European Journal of Orthodontics, 2021, 265–273

doi:10.1093/ejo/cjaa050
Advance Access publication 25 August 2020

Randomized Controlled Trial (RCT)

Dental arch changes comparison between

expander with differential opening and fan-type
expander: a randomized controlled trial

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Camila Massaro1,*, , Guilherme Janson1, Felicia Miranda1, ,
Aron Aliaga-Del Castillo1, , Fernando Pugliese2,
José Roberto Pereira Lauris3 and Daniela Garib1,4
1
Department of Orthodontics, Bauru Dental School, University of São Paulo, Brazil, 2Department of Orthodontics, School
of Dental Medicine, Case Western Reserve University, Cleveland, OH, USA, 3Department of Public Health, Bauru Dental
School, University of São Paulo, Brazil, 4Department of Orthodontics, Hospital of Rehabilitation of Craniofacial Anomalies,
University of São Paulo, Bauru, Brazil

Correspondence to: Daniela Garib, Department of Orthodontics, Bauru Dental School, University of São Paulo, Alameda
Octávio Pinheiro Brisolla 9–75, Bauru, São Paulo 17012–901, Brazil. E-mail: dgarib@usp.br

*This article is based on research submitted by Dr. Camila Massaro in partial fulfilment of the requirements for the degree
of PhD in Orthodontics at Bauru Dental School, University of São Paulo.

Summary
Objectives:  To compare posterior crossbite correction frequency and dentoalveolar changes of the
expander with differential opening (EDO) and the fan-type expander (FE).
Trial design:  Two-arm parallel randomized controlled trial.
Methods:  Forty-eight patients from 7 to 11 years of age were allocated into two groups.Twenty-four
patients were treated with the EDO and 24 patients were treated with the FE. Block randomization
was performed. The study was single blind. Digital dental models were acquired before treatment
and 6  months after rapid maxillary expansion. The primary outcomes were crossbite correction
rate and maxillary arch width changes. Secondary outcomes were interincisal diastema, arch
perimeter, length, size and shape, and mandibular dental arch changes.
Results:  The final sample comprised 24 patients (13 female and 11 male; mean initial age of
7.62 years) in the EDO group and 24 patients (14 female and 10 male; mean initial age of 7.83 years)
in the FE group. The crossbites were corrected in 100 per cent of subjects from EDO group and in
75 per cent of patients in FE group. EDO showed greater increases in maxillary intermolar region
(P < 0.001), while the FE demonstrated greater increases in the intercanine distance (P = 0.008).
Increase in mandibular inter-first permanent molar distance was slightly greater in the EDO group
(mean difference of 0.8 mm). Changes in arch length and perimeter were similar in both groups.
Both expanders changed the maxillary arch shape. The post-treatment arch shape was larger in the
anterior region for FE and in the posterior region in the EDO group.
Harms:  Discomfort during activation was reported by 54 per cent of the participants. A temporary
change in the nasal bridge was reported by one patient from FE group.
Conclusions:  Maxillary arch width and shape changes were distinct between the EDO and the FE.
Greater transversal increases of the anterior and posterior regions were observed for the FE and

© The Author(s) 2020. Published by Oxford University Press on behalf of the European Orthodontic Society.
265
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266 European Journal of Orthodontics, 2021, Vol. 43, No. 3

the EDO, respectively. A slightly greater mandibular spontaneous expansion was observed for the
EDO only at the molar region.
Trial registration:  NCT03705871.

Introduction Methods
Maxillary constriction and posterior crossbites are common con- Trial design and any changes after trial
ditions in paediatric orthodontic patients. Interceptive treatment commencement
starting in the mixed dentition is highly recommended since most This two-arm parallel study was a single-centre randomized con-
of posterior crossbites do not self-correct (1, 2). Rapid maxillary trolled trial (RCT) with a 1:1 allocation ratio. Consolidated
expansion (RME) is a viable option to treat maxillary constriction Standards of Reporting Trials (CONSORT) statement and guide-
and posterior crossbites (3–6). A wide variety of appliance designs lines were followed (22).

