate over the back teeth which is more rigid and stable than either of the other expanders. It also acts as a bite splint to de-program any shift in the jaw which is commonly present with crossbites. Vertically, although the forces from the expansion will want to extrude the back teeth out of the bone, the acrylic overlay prevents this by allowing the occlusion from lower teeth push the upper teeth back into the bone throughout treatment. Finally, the bonded expander covers not only the permanent molars but also the primary molars for added stability and protection against cavities. They have to be custom made for each patient and fit to accommodate individual occlusions so they are a bit more difficult for the orthodontist.
For the reasons above, I will not include further information on the Removable Expander but will instead focus on the remaining accepted Banded and Bonded Expanders.
The first thing you need to know is that YOU will be turning the expander at home. Since we want gradual movement, you will need to activate or turn the expander, usually once to twice per day (see below).
Rapid Palatal Expander Instructions
Step 1: In a well-lit area tip the patient’s head back.
Step 2: Place the key in the hole until it is firmly in place.
Step 3: Pushing the key towards the back of the mouth, you will notice the fender will rotate and the new hole will appear. The rotation stops when the key meets the back of the expander.
Step 4: By pushing back and down towards the tongue, remove the key. The next hole for insertion of the key should now be visible. This counts as one turn.
The second thing you need to expect is that your child will have a little trouble swallowing for the first day or three. This normally manifests as some extra drool and a slurpy noise every 5 to 10 minutes for the first evening or so. I find the best way to help children get over this is to send them for an ice cream cone right after placing the expander (of course they know to brush afterward!). It is important to choose a cone, not a cup, because this forces the child to lick and swallow continuously and will quickly retrain the tongue where to position itself to swallow normally. Having had two children go through this myself, I can tell you that you will want to do whatever is necessary to get them to stop making slurping noises. Ice cream also has the added benefit to show your child he or she can still eat with the expander.
I often use the analogy of placing scotch tape on the pad of a cat’s foot and watching him refuse to walk, that is until he overcomes the mental block of feeling a foreign item on his paw. The expander will be similar but your child, like mine, will be able to eat just about anything within a day or two.
You will need to expect an adjustment period to be able to fully understand your child. It takes a day of talking (and speaking more slowly) for your child to learn to talk around an expander, usually with their “s” sounds. Have them practice counting slowly from “60” to “70” swallowing between every 3 to 4 numbers. Do this until they can say “Mississippi” like a southerner. Another great tool is to have them read a Dr. Seuss book the first evening. A little “Cat in the Hat” goes a long way to restore speech. Finally, make sure you actually make them talk, don’t let them slide by nodding and grunting.
Lastly, let your child’s teachers know that they may be talking a little funny for the first week; if they don’t know what an expander is, you may have them “Google” it or they can visit this site so they know what to expect. If you have an older child in band or choir, talk to the band instructor and assure them your child will be back to 100% with whatever instrument within a week or so.
Two final bits of advise I will share have to do with keeping the gums healthy and the teeth clean. First, make sure your child always has water after every snack/drink/meal. Plaque takes hours to form so a good rinsing with water will clean most of the food and sugar away from the teeth and the appliance. Add a daily rinse with a Fluoride rinse like Listerine’s Total Care or Act with Fluoride; this not only provides fluoride to help re-mineralize teeth each day but also keeps the gums healthier and will usually prevent the gums from “puffing up” during treatment. Last but not least, brush twice daily and after brushing their teeth, make sure your child re-brushes their gums above and around the expander.
So there you have it, a crash course in rapid palatal expansion. Just remember that expansion can prevent removal of permanent teeth later, can reduce risks of impaction to teeth that are blocked due to a narrow upper jaw, can reduce the time in treatment for orthodontics later and can even prevent braces in some cases.
If you have questions or comments concerning this or any orthodontic question, please feel free to make a complimentary new-patient appointment at either my Steiner Ranch location or my North-central Austin location on West 35th street and MoPac.
Dr. James R. Waters is a 1996 graduate from UTHSC Dental School in San Antonio, 1997 graduate of Advanced Dentistry from the UNMC in Nebraska and the 2001 Valedictorian graduate from the prestigious Saint Louis University Orthodontic Program receiving the J.P. Marshall award for clinical excellence in 2001. He holds a Bachelor’s Degree in Science, Doctorate in Dental Surgery, a post-doctorate certificate in Advanced Dentistry, post-doctorate Degree in Orthodontics & Dentofacial Orthopedics and a Master of Science Degree in Orthodontics. Dr. Waters and his wife of 19 years live in Austin, TX with their 4 children where he has a thriving, multi-faceted Specialist practice with locations in Steiner Ranch and North-Central Austin. You can learn more about Dr. Waters at BracesAustin.com.
1814 W. 35th Street
Austin, TX 78703
4302 N. Quinlan Park
Austin, TX 78732