Original Article

Short-term skeletal and dentoalveolar effects of overexpansion:

A pilot randomized controlled trial
Arun K. Balaa; Phillip M. Campbellb; Larry P. Tadlockc; Emet D. Schneidermand; Peter H. Buschange

ABSTRACT

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Objectives: To evaluate whether the amount of rapid maxillary expansion differentially affects the
skeletal and dentoalveolar changes that occur.
Materials and Methods: This randomized controlled trial included 23 patients who had rapid
maxillary expansion (RME). Subjects were randomly assigned to a conventional expansion control
group (n ¼ 12) or an overexpansion group (n ¼ 11), who started treatment at 13.2 6 1.5 and 13.8 6
1 years of age, respectively. Cone beam computed tomography scans (11 cm) were obtained prior
to rapid maxillary expander (RME) delivery and approximately 3.7 months later. Initial hand-wrist
radiographs were used to determine the participants’ skeletal maturity.
Results: The RME screws were activated 5.6 6 1.2 mm and 10.1 6 0.6 mm in the conventional
and overexpansion groups, respectively. Overexpansion produced significantly greater expansion
of the nasal cavity (2.1X–2.5X), maxillary base (2.3X), buccal alveolar crest (1.4X), and greater
palatine foramina (1.9X). Significantly greater intermolar width increases (1.8X) and molar
inclination (2.8X) changes were also produced. The nasal cavity and maxillary base expanded
23%–32% as much as the screws were activated. Skeletal expansion was positively correlated with
RME screw activation (R ¼ 0.61 to 0.70) and negatively correlated (R ¼ 0.56 to 0.64) with the
patients’ skeletal maturation indicators (SMIs). Together, screw activation and the patients’ SMI
scores explained 48%–66% of the variation in skeletal expansion.
Conclusions: This pilot study shows that overexpansion produces greater changes than
conventional expansion, with greater skeletal effects among less mature patients. (Angle Orthod.
2022;92:55–63.)
KEY WORDS: RME; RCT; Humans; Overexpansion; CBCT

INTRODUCTION
Rapid maxillary expansion (RME) has been used as
an adjunct to traditional orthodontic treatment for over
150 years.1 It has been advocated for posterior
a
Private Practice, Austin, TX, USA. crossbites, transverse and anteroposterior maxillary
b
Professor Emeritus, Department of Orthodontics, Texas deficiencies, and mild-to-moderate crowding.2–6 RME is
A&M University College of Dentistry, Dallas, TX, USA.
c
Associate Professor, Department of Orthodontics, Texas often preferred to slow expansion because it maximiz-
A&M University College of Dentistry, Dallas, TX, USA. es the skeletal corrections.3,7 The effects of RME
d
Professor, Department of Biomedical Sciences, Texas A&M include, in order, compression of the periodontal
University College of Dentistry, Dallas, TX, USA. ligament, bending of the alveolar processes, tipping
e
Regents Professor and Director of Orthodontic Research,
Department of Orthodontics, Texas A&M University College of
of the maxillary posterior teeth, and separation of the
Dentistry, Dallas, TX, USA. midpalatal suture.3,7
Corresponding author: Peter H. Buschang, PhD, Professor Cone beam computed tomography (CBCT) provides
and Director of Orthodontic Research, Orthodontic Department, an accurate three-dimensional visualization of RME
Texas A&M University College of Dentistry, Dallas, TX 75246, effects.8 Based on reported CBCT averages, the
USA
(email: phbuschang@tamu.edu) maxillary skeletal base expands 19%–58% as much
as the molars (Table 1).6,9,10 Relative to screw
Accepted: July 2021. Submitted: March 2021.
Published Online: August 13, 2021 activation, the skeletal base expands 22%–50% as
Ó 2022 by The EH Angle Education and Research Foundation, much.11–18 There is no clear pattern of differences
Inc. between or within sites, possibly due to the lack of

DOI: 10.2319/032921-243.1 55 Angle Orthodontist, Vol 92, No 1, 2022

56 BALA, CAMPBELL, TADLOCK, SCHNEIDERMAN, BUSCHANG

Table 1. Skeletal Expansion as a Percent of Molar Expansion and

Screw Activation
Skeletal %
Amount Skeletal Expansion Skeletal
References (mm) Location (mm) Expansion
Molar expansion
Cross et al.13 5.50 Nasal cavity 1.06 19.3
Silva Fihlo et al.8 5.47 Nasal cavity 2.08 38.0
Cross et al.13 5.50 Maxillary base 1.11 20.2
Kartalian et al.14 5.35 Maxillary base 2.25 42.1
Silva Fihlo et al.8 5.47 ANS 2.66 48.6
Cross et al.13 5.50 ANS 3.19 58.0