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can be used to split the midpalatal suture, with successful correction
of maxillary constriction (3, 7–10).
Ethical considerations
Conventional expanders promote transverse increase in the
Ethical approval was obtained from the Research Institutional Board
maxillary arch by means of parallel opening of the expander screw
of Bauru Dental School, University of São Paulo, Brazil (Process
positioned in the centre of the palate (3, 10, 11). Similar increases
number: 71648917.6.0000.5417) before trial commencement.
in intercanine and intermolar distances were found after RME with
Participants who met the eligibility criteria were invited to partici-
the Haas-type and Hyrax expanders (12, 13). The fan-type ex-
pate and informed consent was obtained from all patients and their
pander (FE) can be indicated when an increase in the anterior arch
parents or legal guardians. In addition, the protocol of this study was
width with minimal effects in the molar region is desired (12, 14,
registered at Clinicaltrials.gov with the identifier NCT03705871.
15). More recently, the expander with differential opening (EDO)
was proposed to treat maxillary constriction individualizing the
expansion in the anterior and posterior regions of the dental arch Participants, eligibility criteria, and settings
(5, 7, 13). From November 2017 to June 2018, patients were recruited at the
Previous studies compared the Hyrax and FE outcomes dem- Orthodontic Clinic of Bauru Dental School, University of São Paulo,
onstrating that intercanine distance increase was similar in both Brazil. Eligibility criteria included Class I and Class II patients from
groups, while greater increase in intermolar distance was found for 7 to 11 years of age with maxillary constriction and posterior cross-
the Hyrax expander (12, 14). A previous comparison between Hyrax bites. Individuals with a Class  III malocclusion, craniofacial syn-
and the EDO showed similar intermolar expansion in both groups dromes, clinical absence of maxillary deciduous canines, and history
and greater intercanine expansion for the EDO (13). of previous orthodontic treatment were excluded.
Patients with cleft lip and palate and non-cleft individuals can
demonstrate greater constriction in the anterior region of the dental Interventions
arch (5, 16–18). In this scenario, greater expansion in the anterior Twenty-four patients were treated with the EDO (EDO group). The
region of the maxillary dental arch should be indicated to avoid an EDO was composed by two 10-mm screws, one posteriorly and
over and undesired expansion in the molar region. However, no pre- the other anteriorly positioned on the palate (Peclab Ltda., Belo
vious study compared the FE with the EDO guiding the clinician in Horizonte, MG, Brazil). During the first 6 days of activation, both
the expander selection. expander screws were activated two-quarter turns in the morning
Spontaneous dentoalveolar expansion might be expected in the and two-quarter turns in the evening. For extra 4 days, only the an-
mandibular arch after RME procedure (3, 10, 19, 20). A recent sys- terior screw was activated following the same activation protocol.
tematic review concluded that negligible short and long-term spon- The total expansion was 4.8 mm in the posterior screw and 8 mm in
taneous dentoalveolar changes occur in the mandibular dental arch the anterior screw (Figure 1).
after RME in the mixed and early permanent dentitions (21). No Twenty-four patients were treated with the FE (FE group). The
previous study assessed the spontaneous mandibular dental arch FE was composed by one 11-mm screw anteriorly positioned on the
changes with the EDO and the FE. palate (Morelli Ortodontia, Sorocaba, SP, Brazil). For 10 consecu-
Considering the above-mentioned concerns, some questions tive days, the expander screw was activated two-quarter turns in
remain: is there a difference between the EDO and the FE for the the morning and two-quarter turns in the evening, resulting in an
posterior crossbite correction rate and maxillary arch dimension expansion of 8 mm in the screw (Figure 2).
changes? Is the arch shape influenced by the different appliance de- In both groups, orthodontic bands were adapted on the right
signs? Does the EDO and the FE induce similar spontaneous changes and left maxillary second deciduous molars. Clasps were bonded on
in the mandibular arch dimensions and shape? No clinical study the right and left maxillary deciduous canines and a bilateral palatal
compared the EDO and the FE. extension from the maxillary second deciduous molars to the first
permanent molars was added (Figures 1 and 2). After a 10-day active
Specific objectives or hypotheses phase, the expander was kept as a retainer for 6 months. At the end
The aim of this study was to compare the frequency of posterior of the retention phase, the expander was removed, and a removable
crossbite correction and the maxillary and mandibular dental arch retention plate was delivered. The orthodontic treatment of all pa-
changes of the EDO and the FE in the mixed dentition using digital tients was conducted by the same orthodontist (CM).
dental models. The null hypothesis was that there is no difference Digital dental models of the maxillary and mandibular dental
between the EDO and the FE. arches were obtained for each patient before (T1) and 6 months after
C. Massaro et al. 267

Figure 1.  Maxillary expander with differential opening. (A) Pre-expansion phase. (B) Post-expansion phase.

