Original Article

Orthopedic outcomes of hybrid and conventional Hyrax expanders:

Secondary data analysis from a randomized clinical trial
Daniela Gariba; Felicia Mirandab; Juan Martin Palomoc; Fernando Pugliesed; José Carlos da Cunha
Bastose; Alexandre Magno dos Santosf; Guilherme Jansong

ABSTRACT
Objectives: To compare the effects of a hybrid miniscrew-supported expander versus a
conventional Hyrax (CH) expander in growing patients.
Materials and Methods: Forty patients were randomized into two groups: a hybrid Hyrax (HH)
expander group using a Hyrax expander with two miniscrews and a CH expander group. The final
sample had 18 subjects (8 female, 10 male; initial age of 10.8 years) in the HH group and 14
subjects (6 female, 8 male; initial age of 11.4 years) in the CH group. Cone-beam computed
tomography examinations and digital dental models were obtained before expansion and 11
months postexpansion. The primary outcomes included the orthopedic transverse effects of
expansion. Intergroup comparison was performed using analysis of covariance (P , .05).
Results: Significantly greater increases in the nasal cavity width, maxillary width, and buccal
alveolar crest width were found for the HH group. No intergroup differences were observed for
dental arch width or shape changes.
Conclusions: The HH group showed greater increases in the nasal cavity width, maxillary width,
and buccal alveolar crest width. No differences were observed for intermolar, interpremolar, or
intercanine widths; arch length; or arch perimeter. Arch size and shape showed similar changes in
both groups. (Angle Orthod. 2021;91:178–186.)
KEY WORDS: Orthodontics; Interceptive; Orthodontic appliance; Palatal expansion technique;
Dental models; Imaging; Three-dimensional

INTRODUCTION
a
Associate Professor, Department of Orthodontics, Bauru Rapid maxillary expansion (RME) is indicated for the
Dental School, Hospital for Rehabilitation of Craniofacial
treatment of maxillary constriction. Orthopedic opening
Anomalies, University of São Paulo, Bauru, SP, Brazil.
b
PhD student, Department of Orthodontics, Bauru Dental of the midpalatal suture represents the main effect of
School, University of São Paulo, Bauru, SP, Brazil. an RME procedure.1 Conventional expanders are
c
Professor and Residency Director, Department of Orthodon- commonly used for RME. Recently, innovative ex-
tics, School of Dental Medicine, Case Western Reserve panders using skeletal anchorage for performing RME
University, Cleveland, Ohio.
d
Clinical Assistant Professor, Department of Orthodontics,
procedure have been described.2,3 Is there an increase
School of Dental Medicine, Case Western Reserve University, in the orthopedic effect of RME by incorporating
Cleveland, Ohio. skeletal anchorage to conventional expanders?
e
Maxillofacial Surgeon, Hospital for Rehabilitation of Cranio- The first report of skeletal-anchored RME was in a
facial Anomalies, University of São Paulo, Bauru, SP, Brazil. 14-year-old girl and used two small implants in the
f
Private practice, Minas Gerais, Brazil.
g
Professor, Department of Orthodontics, Bauru Dental palate.4 Lee et al.2 used a miniscrew-supported RME
School, University of São Paulo, Bauru, SP, Brazil. procedure. Using four palatal miniscrews as anchor-
Corresponding author: Dr Daniela Garib, Department of age, increases of 8.3 mm and 2.4 mm were obtained in
Orthodontics, Bauru Dental School, University of São Paulo, the intermolar distance and in the maxillary basal bone,
Alameda Octávio Pinheiro Brisolla 9-75 Bauru, SP 17012-901,
respectively, in a young adult patient.2 Miniscrew-
Brazil
(e-mail: dgarib@usp.br) anchored rapid palatal expansion (MARPE) seems to
extend the age limit for RME.2,5 A previous study using
Accepted: November 2020. Submitted: June 2020.
Published Online: January 12, 2021 MARPE in a sample of 69 adult patients with a mean
Ó 2021 by The EH Angle Education and Research Foundation, age of 20.9 years showed a success rate of 86.96% in
Inc. opening the midpalatal suture.5 An increase in the