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Screw activation
Chung et al.15 7.58 Nasal cavity 1.75 23.1
Kanomi et al.19 5.00 Nasal cavity 1.28 25.6 Figure 1. Patient flow through the study.
Baratiera et al.16 7.00 Nasal cavity 2.11 30.1
Garrett et al.18 5.08 Nasal cavity 1.89 37.2
Pereira et al.20 8.00 Maxillary base 1.76 22.0
To be eligible for the study, patients had to be in the
Podesser et al.21 7.00 Maxillary base 1.70 24.3 late mixed or early permanent dentition stages, less
Chung et al.15 7.58 Maxillary base 2.28 30.1 than 16 years old, require at least 4 mm of palatal
Garib et al.17 7.00 Maxillary base 2.60 37.1 expansion to treat transverse deficiencies, and be in
Weissheimer et al.22 8.00 Maxillary base 3.10 38.8 good periodontal health (ie, pocket depths , 2 mm;
Podesser et al.21 7.00 Midpalatal suture 1.60 22.9
Weissheimer et al.22 8.00 Midpalatal suture 3.14 39.3
attached gingiva; no more than localized gingivitis).
Garrett et al.18 5.08 Midpalatal suture 2.55 50.2 Patients were excluded if they had pre-treatment
hypodontia, craniofacial anomalies or were being
treated with any other appliances.
variability in the amounts of expansion performed. The A power analysis, assuming a power of 90%, a type I
relationship between the amount of maxillary expan- error of 5%, and an effect size of 1.2 (based on
sion and the skeletal response provides the basis for reported dentoalveolar changes),12 indicated that 12
understanding the stability of dental and skeletal patients per group were required. A total of 28 patients
components.5,19,20 To address possible post-retention were recruited between August 2018 and April 2019,
relapse associated with dental tipping and dentoalve- with four additional subjects to account for dropouts
olar bone bending, 2 to 4 mm of overexpansion has (Figure 1). The study was approved by the Institutional
been recommended.3,6,10 Haas4 advocated substantial- Review Board at Texas A&M University College of
ly more overexpansion, suggesting that the mandibular Dentistry (2017-0585-CD-FB). Stratified by sex, the
arch should be completely contained by the maxillary subjects were randomly allocated to a conventional
arch. He proposed an average 12 mm of expansion, expansion control group (n ¼ 14) or an overexpansion
and a minimum of 10 mm.5 experimental group (n ¼ 14) using the Microsoft Excel
The objective of the present study was to determine (version 16.0, Microsoft Corporation, Redmond, WA,
how the amount of expansion is related to the amounts USA) randomization function. The conventional and
of dental and skeletal responses that occur. The null overexpansion groups were 13.2 6 1.5 and 13.8 6 1
hypothesis was that greater amounts of screw activa- years of age at the start of treatment, respectively. Chi-
tion have no effect on the relative (skeletal vs dental) square analysis indicated that there was no significant
amounts of expansion that occur. To date, the skeletal (P ¼ 0.292) between-group difference with regard to
effects of overexpansion have not been objectively the sex distribution. There were no changes to the trial
evaluated. Overexpansion is planned to gain greater after it commenced. To determine whether the treat-
amounts of skeletal changes, with the dental and ment response was related to the participants’ skeletal
dentoalveolar aspect of overexpansion being corrected maturity, Fishman’s skeletal maturity indicators (SMI)
during fixed appliance therapy. were used.21

MATERIALS AND METHODS Appliance Design and Expansion Protocol

A randomized controlled trial was designed to Hyrax expander screws (either 10 or 12 mm) were
evaluate the effects of overexpansion among ortho- used, with bands on the maxillary first molars and
dontic patients. The study included patients recruited at metal arms extending anteriorly to the second and first
Texas A&M College of Dentistry. All data were premolars, or deciduous molars when applicable. The
collected and maintained at the College of Dentistry. conventional group was expanded until the palatal
This trial was not registered. cusps of the posterior maxillary teeth were positioned