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Figure 2.  Fan-type expander. (A) Pre-expansion phase. (B) Post-expansion phase.

RME (T2) using TRIOS 3 intraoral scanner (3-Shape, Copenhagen, Sample size calculation
Denmark). Digital dental models were saved in .stl file format. The intercanine distance was selected for sample size calculation be-
cause both expanders are indicated to treat maxillary constrictions
Outcomes (primary and secondary) and any that are more severe in the canine region (7, 8, 12–14). Additionally,
changes after trial commencement a minimal difference of 2 mm was considered clinically relevant. In
The primary outcomes were the frequency of crossbite correction order to detect a difference of 2 mm in intercanine width change, with
and the maxillary arch width changes. Interincisal diastema, arch a standard deviation of 2.18 mm (13), power of 80 per cent, and alpha
perimeter, arch length, arch size, arch shape, and mandibular dental of 5 per cent, a sample size of 20 patients per group was required.
arch changes were considered secondary outcomes. The amount of Considering possible losses, 24 patients were selected in each group.
differential expansion between the anterior and posterior region of
the maxillary dental arch was also considered a secondary outcome. Randomization
Other secondary outcomes stated in the trial registration will be re- After recruitment, patients were randomly allocated into two study
ported in further studies. groups. A  block randomization was performed before trial com-
All variables except the midline diastema were measured mencement using the Web site Randomization.com (http://www.
on the pre- and post-expansion digital dental models using the randomization.com) to ensure that the trial arms have equal num-
OrthoAnalyzer 3D software (3-Shape A/S, Copenhagen, Denmark) bers of participants (27). Opaque, sealed, and sequentially numbered
as shown in Figure  3. The width of the maxillary interincisal dia- envelopes containing the treatment allocation cards were prepared
stema (Figure 4) was clinically measured before treatment and imme- before trial commencement. The envelopes were sequentially opened
diately after the active phase of the expansion using an odontometric for each participant during recruitment. The initials of the name of
calliper (Precision equipment co., Boston, Massachusetts, USA). the participant were written on the envelope before opening it. The
For dental arch size and shape analyses, 14 landmarks were generation of randomization list, allocation concealment, and im-
placed on the occlusal surface of the T1 and T2 digital dental plementation were performed independently by different researches.
models of each patient using the Stratovan Checkpoint software
(Stratovan Corporation, Davis, California, USA) as shown in Blinding
Figure  3D (23). The x and z coordinates for each landmark were Double blinding was not possible since the patient and the operator
extracted and imported into the MorphoJ software (Klingenberg were aware of the type of expander delivered. However, blinding
Lab, Manchester, UK). The dental arch size was calculated auto- was accomplished during outcome assessment since all data were
matically in the MorphoJ software considering the square root of unidentified before analysis and all the digital dental models were
the sum of the squared distances between the dental arch centroid taken without the expander in the oral cavity.
point to each of the 14 landmarks (23–25). Using the same coord-
inates, a Generalized Procrustes Analysis (23, 26) was performed Statistical analyses
in the MorphoJ software to assess the maxillary and mandibular All assessments were performed by the same observer and 50 per
arch shapes. A mean shape of the dental arch was obtained for each cent of the sample was evaluated twice after a 30-day interval. The
group at the two time points and a Procrustes mean shape superim- intrarater error was assessed using intraclass correlation coefficients
position was performed. (ICC) and Bland–Altman method (28).
268 European Journal of Orthodontics, 2021, Vol. 43, No. 3

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Figure 3.  Maxillary and mandibular arch dimensions assessment: (A) arch widths were measured at the level of the cusp tips of the deciduous canines, first
deciduous molars, second deciduous molars, and first permanent molars; (B) arch perimeter was the sum of the four segments from mesial aspect of the right
first permanent molar to the mesial aspect of the contralateral tooth; (C) arch length was measured on the horizontal plane from the mesial aspect of the first
permanent molars to the mesial edge of the right permanent incisor; (D) 14 landmarks at the level of cusp tips and incisal edges of the maxillary and mandibular
teeth were selected on the digital dental model surface to provide raw coordinates representing dental arch shape and size. The dental arch size (centroid size
method) was automatically calculated in the MorphoJ software considering the square root of the sum of the squared distances between the arch centroid (AC)
to each 14 landmarks.