Angle Orthodontist, Vol 91, No 2, 2021 178 DOI: 10.2319/060820-527.1

OUTCOMES OF HYBRID AND HYRAX EXPANDERS 179

maxillary width of 2.11 mm was found after MARPE.5 The individuals were recruited in the Clinic of
The nasal cavity width and intermolar width also Orthodontics of Bauru Dental School, University of
showed significant increases of 1.07 mm and 8.32 São Paulo, from July 2017 to March 2018. The sample
mm, respectively, after expansion.5 consisted of 40 individuals with posterior crossbites
Wilmes et al.3 reported the use of a hybrid Hyrax and age varying from 9 to 13 years. The eligibility
(HH) for growing patients. The HH was anchored on criteria included (1) both sexes, (2) late mixed or early
the maxillary permanent first molars and on two permanent dentition, and (3) Class I and Class III
parasutural miniscrews in the anterior region of the malocclusions. Exclusion criteria included individuals
palate.3 The use of a HH was indicated as anchorage with a history of previous orthodontic treatment and
for maxillary protraction with facemask therapy.6 A patients with special needs or syndromes.
previous study compared the periodontal and skeletal
effects produced by RME using hybrid and conven- Interventions
tional Hyrax (CH) expanders in adolescent patients in The HH group was treated with a premanufactured
the permanent dentition.7 Similar skeletal effects were 9-mm HH expander (PecLab, Belo Horizonte, Brazil).
found in both groups.7 The Hyrax expander produced The expander was inserted posteriorly to the third
greater increases in the interpremolar distances as palatal rugae, supported by bands on the maxillary first
compared with the hybrid expanders.7 A greater permanent molars and 1-mm away from the palatal
decrease in the first premolar buccal bone plate was surface (Figure 2A). Two parasutural miniscrews of
found for the CH expanders when compared with 1.8-mm diameter, 7-mm length, and 4-mm trans-
hybrid expanders.7 mucosal length were installed in the expander slots
The orthopedic outcomes of miniscrew-supported (Figure 2A). The miniscrews were installed under local
maxillary expanders were more extensively studied in anesthesia, using a contra-angle implant driver with
adult patients.2,5 The literature is limited regarding the maximum insertion torque of 35 Ncm and 30 rotations/
dentoskeletal effects of the hybrid expander in growing min. The miniscrews were installed with approximately
patients. A previous study compared the dentoskeletal a 458 inclination relative to the occlusal plane, following
and periodontal effects of the hybrid and CH expand- the expander slot chamfer (Figure 3).
ers. However, a small sample size and the amount of In the CH group, the RME was performed using a
screw activation was not standardized.7 Further studies CH expander (Figure 2B). Bands on the maxillary first
are necessary to more extensively compare the permanent molars and bonded C-shape clasps on the
orthopedic effects produced by the hybrid and CH maxillary canines or premolars were used to support
expander in growing individuals. the expander (Figure 2B). In both groups, the expander
screw was activated a one-quarter turn twice a day for
Objective 14 days, achieving 5.6 mm of expansion. After the
The aim of this study was to compare the orthopedic active phase, the expanders were maintained in the
outcomes of hybrid and CH expanders in growing oral cavity for 11 months as retention until bone-
patients. The null hypothesis was that the dentoskele- anchored maxillary protraction therapy was performed
tal effects produced by both expanders were similar. for a previous study. The treatment times were 11.38
and 11.00 months for the experimental and control
MATERIALS AND METHODS groups, respectively.
Cone-beam computed tomography (CBCT) and
Trial Design and Settings digital dental models were obtained before expansion
(T1) and after the expander removal (T2). The head
This study was a secondary data analysis from a
orientation was standardized in the sagittal view,
previous single-center randomized clinical trial (RCT).
positioning the palatal plane parallel to the horizontal
Two parallel arms and a 1:1 allocation ratio was used.
plane; in the frontal view, leveling the orbital plane
Changes in participant number were made after trial
parallel to the horizontal plane; and, in the axial view,
commencement (Figure 1).
positioning the vertical plane simultaneously on the
The study followed the Consolidated Standards of
anterior and posterior nasal spine.
Reporting Trials guidelines (CONSORT). The study
was approved by the Ethics in Research Committee of
Outcomes
Bauru Dental School, University of São Paulo, Brazil
(protocol No. 67610717.7.0000.5417). All patients and The primary outcomes of this RCT were the
parents provided written informed consent before dentoskeletal changes produced by maxillary protrac-
treatment. tion that were evaluated in a previous study.