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Figure 2. Orientation of (A) coronal view on the orbits, (B) sagittal view on ANS and PNS, and (C) axial view on midpalatal suture.

along the lingual incline of the buccal cusps of the The floors of the right and left orbits were oriented
posterior mandibular teeth. Subjects in the overex- along the true horizontal in the coronal plane (Figure
panded group were expanded to the limits of the RME 2); in the sagittal plane, ANS and PNS were oriented
screws (5 with the 10 mm and 6 with the 12 mm along the true horizontal. In the axial plane, the
screws). All participants were instructed to turn the midpalatal suture was oriented along the true vertical.
expansion screw one turn (0.25 mm) per day and to Seven measurements were made on the coronal slice
record their turns. When expansion was completed, passing through the centers of the maxillary first molar
screw activation was measured twice intraorally using palatal roots (Table 2).10,12–14,16–18 Anterior nasal width
digital calipers, and averaged for the analyses. was measured on the coronal slice passing through the
center of the incisive foramen (Figure 3). 22 To
CBCT Methodology determine skeletal expansion posterior to the first
molars, greater palatine foramina width was measured
To quantify the skeletal and dental effects of as the distance between the lateral margins of the
expansion, 11-cm CBCT scans were obtained prior to greater palatine foramina on the axial slice passing
RME delivery (T1) and after expansion/retention was through the center of the hard palate.22 Molar and
complete (T2). The CBCT scans were taken using an i- alveolar bone inclinations were measured bilaterally
CAT FLX unit (Imaging Sciences International, Hat- and averaged (Figure 4). All measurements were
field, PA, USA) at 0.3-mm voxel size, with a pulsed made by one blinded operator. The CBCTs of 10
scan time of 8.9 seconds. The CBCTs were evaluated randomly selected subjects were re-oriented and re-
using Dolphin 3D software (version 11.9, Dolphin measured. No statistically significant systematic differ-
Imaging & Management Solutions, Chatsworth, CA, ences were found; method error ranged from 0.3 to 0.4
USA). The patients continued into fixed orthodontic mm for linear, and from 0.28 to 1.28 for angular
treatment after the T2 CBCT had been taken. measurements.

Table 2. Measures, Their Abbreviations (Abbr), Units, and Definitions. All Measurements Except ANW and GPFW Were Made on the Coronal
Slice Taken Through the Center of the Maxillary First Molar Palatal Roots
Measure Abbr Units Definitions
Anterior nasal width ANW mm The widest portion of the nasal aperture on slice take at the center of the incisive
foramen (Figure 3A)
Posterior nasal width PNW mm The widest portion of the nasal aperture (Figure 3B)
Maxillary width at nasal floor Mx_NF mm Distance between the maxillary cortical plates at the level of the nasal floor (Figure 3C)
Maxillary width at alveolar crest Mx_AC mm Distance between the maxillary cortical plates at the levels of the buccal alveolar
crest (Figure 3C)
Greater palatine foramina width GPFW mm Distance between the lateral margins of the greater palatine foramina taken on an
axial slice through the center of the hard palate (Figure 3D)
Inner molar width IMW mm Distance between the palatal cusp tips of the maxillary first molars (Figure 4A)
Molar inclination MInc 8 Average of right and left angles formed by the intersections of the lines connecting
the palatal cusp tips and root apices of the maxillary first molars and the true
horizontal (Figure 4A)
Inner alveolar bone inclination ABInc_I 8 Average of right and left angles formed by the intersections of the lines tangent to
the inner cortical plates of alveolar bone and the true horizontal (Figure 4B)
Outer alveolar bone inclination ABInc_O 8 Average of right and left angles formed by the intersection of the lines tangent to
the outer cortical plate of alveolar bone and the true horizontal (Figure 4C)

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Figure 3. (A) anterior nasal width (ANW), (B) posterior nasal width (PNW), (C) maxillary nasal floor (Mx_NF) and alveolar crest (Mx_AC), and (D)
greater palatine foramina width (GPFW) measured on the coronal slice.