Figure 4. Maxillary interincisal diastema (A) before and (B) immediately after the active phase of the expansion. (C) The interincisal diastema width was
measured between the mesial incisal edge of right and left maxillary incisors before and after the active phase of the expansion using an odontometric calliper.
T1–T2 differences were considered interincisal diastema width changes.

Kolmogorov–Smirnov test was used to verify normal distri- Numbers analysed for each outcome, estimation,
bution. All variables showed normal distribution. Intergroup ini- and precision
tial age and sex ratio at baseline were assessed with t-test and The EDO group comprised 24 patients (13 female and 11 male) with
chi-square test, respectively. Crossbite data at baseline and inter- a mean age of 7.62 years (SD = 0.92) treated with the EDO. The FE
group comparison of the correction rate was performed using group comprised 24 patients (14 female and 10 male) with a mean
chi-square tests. T-tests with Holm–Bonferroni correction were age of 7.83 years (SD = 0.96) who underwent RME using the FE.
used for other intergroup comparisons. The significance level con- All patients were properly analysed in their original assigned groups.
sidered was 5 per cent. All statistical analyses were performed The complete sample demonstrated midpalatal suture split. No pa-
using Statistica software (Statistica for Windows version 11.0; tients were lost during the follow-up period.
StatSoft, Tulsa, Oklahoma, USA). The error study showed an excellent intraexaminer reproduci-
bility, with ICC varying from 0.947 to 1.00 (29). The variable with
Results the greatest Bland–Altman limits of agreement was the mandibular
arch perimeter (−0.56 and 0.63) and the variable with smallest was
Participant flow the maxillary intercanine distance (−0.33 to 0.27).
Figure 5 shows the CONSORT flow diagram of the study. A total The frequency of posterior crossbite correction was greater in the
of 48 patients were enrolled and were followed during the entire EDO group (Table 3). The crossbites were corrected in 100 per cent
observation period. of the patients from EDO group and in 75 per cent of patients from
FE group (P = 0.008).
Baseline data Both groups demonstrated similar changes in the maxillary inter-
Both groups showed similar baseline characteristics (Table 1). All incisal diastema width (Table  3). The interincisal diastema width
unilateral crossbites showed CO–CR shift at pre-treatment. No sig- opened 3.6 and 3.4  mm in groups EDO and FE, respectively. The
nificant intergroup differences were found for the initial dental arch EDO group showed greater increases in the maxillary inter-second de-
dimensions showing adequate intergroup comparability (Table  2 ciduous (mean difference of 1.4 mm) and inter-first permanent (mean
and Figures 6 and 7). difference of 2.7 mm) molars distances (P < 0.001). Conversely, the FE
C. Massaro et al. 269

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Figure 5.  Consolidated standards of reporting trial flow diagram showing the study design.

Table 1.  Intergroup comparisons for age, sex ratio, and frequency The mandibular dental arch showed mild spontaneous changes
of posterior crossbite at baseline (t-test and chi-square tests). after RME in both groups (Table 3). No intergroup differences were
observed except for the slightly greater increase in mandibular inter-
EDO FE
first permanent molars distance observed in the EDO group (mean
N = 24 N = 24
change of 0.9  mm ± 0.9 and 0.1  mm ± 0.8 for the EDO and FE
Variable Mean SD Mean SD P groups, respectively).
Changes in the maxillary and mandibular arch length and per-
Initial Age (y) 7.62 0.92 7.83 0.96 0.448
imeter after RME were similar in both groups (Table 3). The EDO
Sex Female 13 (54%) 14 (58%) 0.771
Male 11 (46%) 10 (42%) group showed greater increase in arch size (centroid size method)
Posterior Unilateral 18 (75%) 19 (80%) 0.731 than the FE group for maxillary (P  <  0.001) and mandibular
crossbite Bilateral 6 (25%) 5 (20%) (P = 0.008) arches.
The maxillary arch shape demonstrated significant changes in
EDO, expander with differential opening; FE, fan-type expander; SD, stand- both groups (Figure 6). Mandibular arch shape changed very slightly
ard deviation. only in the EDO group (Figure  7). The post-expansion maxillary
arch shape was different in the EDO and FE groups (P  <  0.001).
A  larger anterior width was observed for the FE group, while a
larger posterior width was found for the EDO group (Figure 6D).
group showed greater increase in intercanine distance (mean change of Post-expansion mandibular arch shape was similar in both groups
7.7 mm ± 1.2 for the EDO group and 8.8 mm ± 1.3 for the FE group). (Figure  7D). The differential expansion between anterior and
270 European Journal of Orthodontics, 2021, Vol. 43, No. 3

Table 2.  Baseline comparisons (t-tests).