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180 GARIB, MIRANDA, PALOMO, PUGLIESE, BASTOS, SANTOS, JANSON

Figure 1. CONSORT flow chart.

The outcomes of the current study included the according to a previous study (Figures 4C; Figure 5).8
dentoskeletal changes of RME measured on CBCT Digital dental models were imported into the Stratovan
scans. A coronal section passing through the center of Checkpoint software. Fourteen landmarks were placed
the palatal root of the right maxillary permanent first on both T1 and T2 dental models (Figure 4C). The
molar was used to evaluate the transverse measure- landmark coordinates (x and z) were imported into the
ments (Table 1). The variables illustrated in Figure 4A MorphoJ software. The arch size was calculated by
were measured using Nemoscan software (Nemotec, using the centroid size of each dental arch at T1 and
Madrid, Spain). T2. Generalized Procrustes analysis was used to
The arch widths (at the molars, premolars, and calculate the mean arch shape at each time point
canines), arch length, and arch perimeter (Figure 4B; and the interphase arch shape changes.
Table 1) were evaluated using OrthoAnalyzer 3D
software (3Shape A/S, Copenhagen, Denmark). Arch Sample Size Calculation
size and shape were measured using the software Sample size calculation was performed to provide
Stratovan Checkpoint (Stratovan Corporation, Davis, 80% test power, a significance level of .05, a standard
Calif) and MorphoJ (Klingenberg Lab, Manchester, UK) deviation of 1.18 mm for maxillary width,9 and a

Angle Orthodontist, Vol 91, No 2, 2021

OUTCOMES OF HYBRID AND HYRAX EXPANDERS 181

Figure 2. (A) Hybrid Hyrax expander group. (B) Conventional Hyrax expander group.

minimum intergroup difference of 2.0 mm. A sample of Statistical Analyses

eight patients was required for each group.
After 1 month, the same operator (F.M.) randomly
selected and remeasured 30% of the sample. The
Randomization and Blinding intraclass correlation coefficient (ICC) was used to
Randomization was performed electronically using assess the reliability of repeated measures.
Normal distribution was verified by Kolmogorov-
the Randomization.com website (http://www.
Smirnov tests. We used t-tests for baseline compari-
randomization.com). Opaque, sealed, and numbered
sons. Nonparametric tests were applied to variables
envelopes containing the group name were organized
without normal distribution. An analysis of covariance
and opened according to the sequence generated by using the baseline data as a covariate was applied to
the randomization. adjust for the influence of the initial maxillary dimen-
All CBCT scans were deidentified before assess- sions on the expansion changes. A significance level of
ment to avoid bias. Only a simple blinding was 5% was regarded for all tests.
performed, once both operator and patient were aware
of the type of treatment performed. RESULTS
Forty growing individuals agreed to participate of the
trial. Twenty patients were allocated to the HH group.
One patient interrupted treatment, and one was
excluded because of palatal miniscrew instability. The
final sample of the HH group included 18 individuals (8
female; 10 male) with a mean age of 10.80 years. The
total treatment time was 11.38 months.
Fifteen individuals were allocated to the CH group.
Five were not allocated because of group interruption
related to side effects observed during maxillary
protraction in the original RCT. One patient quit
treatment. The final sample of the CH group was
Figure 3. Miniscrews installed with a 458 inclination in the composed of 14 individuals with a mean age of 11.44
paramedian anterior palate in a subject using the hybrid expander. years (6 female and 8 male) and 11 months of

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182 GARIB, MIRANDA, PALOMO, PUGLIESE, BASTOS, SANTOS, JANSON

Table 1. Variable Definitions

Variable Definition
Transversal distances (mm)
Nasal cavity width The greater width of the nasal cavity lower third measured in parallel to the horizontal plane
Palatal root distance width Dental arch width measured at the most apical level of the palatal roots parallel to the horizontal plane
Maxillary width Maxillary width at the level of the hard palate parallel to the horizontal plane
Palatal alveolar crest width Maxillary width at the level of the interpalatal alveolar crest parallel to the horizontal plane
Buccal alveolar crest width Maxillary width at the level of the buccal alveolar crest parallel to the horizontal plane
Arch width Dental arch width measured at the level of the buccal cusp points parallel to the horizontal plane
Tooth inclination Angle between lines passing through the buccal and lingual cusp tips of the first molars
Dental model analysis (mm)
6-6 width Intermolar width measured at the level of the cusp tips
5-5 width Inter–second premolar width measured at the level of the cusp tips
4-4 width Inter–first premolar width measured at the level of the cusp tips
3-3 width Intercanine width measured at the level of the cusp tips
Arch length Arch length measured perpendicularly in the horizontal plane from a line connecting the mesial aspects of
the first permanent molars to the mesial edge of the right permanent incisor
Arch perimeter Arch perimeter measured by the sum of four segments connecting the mesial aspect of the right first
permanent molar to the mesial aspect of the left first permanent molar

treatment time. Figure 1 contains the completed found for dimensional measurements in both types of
participants’ flow chart. three-dimensional images (ICC ranging from .883 to
Similar characteristics regarding sex, initial age, and .999). Previous studies also reported good reproduc-
treatment time were found in both groups (Table 2). ibility for measures performed on digital dental mod-
Intergroup differences were found for 3 of 15 variables els.12,13 In agreement, a previous study also reported
at T1 (Table 3). The HH group presented slightly excellent intraexaminer reproducibility by assessing
greater transverse dimensions before treatment than bone morphology in CBCT with different voxel sizes.14
the CH group did. A previous study also reported good intraexaminer
The ICC ranged from .883 to .999 for all transverse reproducibility for transverse dimensions of the maxilla
measurements, showing good reproducibility. Land- measured after RME on CBCT.15 In this study, CBCT
marks assigned for arch shape analysis demonstrated three-dimensional images were used for planning
ICCs ranging from .745 to .999. miniscrew installation at T1 and planning comprehen-
All patients from both groups demonstrated a sive orthodontic treatment at T2.
midpalatal suture split during RME. A significantly The hybrid expander is an innovative treatment
greater increase in nasal cavity and maxillary width option for maxillary constriction, which incorporated
and buccal alveolar crest width was found for the miniscrews into the expansion procedure.2,3,5 In adult
hybrid expander (Table 4). No intergroup differences patients, greater bone resistance to midpalatal suture
were found for the other maxillary widths and tooth opening requires four miniscrews as anchorage.2,5 In
inclinations. growing patients, previous studies used two mini-
No intergroup differences were found for intermolar, screws in the maxillary expander with skeletal anchor-
interpremolar, or intercanine distances; arch length; or age.3,7 In this study, midline diastema and radiologic
perimeter (Table 4). Arch size displayed similar suture opening was observed for all patients from both
increases after treatment in both groups (Table 4). groups.
Both types of expander produced similar arch shape Previous studies demonstrated high stability rates
changes after RME (Figure 5). for the palatal miniscrews.5,16 Only 1 of 38 palatal
One of the 38 palatal miniscrews was lost in the HH miniscrews was lost during maxillary expansion. In
group. A 97.36% stability rate was found for palatal agreement with these findings, a sample of 69 adult
miniscrews. One patient was excluded from the sample patients treated with MARPE showed a stability rate of
after palatal miniscrew instability. 95% for palatal miniscrews.5 The palate is a very
suitable place to receive miniscrews with high stability
DISCUSSION
rates, supporting heavier forces from RME.16 The
This study aimed to compare the orthopedic effects possible explanations are the favorable bone quality
of RME with hybrid and CH expanders in growing and quantity and the presence of extensive keratinized
patients. Both CBCT and digital dental models provide mucosa in the paramedian anterior palate.17 In addi-
accurate information regarding the dentoskeletal ef- tion, previous studies demonstrated that stability is
fects produced by RME.10–12 Good reproducibility was increased by splitting two miniscrews in the palate.16

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OUTCOMES OF HYBRID AND HYRAX EXPANDERS 183

Figure 4. (A) Coronal slice showing the transverse measurements (Table 1). (B) Transverse measurements performed on the digital dental
models (Table 1). (C) Landmarks used for arch shape analysis.

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184 GARIB, MIRANDA, PALOMO, PUGLIESE, BASTOS, SANTOS, JANSON

Figure 5. (A) Intergroup comparison of preexpansion arch shape. (B) Intergroup comparison of postexpansion arch shape. (C, D) Arch shape
before (black line) and after expansion (gray) in the hybrid (C) and conventional Hyrax (D) groups.

A greater increase in the nasal cavity width was conventional expanders demonstrated an orthopedic
found for the HH expander as compared with the effect of approximately 40% and 20%, respectively.
conventional expanders (Table 4). The hypothesis is The hybrid expander also demonstrated a greater
that the palatal miniscrews transfer the expansion increase in maxillary width as compared with the
forces to higher maxillary levels, increasing the conventional expander (Table 4), demonstrating a
orthopedic outcome of RME in the nasal cavity. greater orthopedic effect at the level of maxillary basal
Previous studies have demonstrated an increase in bone. A previous study also demonstrated a greater
nasal cavity width varying from 1.2 to 2.73 mm after increase in maxillary width in the bone-borne expander
conventional RME.7,15,18 A previous study in adoles- group as compared with the conventional expander in
cents corroborated the current findings, demonstrating a sample of adolescents.9 Conversely, another study
a greater increase in the nasal cavity width with a reported similarity between conventional and hybrid
bone-borne expander as compared with a conventional expanders for orthopedic effects in growing individu-
tooth-borne expander.18 On the other hand, another als.7 These differences might be related to the lack of
study demonstrated similar increases in nasal cavity expansion standardization.7
width after expansion using hybrid and Hyrax expand- The buccal alveolar crest width also showed a
ers in growing individuals.7 The possible explanation greater increase after treatment in the HH group than in
for this discrepancy was that, in the latter study, the the CH group (Table 4). During the active expansion
phase, hybrid expanders usually demonstrated a slight
amount of screw expansion was not standardized, and
posterior divergence of the screw hinges due to the
the cusp tip relationship was individually used as a
expansion limitation caused by the anterior skeletal
reference to determine the amount of expansion.7
anchorage (Figure 2A). As a consequence, the
Considering the ratio between nasal cavity increase
expansion force might have a greater impact on the
and the amount of screw activation, the Hybrid and
dentoalveolar region of the maxillary first molars.
Another assumption was that first molar eruption was
Table 2. Baseline Characteristics of the Groups and Treatment
Times restrained during the time the HH was in the oral cavity.
A relative intrusion of maxillary first molars was
Variable Group HH Group CH P Valuea
observed in subjects of the HH group. These side
Sex, n .928 effects could have combined to increase the molar
Male 10 8
Female 8 6
intercrestal distance. Posterior tooth inclination in-
Total, n 18 14 creased similarly in both groups (Table 4). Two
Mean age, y (SD) 10.80 (1.04) 11.44 (1.26) .102 previous studies were controversial when comparing
Treatment time, m (SD) 11.38 (3.98) 11.00 (3.78) .782 the amount of buccal inclination between tooth-borne
a
Chi-square test (sex); t-test (age and treatment time). and tooth-bone-borne expanders.7,18 Variations in

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OUTCOMES OF HYBRID AND HYRAX EXPANDERS 185

Table 3. Intergroup Comparisons of the Starting Forms (t-Test and Mann-Whitney U-Test)
Variable Group HH, Mean (SD) Group CH, Mean (SD) 95% CI, Lower, Upper P Value*
Transversal distances (mm)
Nasal cavity width 28.81 (2.35) 28.33 (2.18) 1.18, 2.14 .561
Palatal root distance width 34.56 (2.86) 31.65 (3.31) 0.64, 5.18 .021*a
Maxillary width 64.64 (3.47) 62.59 (4.85) 0.96, 5.05 .175
Palatal alveolar crest width 36.32 (2.66) 33.94 (3.97) 0.06, 4.83 .056
Buccal alveolar crest width 59.94 (3.40) 57.08 (3.86) 0.19, 5.52 .036*
Arch width 57.02 (3.12) 54.69 (4.32) 0.41, 5.07 .093
Premolar inclination 162.66 (13.61) 156.73 (9.63) 4.38, 16.24 .245
Molar inclination 158.26 (11.52) 153.66 (7.03) 2.61, 11.80 .203
Dental model analysis (mm)
6-6 width 55.35 (3.27) 52.59 (4.77) 0.31, 5.82 .077
5-5 width 50.47 (2.95) 47.57 (5.12) 0.25, 6.05 .070
4-4 width 45.61 (2.72) 42.63 (3.86) 0.36, 5.58 .027*
3-3 width 36.83 (2.66) 34.78 (3.00) 0.99, 5.08 .170
Arch length 29.09 (3.00) 27.66 (2.80) 0.80, 3.66 .201
Arch perimeter 77.64 (5.03) 75.02 (5.52) 1.75, 7.00 .228
Arch size
Maxillary arch size 91.96 (5.54) 91.09 (5.86) 4.00, 5.74 .716
a
P values for Mann-Whitney U-test.
* Statistically significant at P , .05, t-test.

these outcomes might be explained by different shape.8 However, that study was conducted in patients
expander designs. In addition, the current findings with bilateral complete cleft lip and palate, which might
should be analyzed with caution because cusp tip explain the discrepancy.
definitions in CBCT are not adequate.
All maxillary dental arch widths increased similarly in Limitations
both groups (Table 4). The arch shape changes
observed in Figure 5 were also similar between groups. One limitation of the study was the lack of a nasal
It was observed that the premolar region demonstrated airflow analysis. Considering the nasal cavity width
a slightly greater expansion in the CH expander group changes, future studies should evaluate the influence
compared with the HH group (Figure 5B), although of HH expanders in the respiratory function of patients
both groups demonstrated a significant arch shape with oral breathing and sleep apnea. The sample size
change (Figure 5C,D). Arch size also increased of the CH group was also a limitation. Future studies
similarly in both groups. A previous study reported that should be conducted to compare the effects of tooth-
the Hyrax expander did not produce a change in arch bone-borne and bone-borne expanders.

Table 4. Intergroup Treatment Change Comparisons (Analysis of Covariance)

Group HH, Group CH, Difference, 95% CI,
Variable Mean Changes (SD) Mean Changes (SD) Mean Lower, Upper P Value*
Transversal distances (mm)
Nasal cavity width 2.26 (1.17) 1.11 (0.95) 1.15 0.40, 1.99 .004*
Palatal root distance width 3.52 (1.04) 2.83 (1.34) 0.69 0.47, 1.48 .301
Maxillary width 1.82 (1.47) 0.99 (0.84) 0.83 0.04, 1.89 .041*
Palatal alveolar crest width 3.67 (1.26) 3.02 (1.24) 0.65 0.15, 1.81 .097
Buccal alveolar crest width 3.22 (1.55) 2.03 (1023) 1.19 0.19, 2.47 .023*
Arch width 2.89 (1.40) 2.67 (1.22) 0.22 0.52, 1.47 .335
Premolar inclination 1.81 (9.80) 9.79 (11.21) 7.98 10.82, 2.41 .200
Molar inclination 2.86 (14.16) 7.08 (11.00) 4.22 6.12, 7.59 .827
Dental model analysis (mm)
6-6 width 3.5 (1.24) 3.47 (1.21) 0.03 0.75, 1.23 .624
5-5 width 3.18 (2.12) 4.23 (1.23) 1.05 2.19, 0.78 .338
4-4 width 2.62 (1.76) 4.07 (1.19) 1.45 1.99, 0.44 .201
3-3 width 0.94 (1.12) 0.54 (1.55) 0.4 0.85, 2.20 .356
Arch length 1.94 (1.36) 2.2 (1.68) 0.26 0.60, 1.66 .347
Arch perimeter 0.11 (2.31) 0.51 (1.70) 0.62 0.58, 2.71 .195
Arch size
Maxillary arch size 3.62 (2.48) 3.30 (1.92) 0.32 -1.01, 2.12 0.474
* Statistically significant at P , .05.

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186 GARIB, MIRANDA, PALOMO, PUGLIESE, BASTOS, SANTOS, JANSON

In all, while the functional outcomes of Hybrid 6. Nienkemper M, Wilmes B, Franchi L, Drescher D. Effective-
expanders are unknown, the indication for skeletal ness of maxillary protraction using a hybrid Hyrax-facemask
anchored maxillary expansion in growing patients combination: a controlled clinical study. Angle Orthod. 2015;
85:764–770.
should be restricted to subjects with deficient dental
7. Gunyuz Toklu M, Germec-Cakan D, Tozlu M. Periodontal,
anchorage for conventional expanders (oligodontia
dentoalveolar, and skeletal effects of tooth-borne and tooth-
and tooth transition), patients with periodontal bone bone-borne expansion appliances. Am J Orthod Dentofacial
deficiencies on the anchorage teeth, and as anchorage Orthop. 2015;148:97–109.
for bone protraction in Class III patients. The absence 8. Pugliese F, Palomo JM, Calil LR, de Medeiros Alves A,
of an untreated control group for growth comparisons Lauris JRP, Garib D. Dental arch size and shape after
was another limitation of this study. However, using maxillary expansion in bilateral complete cleft palate: a
CBCT images in untreated subjects would have raised comparison of three expander designs. Angle Orthod. 2019;
ethical concerns. 90:233–238.
9. Lin L, Ahn HW, Kim SJ, Moon SC, Kim SH, Nelson G. Tooth-
borne vs bone-borne rapid maxillary expanders in late
CONCLUSIONS
adolescence. Angle Orthod. 2015;85:253–262.
 The hybrid Hyrax expander produced greater in- 10. Garib DG, Henriques JF, Janson G, Freitas MR, Coelho RA.
creases in the nasal cavity and maxillary widths as Rapid maxillary expansion-tooth tissue-borne versus tooth-
compared with the conventional Hyrax expander. borne expanders: a computed tomography evaluation of
 Similar dental effects were observed for hybrid and dentoskeletal effects. Angle Orthod. 2005;75:548–557.
11. Fleming PS, Marinho V, Johal A. Orthodontic measure-
conventional expanders.
ments on digital study models compared with plaster
 Arch size and shape changes were similar for both models: a systematic review. Orthod Craniofac Res.
types of expanders. 2011;14:1–16.
12. Grunheid T, Patel N, De Felippe NL, Wey A, Gaillard PR,
Larson BE. Accuracy, reproducibility, and time efficiency of
ACKNOWLEDGMENTS
dental measurements using different technologies. Am J
This study was financed in part by the Coordenação de Orthod Dentofacial Orthop. 2014;145:157–164.
Aperfeiçoamento de Pessoal de Nı́vel Superior - Brasil (CAPES) 13. Stevens DR, Flores-Mir C, Nebbe B, Raboud DW, Heo G,
- Finance Code 001 and by the São Paulo Research Foundation, Major PW. Validity, reliability, and reproducibility of plaster vs
FAPESP (grants 2017/04141-9, 2017/24115-2 and 2019/03175- digital study models: comparison of peer assessment rating
2). The authors thank PecLab (Belo Horizonte, Brazil) and and Bolton analysis and their constituent measurements.
Morelli (Sorocaba, Brazil) for the support. Am J Orthod Dentofacial Orthop. 2006;129:794–803.
14. Sun Z, Smith T, Kortam S, Kim DG, Tee BC, Fields H. Effect
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Angle Orthodontist, Vol 91, No 2, 2021