Statistical Analyses mm) than control (5.6 6 1.2 mm) group (Table 4).
Anterior nasal width (D ANW; 2.1X), posterior nasal
All analyses were performed using IBM SPSS
width (D PNW; 2.5X), maxillary width at the nasal floor
Statistics software (version 25.0, IBM Corporation,
(D Mx_NF; 2.3X), greater palatine foramina width (D
Armonk, NY, USA). The significance level was set at
GPFW; 1.9X), and intermolar width (D IMW; 1.8X) all
0.05. Because the continuous outcome variables were
increased significantly more in the overexpansion
normally distributed, independent sample t-tests were
group. The between-group difference in maxillary
used to compare the groups, with Bonferroni correc-
alveolar crest width (D Mx_AC) was not statistically
tions. Linear and multiple regressions were used to
significant after Bonferroni adjustment. Changes in
evaluate the relationships.
molar inclination (D MInc; 2.8X) were also significantly
greater in the overexpansion than conventional expan-
RESULTS
sion group. Outer and inner alveolar bone inclinations
There was no statistically significant (P ¼ 0.372) pre- (D ABInc_I and D ABI_O) showed no statistically
treatment difference in SMI scores between the significant between-group treatment differences.
experimental and control groups (7.64 6 3.1 vs 6.4 Nasal widths and nasal floor width increased 23%–
6 3.3, respectively). Independent t-tests showed no 32% of screw activation among the experimental
statistically significant between-group pre-treatment group, which was 5.5%–7.6% greater than the increas-
morphological differences (Table 3). The screws were es among the conventional group (Figure 5). The Mx
activated 1.8X more in the experimental (10.1 6 0.6 AC increased 9.1% more in the conventional than the

Figure 4. (A) Intermolar width (IMW) and molar inclination (Minc), (B) inner alveolar bone inclination (ABInc_I), and (C) outer alveolar bone
inclination (ABInc_O) measured on the coronal slice.

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SHORT-TERM EFFECTS OF OVEREXPANSION 59

Table 3. Comparisons of the Conventional Expansion and

Overexpansion Groups at T1
Conventional
Expansion Overexpansion
Units Mean SD Mean SD Probability
ANW mm 21.8 1.7 22.9 1.6 .135
PNW mm 27.6 3.5 27.1 1.0 .630
Mx_NF mm 63.6 4.7 64.1 2.5 .782
Mx_AC mm 57.7 3.5 59.6 2.5 .157
GPFW mm 30.3 2.5 30.5 1.6 .853 Figure 5. Skeletal expansion as a percent of screw activation.
IMW mm 39.7 3.1 39.8 1.5 .946

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MInc 8 102.5 4.5 101.0 2.2 .326
ABInc_I 8 107.1 4.9 104.5 1.2 .113 activation explained 49%–67% of the individual differ-
ABInc_O 8 88.1 11.3 92.8 4.1 .194 ences in skeletal expansion and inclination changes
(Table 7). Each unit increase of the SMIs decreased
the amount of skeletal expansion and increased the
overexpanded group (Figure 5). None of the between-
amount of molar inclination. Skeletal age was approx-
group differences were statistically significant. Skeletal
imately 0.5 to 0.7 times as important as screw
and dentoalveolar changes as a percent of molar
activation in determining the changes that occurred.
expansion showed similar between-group differences,
with none attaining statistical significance (Figure 6).
DISCUSSION
Relationships Among Skeletal Changes, Age and As expected, overexpansion produced greater ab-
Screw Activation solute skeletal increases than conventional expansion,
but the actual amounts have not been previously
The amounts of expansion were not significantly
established. While screw activation was approximately
correlated with chronological age (Table 5). While
1.8X greater among the overexpansion group, skeletal
absolute amounts of expansion were unrelated, pa-
expansion was 2.1–2.5X greater (Figure 8). These
tients’ SMI scores were negatively correlated with the
differences were expected because more screw
percent increases in ANW, PNW, and GPFW. After
activation necessitates longer application of transverse
Bonferroni adjustments, the absolute increases in
forces, resulting in greater overall effects. At the level
ANW, PNW, Mx_NF, Mx_AC, GPFW, and MInc were
of the nasal floor, the amount of skeletal changes
all positively related to screw activation (Table 6). For
produced with overexpansion was similar to the
every mm of screw activation, the maxilla expanded
amount produced with miniscrew-supported RME.23
approximately 0.4 mm, with slightly greater amounts of
As such, overexpansion provides orthodontists with a
expansion at the alveolar crest and slightly lesser
way to obtain greater skeletal expansion without
amounts distal to the molar. The association between
miniscrews; both produce a wider skeletal base for
DIMW and screw activation was linear, with slightly
more stable long-term treatment results. The dental
greater amounts of molar expansion with every mm of
and dentoalveolar aspects of overexpansion must be
activation (Figure 7).
corrected during subsequent orthodontic treatment to
Multiple regression analyses showed that, in combi-
prevent relapse.
nation, the patients’ SMIs and the amount of screw
Skeletal increases expressed as a percent of screw
activation showed no statistically significant between-
Table 4. Comparisons of Changes From T1 to T2 for the
Conventional Expansion and Overexpansion Groups group differences. However, there was a consistent
trend of 5.5%–7.6% greater changes among the
Conventional
Expansion Overexpansion
overexpansion group and post-hoc power analyses
Units Mean SD Mean SD Probability
Screw activation mm 5.6 1.2 10.1 0.6 ,.001
D ANW mm 1.5 0.9 3.2 1.3 .001
D PNW mm 1.3 0.9 3.2 1.2 ,.001
D Mx_NF mm 1.3 1.1 3.0 1.3 .002
D Mx_AC mm 3.4 1.5 4.9 1.6 .027
D GPFW mm 1.5 0.9 2.8 1.1 .006
D IMW mm 5.7 1.4 10.4 1.0 ,.001
D MInc 8 2.8 3.2 7.8 3.9 .003
D ABInc_I 8 4.2 3.5 6.9 3.4 .073
D ABInc_O 8 5.3 6.0 6.0 2.9 .756
Figure 6. Skeletal expansion as a percent of molar expansion.

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60 BALA, CAMPBELL, TADLOCK, SCHNEIDERMAN, BUSCHANG

Table 5. Correlations of Chronological Age and SMI With Skeletal Table 6. Relationships Between the Amount of Screw Activation
Expansion (Absolute and as a Proportion of Screw Activation) and Changes of the Skeletal and Dentoalveolar Measurements
Chronological Age SMI Intercept Slope R Probability
R Probability R Probability D ANW 0.627 0.382 0.67 ,.001*
D PNW 0.922 0.401 0.70 ,.001*
Absolute skeletal expansion
D Mx_NF 0.970 0.399 0.66 .001*
D ANW 0.15 .486 0.32 .141
D Mx_AC 0.843 0.415 0.61 .002*
D PNW 0.02 .945 0.30 .172
D GPFW 0.239 0.299 0.61 .002*
D Mx_NF 0.11 .606 0.32 .140
D IMW 0.108 1.037 0.95 ,.001*
D Mx_AC 0.05 .837 0.23 .292
D MInc 3.234 1.087 0.62 .002*
D GPFW 0.16 .462 0.38 .750
D ABInc_I 0.199 0.731 0.49 .018
D MInc 0.20 .365 0.17 .434
D ABInc_O 2.491 0.406 0.21 .333

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Skeletal expansion as a percent of screw activation
D ANW % 0.39 .067 0.57 .005* * Indicates statistical significance after Bonferroni correction.
D PNW % 0.17 .436 0.56 .005*
D Mx_NF % 0.26 .225 0.52 .010 variation in skeletal expansion was explained by the
D Mx_AC % 0.17 .440 0.45 .032 amount of screw activation. Similar associations have
D GPFW % 0.39 .065 0.64 .001*
D MInc_% 0.37 .083 0.43 .039
been reported for nasal width and nasal floor chang-
es.14 Weaker statistical relationships have also been
* Indicates statistical significance after Bonferroni correction.
reported.22 Importantly, the association between screw
activation and skeletal expansion was not strong,
confirmed insufficient sample size to rule out possible implicating other possible explanatory factors.
type II errors. Since differences between expansion The present study found greater (58) molar inclina-
and overexpansion relative to screw activation have tion changes in the overexpansion group, a positive
not been previously evaluated, more research with correlation between screw activation and molar incli-
larger samples is needed. Greater orthopedic effects nation changes, and a positive association between
with increasing amounts of screw activation might be inclination changes and the patients’ SMIs. The
expected if dentoalveolar changes are the primary positive associations between the patients’ SMIs and
goals at the start of RME.3,4,7 This could explain the inclination changes demonstrated that older (more
difference in dentoalveolar expansion in the present skeletally mature) patients exhibited greater dental
study (47.5% and 57.4% in the overexpansion and changes than younger patients. Controlling for the
conventional groups, respectively), which fell within the amount of screw activation, the multiple regression
range reported previously.12,13,16–18 indicated that molar inclination increased 0.58 for every
The amount of skeletal expansion achieved with unit increase of SMI; patients starting with an SMI of 11
RME depended on the amount of appliance activation. would have 4.58 greater inclination changes than
The present study showed that 30% to 42% of the patients starting with an SMI of 2.