EDO FE
N = 24 N = 24

Variables Mean SD Mean SD P

Interincisal diastema (mm) 1.45 1.10 1.14 1.10 0.341

Arch dimensions Maxilla c–c 29.70 3.01 29.24 2.25 0.557
(mm) d–d 36.29 2.22 34.78 2.21 0.051
e–e 42.47 2.38 41.26 2.64 0.103
6–6 49.23 2.71 47.91 2.65 0.096
Arch length 29.27 2.64 29.39 2.27 0.865
Arch perimeter 76.30 4.65 75.34 4.38 0.465
Arch size 83.00 3.99 81.71 4.20 0.286
Mandible c–c 27.74 2.46 26.50 2.21 0.115
d–d 33.13 2.47 31.64 1.47 0.041

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e–e 40.15 2.97 39.06 2.06 0.167
6–6 46.03 2.68 45.36 2.42 0.373
Arch length 25.26 1.91 24.86 1.80 0.461
Arch perimeter 70.57 3.38 69.23 3.76 0.234
Arch size 76.96 3.29 75.53 3.69 0.168

P < 0.05; Holm–Bonferroni correction method was applied. EDO, expander with differential opening; FE, fan-type expander; SD, standard deviation; c, decidu-
ous canines; d, first deciduous molars; e, second deciduous molars; 6, first permanent molars.

Figure 6.  Superimpositions of maxillary dental arch shape. (A) Pre-expansion maxillary dental arch in the fan-type expander (FE) group (grey line) and in the
expander with differential opening (EDO) group (black line). (B) Maxillary dental arch before (grey line) and after expansion (black line) in the EDO group. (C)
Maxillary dental arch before (grey line) and after expansion (black line) in the FE group. (D) Post-expansion maxillary dental arch in the FE group (grey line) and
in the EDO group (black line). The P-value is observed for each comparison (variance analysis).

posterior regions of the maxillary dental arch was significantly FE to allow intergroup comparisons. Additionally, only Class I and
greater in the FE group (Table 4). Class II patients were included in this study. Class III patients were
not included once maxillary protraction could influence the out-
Harms comes. The baseline comparisons showed no intergroup differences
confirming the homogeneity of the sample (Tables 1 and 2). These
No important harm was caused to the participants of this study.
results ensure the effectiveness of randomization and allocation of
Fifteen patients from the EDO group (62 per cent) and 11 from the
patients, decreasing the risk of bias in the intergroup comparisons
FE group (45 per cent) reported a slight pain or discomfort during
of treatment changes (31).
the activation of the expander screw. Additionally, one patient from
In the present study, digital dental models were obtained using
the FE group showed a clinical change in the nasal bridge after ex-
an intraoral scanner. Previous studies showed adequate accuracy
pansion probably caused by the opening of the nasomaxillary suture.
and reliability of interarch and intra-arch measurements performed
The nasal alteration was reported by parents and spontaneously re-
on digital dental models derived from intraoral scans (32–34). Our
covered during the follow-up period.
results are in accordance with previous studies demonstrating ad-
equate intraexaminer reproducibility. The dental arch size and shape
Discussion analyses were based on the centroid size and location (23–26) pro-
viding a visual representation of intergroup comparisons.
Sample and methodology
No previous study compared the outcomes of the EDO and the
FE. Comparisons between RME treatment outcomes are difficult Main findings
since the clinical studies vary regarding sample size, age of the pa- In this study, 48 patients in the mixed dentition with posterior cross-
tients, and amount of expansion achieved (4, 30). A  controlled bites were treated with RME procedure. The crossbites were cor-
prospective study with sufficient power and standardized method- rected in all 24 subjects from the EDO group (100 per cent) and in
ology is important for answering clinical questions. An expansion 18 out of 24 patients from the FE group (75 per cent). The FE did
of 8 mm was performed in the anterior screw of the EDO and the not completely correct the posterior crossbite in six patients because
C. Massaro et al. 271

Table 3.  Intergroup comparisons of the interphase changes (t-tests and chi-square test).

EDO FE
N = 24 N = 24

Mean SD Mean SD
Variables (T2–T1) (T2–T1) P

Interincisal diastema (mm) 3.65 0.74 3.43 1.13 0.449

Arch dimensions Maxilla c–c 7.76 1.23 8.80 1.33 0.008*
(mm) d–d 7.85 1.31 7.42 1.66 0.398
e–e 6.36 0.84 4.90 0.91 <0.001*
6–6 5.10 1.17 2.33 0.75 <0.001*
Arch length −0.54 0.86 −0.36 0.76 0.449
Arch perimeter 5.14 1.56 5.33 1.40 0.662
Arch size 9.28 1.28 7.01 1.05 <0.001*
Mandible c–c −0.35 1.11 −0.05 0.67 0.324

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d–d 0.27 0.83 0.35 0.88 0.803
e–e 0.59 0.66 0.31 0.79 0.225
6–6 0.93 0.91 0.12 0.89 0.003*
Arch length −0.55 0.60 −0.52 0.60 0.844
Arch perimeter −0.64 0.86 −0.66 1.27 0.955
Arch size 1.02 0.83 0.23 1.09 0.008*
Posterior crossbite correction
Yes 24 18 0.008**
No 0 6

P < 0.05; Holm–Bonferroni correction method was applied.

*Statistically significant (t test).
**Statistically significant (chi-square test).
EDO, expander with differential opening; FE, fan-type expander; SD, standard deviation.

Figure 7.  Superimpositions of mandibular dental arch shape. (A) Pre-expansion mandibular dental arch in the fan-type expander (FE) group (grey line) and in the
expander with differential opening (EDO) group (black line). (B) Mandibular dental arch before (grey line) and after expansion (black line) in the EDO group. (C)
Mandibular dental arch before (grey line) and after expansion (black line) in the FE group. (D) Post-expansion mandibular dental arch in the FE group (grey line)
and in the EDO group (black line). The P-value is observed for each comparison (variance analysis).

the appliance posterior hinge restricted the expansion in the pos- Table 4.  Intergroup comparison of the differential expansion in the
terior region (second deciduous and fist permanent molars). The re- deciduous canines and first permanent molars (t-test).
sults from the present study demonstrated that the FE should be
c–c 6–6 Difference
selected to treat posterior crossbites restricted to the canine and first
deciduous molar regions. When the posterior crossbite extends to Mean SD Mean SD Mean SD
the second deciduous and/or permanent molars, the EDO should be Group change change P
preferred over the FE.
EDO 7.76 1.23 5.10 1.17 2.65 1.47 <0.001*
Similar opening of the interincisal diastema was observed in both
FE 8.80 1.33 2.31 0.76 6.09 1.47
groups (Table 3). An opening of 3.6 mm for the EDO and 3.4 mm
for the FE (45 and 42 per cent of the screw activation, respect-
P < 0.05; *Statistically significant. EDO, expander with differential open-
ively) were observed. These outcomes were expected since the same
ing; FE, fan-type expander; SD, standard deviation; c, deciduous canines; 6,
amount of expansion was performed in the anterior screw of the first permanent molars.
EDO and in the FE (8 mm). A previous study reported an opening of
4.1 mm in the interincisal diastema width with the EDO and 2.4 mm
with Hyrax expanders (13). A meta-analysis showed a mean increase Increase in intercanine distance was slightly greater in the FE
in the midline diastema of 2.9  mm after RME with conventional group (Table 3). Since the anterior expansion amount was the same
expanders (30). The slightly greater mean values found for the EDO in both groups, it is possible to suggest that this small transverse
and the FE compared to conventional expanders might be explained difference (approximately 1 mm) was probably caused by a greater
by the greater anterior activation. canine buccal inclination after a fan expansion. Greater tendency for
272 European Journal of Orthodontics, 2021, Vol. 43, No. 3

labial inclination of the anterior supporting teeth with the FE was Differential expansion between molar and canine regions was
previously reported in cleft patients (16). The assumption is that the observed in both groups with more intensity for the FE group. The
FE concentrates the activation force in the canine region. On the ratio between intercanine and intermolar expansions were approxi-
other hand, the EDO might distribute the expansion stress by all an- mately 1.5:1 in the EDO group and 3.5:1 in the FE group. Our re-
chored teeth, mainly in the first days of the active phase. sults are in accordance with previous studies that found a ratio of
Conversely to intercanine increase, intermolar expansion was 1.7:1 for the EDO (13) and 3.5:1 for the FE (14). The EDO and the
greater in the EDO group (Table  3). The possible explanation is FE are two viable options to treat maxillary arch constriction with
the presence of the posterior screw in the EDO. A  previous RCT very similar impact on the canine region. The decision between both
showed that the EDO caused an intermolar expansion similar to the expander designs should consider the required amount of expansion
Hyrax expander (13). Using a fan-shape expander, the intermolar in the intermolar distance and the presence of posterior crossbite,
increase was not clinically important (2.3  mm). These results cor- including molars.
roborate with a previous study showing an intermolar width in-
crease of 2.6 mm after RME with an FE (12). Despite the intergroup Limitations
differences in maxillary arch width expansion, the arch perimeter This was a single-centre study and the treatment was conducted by
increased similarly in both EDO and FE groups (Table 3). In this per-

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one operator. Moreover, the participants and the operator were not
spective, both appliances can be indicated to solve maxillary incisor blinded as a consequence of the differences in the appliance designs.
crowding (4, 35, 36). A slight decrease in maxillary arch length was However, data were de-identified before analysis. Other limitation
observed in both groups and might be explained by the slight palatal of this study was the lack of a tension distribution analyses. Further
inclination of the maxillary central incisors after RME related to studies should assess the EDO and the FE force concentration using
interincisal diastema closure (6, 37, 38). finite element analysis.
The mandibular dental arch changes were very mild in the
EDO and FE groups (Table 3). Additionally, the mandibular out-
Generalizability
comes were similar in both groups, except for the greater increase
The results of the present study may be generalized to non-cleft pa-
in inter-first permanent molar distance in the EDO group (mean
tients in the mixed dentition. Additionally, the generalizability of the
difference of 0.8 mm; Table 3). The greater transverse change in the
results should be limited to similar expanders using the same acti-
posterior region of the mandibular arch in the EDO group might
vation protocol.
be explained by the greater maxillary molar expansion caused by
the EDO (Table 3). Previous studies assessing the mandibular arch
changes after a conventional RME also showed spontaneous in- Conclusions
crease in the mandibular intermolar width (3, 10, 19). The small
The null hypothesis was rejected.
widening in the mandibular dental arch after RME might be ex-
plained by changes in balance between the tongue and buccinator 1. A greater frequency of posterior crossbite correction was ob-
muscles. The cusp-fossa occlusal contact between the palatal cusp served in the EDO group.
tip of the maxillary molar and the occlusal aspect of the mandibular 2. The EDO showed greater expansion at the level of the maxillary
molars also might have contributed to the slight uprighting of the second deciduous and first permanent molars.
mandibular posterior teeth (3, 20). Both the EDO and the FE in- 3. The FE produced greater maxillary intercanine distance increase.
duced very small widening of the mandibular dental arch, however, 4. A greater mandibular dental arch change was observed after
without causing a perimeter arch increase (Table  3). Mandibular RME with the EDO compared to the FE.
arch length decreased equally in both groups, probably as a result 5. The EDO and the FE induced distinct post-expansion arch
of dental development in the mixed dentition leading to Leeway shapes.
Space loss (39).
Interestingly, both expanders were capable of changing the max-
illary arch shape (Figures 6B and 6C). In this study, the post-expan- Funding
sion maxillary arch shape differed between the groups (Figure 6D).
This study was financed in part by the Coordenação de
The mean final arch shape was wider in the molar region for the
Aperfeiçoamento de Pessoal de Nível Superior - Brasil (CAPES) -
EDO group and wider in the canine region for the FE group.
Finance Code 001, and by the São Paulo Research Foundation
Mandibular arch shape after RME was similar in both groups. The
(FAPESP) - Grant numbers 2017/12911-9 and 2017/24115-2.
literature is scarce for arch shape analysis after RME. A  previous
study showed that the arch shape changed in 98 per cent of the
patients after conventional expansion (40). In cleft patients, using Conflict of interest
similar methodology, arch shape changes were observed after ex-
pansion with Quad-helix and EDO (23). In addition, the arch size Licensed patent of the expander with differential opening (PI
calculated thought the centroid size method increased more in the 1101050-9) registered by the last author, FAPESP and University
EDO group both in the maxilla and mandible (Table 3). These dif- of São Paulo at the National Institute of Industrial Property
ferences might be explained by a greater expansion in the posterior (INPI-Brazil).
region of both dental arches in the EDO group. No previous study
evaluated the arch size after RME using the centroid size method in
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