In the past month, I saw the mother of a young girl who had an upper fixed rapid maxillary expander for her bilateral crossbite. Fortunately, the girl was 9 years old and the RME worked as predicted. Her mother had a bilateral posterior crossbite with a really narrow maxilla and I knew if she was to have correction for this, she would need a maxillary surgically assisted expansion.
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When the mid-palatal suture starts to ossify, the posterior alveolus and teeth start to bend more buccally, with palatal expansion. This gives the impression of upper side teeth that are flared. What this means is that the buccal expansion achieved is not as stable once the expander is removed.
The more severe the posterior crossbite, the earlier the palatal expansion should be done.
This means in adults, the options for correcting the posterior skeletal crossbite is to maintain it, or correct this as much as possible within the limits of the alveolus, or a surgically assisted upper jaw expansion. The biggest drawback with a surgically assisted maxillary expansion are the risks of surgery. There are a variety of surgical techniques for maxillary expansion used by different oral & maxillofacial surgeons- the basic premise is the same ie: to free up the maxilla and its articulations with the adjacent bones including the adjacent maxillae, to produce true skeletal expansion. One of the biggest concerns among our adult patients with a narrow maxilla needing surgical expansion is the risk of pulpal necrosis of the upper central incisors.
In hindsight, all our adult patients would have acted upon earlier if they had known that maxillary skeletal expansion would get much more difficult once they are past their mid-teens of 15-16 years.
If you do see your next child, early or mid teen patient in the chair, and they have upper anterior crowding, or a unilateral or bilateral crossbite, please advise them to seek an orthodontic opinion and let them know of the importance of early timing in upper maxillary expansion.