Figure 7. Association between molar expansion (DIMW) and screw activation.

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SHORT-TERM EFFECTS OF OVEREXPANSION 61

Table 7. Multiple Regression Relating SMI and Screw Activation Performed to Changes of the Skeletal and Dentoalveolar Measurements, With
Unstandardized (Beta) and Standardized Beta (Stand B) Coefficients
SMI Screw Activation
Constant Beta Stand B Beta Stand B R Probability
D ANW 0.384 0.187 0.431 0.420 0.741 0.80 ,.001
D PNW 0.056 0.180 0.414 0.437 0.766 0.81 ,.001
D Mx_NF 0.102 0.198 0.430 0.439 0.729 0.79 ,.001
D Mx_AC 1.782 0.173 0.331 0.450 0.657 0.69 .002
D GPFW 0.743 0.181 0.485 0.336 0.686 0.78 ,.001
D MInc 5.780 0.469 0.347 0.992 0.561 0.70 .001

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Alveolar bone bending did not appear to be related are 5 SMI units less mature will experience almost 1
to the amount of RME activation. In the present study, mm more skeletal expansion at the nasal floor.
alveolar bone inclination changes did not show any The amount of orthopedic expansion obtained with
between-group differences or associations with screw RME was inversely related to the patient’s skeletal
activation. They compared closely to changes previ- maturity. Skeletal expansion percentages, as calculat-
ously reported.10 Alveolar bone bending is an initial ed in the present study, were significantly and
response to the transverse forces delivered by the negatively correlated with the patients’ SMIs. For
RME appliance3,4,7 and is essentially complete within example, greater palatine foramina width (GPFW), as
the first week of screw activation.24 This could explain a percentage of screw activation, decreased approx-
why alveolar bone inclination changes and midpalatal imately 5% for every two units of SMI increase (Figure
suture separation are not closely related. The lack of 9). Patients’ maturity has been previously associated
continual alveolar bone bending in the present study with skeletal expansion,7 with patients treated during
may have been related to the design of the appliance cervical vertebral maturation (CVM) stages 1–3 dem-
used, which applied forces to the dentition rather than onstrating greater long-term skeletal changes than
the alveolus. those treated during CVM stages 4–6.2 This associa-
Except for the youngest patients, less than one-third tion was due to the increased complexity of the
of screw expansion was expressed at the skeletal midpalatal suture with age.25 Skeletal maturity and
level. Previous studies have reported 23%–30% of midpalatal suture maturation have been shown to be
nasal cavity expansion, 22%–39% of the maxillary strongly correlated.26 It has been suggested that the
base expansion, and 23%–50% of midpalatal suture ideal time to begin expansion is between SMI 1 to 4,
expansion (Table 1). Percentages that were greater and that it should be completed by SMI 9 for separation
than those reported in the present study pertained to of the midpalatal suture.27 The present study showed
younger samples.12,13,18 RME prior to or during the that the relationship is linear (ie, there is no cut-off
pubertal growth spurt has been shown to produce age), with skeletal separation still possible, albeit more
greater skeletal expansion than RME after the limited, after SMI 9.
spurt.2,3,7,20 The present study showed that, given the RME produced greater inferior than superior, and
same amount of skeletal expansion, individuals who greater anterior than posterior expansion. The treat-

Figure 8. Overexpansion change as a percentage of conventional expansion change.

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Figure 9. The effect of skeletal age (SMI) on greater palatine foramina width (GPFW) changes, as a percentage of screw activation.

ment effects in both groups were greater at the  The effects of RME treatment are triangular from a
alveolar crest than at the nasal cavity, as previously coronal perspective and greater inferiorly than
reported.6,7,9,10 This triangular pattern of expansion superiorly.
gives the false impression that substantial amounts of
skeletal expansion occurred, when true expansion of
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