Home | About Us | Editorial Board | Current Issue | Archives | Search | Instructions | Subscription | Feedback | e-Alerts | Login 
Journal of Indian Society of Pedodontics and Preventive Dentistry Official publication of Indian Society of Pedodontics and Preventive Dentistry
 Users Online: 695  
  Print this page Email this page   Small font sizeDefault font sizeIncrease font size

  Table of Contents    
Year : 2018  |  Volume : 36  |  Issue : 3  |  Page : 225-233

Comparison of effectiveness of quad helix appliance with other slow maxillary expanders in children with posterior crossbite: A systematic review

1 Department of Pedodontics and Preventive Dentistry, Dr. D. Y. Patil Vidyapeeth, Dr. D. Y. Patil Dental College and Hospital, Pimpri, Pune, Maharashtra, India
2 Department of Public Health Dentistry, Dr. D. Y. Patil Vidyapeeth, Dr. D. Y. Patil Dental College and Hospital, Pimpri, Pune, Maharashtra, India

Date of Web Publication24-Sep-2018

Correspondence Address:
Dr. