THE READERS' CORNER

Topic include arch expansion and divorced parents.

1. What appliance do you use for rapid palatal expansion? What is your usual treatment regimen (adjustment amount and frequency, duration, retention, etc.)? What are your criteria for case selection, and timing and amount of expansion? Have you had any success with adult cases? Do you see a difference between rapid and slow palatal expansion?

Diagnosis

Posterior crossbites of skeletal origin, shape of the palate, facial form, and respiratory habits were frequently mentioned criteria for expansion. Also mentioned was the need to expand the maxilla to ensure normal transverse relationships when the mandible is advanced with functional appliances.

Rapid vs. Slow Expansion

Readers overwhelmingly preferred rapid palatal expansion, particularly when the patient was in the permanent dentition. For patients under 11 or 12 years old, several readers preferred slower expansion using quadhelix appliances or bonded appliances. Several practitioners mentioned that they had had little success with patients over 15 years old. Expansion was rarely suggested for adults--and then only with an all-wire appliance, to avoid the possibility of the acrylic causing pressure necrosis of the mucosa if the suture failed to open and the appliance continued to be activated. Comments included:

"RPE gives a more predictable treatment time and may be more stable on completion because the maxillary posterior teeth are not tipped buccally as much as with a quadhelix appliance".

"I don't see a difference between slow and rapid palatal expansion, as I retain for over six months".

"I find slow expansion hard to control because of the rapid relapse if the appliance is not worn properly".

Appliance Type

Banding the maxillary first molars and first bicuspids, with a lingual wire connecting these teeth, was the most popular method. Several clinicians used acrylic bonded appliances, particularly in the mixed dentition.

"Mixed dentition cases will have a combination of bands on the maxillary first molars and bonded pads on the lingual of the maxillary primary cuspids".

"The bands have tubes and brackets welded onto them prior to the impression. This serves two purposes: (1) secure seating into the alginate impression, and (2) the ability to insert a stiff buccal rectangular wire for appliance stability. A distal extension of this wire can be used for Class III elastics off a chin cup if advancement of the maxilla is desired".

"Posterior high-pull headgear is used if there is any tendency toward an anterior open bite".

Treatment Regimen

Turning the expansion screw twice daily, once in the morning and once in the afternoon, was the

almost universally recommended treatment. Most readers reported active treatment times of two to three weeks. Some said they continued expansion until the buccal inclines of the maxillary lingual cusps were contacting the lingual inclines of the mandibular buccal cusps.

"An occlusal radiogram is taken on the fourth or fifth day after treatment initiation to evaluate the separation of the palatal shelves, which usually occurs between the third and eighth day. If separation does not occur 15 days into active treatment, the appliance is discontinued".

Retention

Those who used an RPE reported a retention period of about three months. Longer periods of retention, commonly six months to a year, were suggested for patients older than 14 or 15. The appliance itself was the most commonly used retainer.

"After activation the screw is plugged with self-curing acrylic. After the retainer is removed, it is replaced by a thin acrylic wafer retainer. This is loose fitting and thus stimulates the patient subconsciously to place the tongue against it. This helps to retrain tongue position, which usually had a low posture in a constricted maxilla".

"Clinical impression is that unilateral crossbites are easier to treat and retain than bilateral crossbites. They require less expansion and rather require the elimination of functional interferences, often by grinding the primary canines".

2. In cases of child patients with divorced parents, how do you handle the case presentation, fee presentation, and delinquency of payment or cooperation?

Many practitioners reported doing a case presentation only for the parent who brought the child in for treatment. Some insisted on both parents being present; if this was not possible, the other parent was given a "telephone consultation". Other suggestions included:

"We sent copies of letters to both parents".

"Clearly identify who is responsible for payment, ask that person to sign the treatment contract; that person is then responsible for delinquency of payments".

"If both parents are paying, each should have a separate contract detailing responsibilities".

"In cases of delinquent payments the format is as follows: 30 days-- statement, 60 days--statement and phone call, 90 days--collection" .

"If the child is on the father's insurance but the mother is paying the account, we sometimes encounter the problem of the insurance paying the father, but the mother having difficulty obtaining funds from the father. To circumvent this we have the father sign a release that insurance funds can be sent directly to the mother; alternatively we assign the insurance funds to ourselves and then countersign the check so the mother can then cash it.

"If payments are delinquent I send statements for the total amount to both parents".

"Cooperation problems are dealt with directly with the child and the parent he or she is living with; all negative behaviors (cooperation or appointment keeping) are recorded in red on the chart. More than one red entry stimulates a response from the doctor".

JCO wishes to thank the following participants in this month's column:



Dr. Iren M. Baker, Louisville, KY

Dr. Helen P. Delivanis, Louisville, KY

Dr. Philip M. Campbell, Huntsville, TX

Dr. Ronald L. Gallerano, Houston, TX

Dr. David B. Kennedy, Vancouver, BC

Dr. Mladen M. Kuftinec, Louisville, KY

Dr. George W. Lundstedt, Lynnfield, MA

Dr. Barry D. McNew, Greenville, TX

Dr. Kevin J. Showfety, Louisville, KY

Dr. Barton H. Tayer, Brookline, MA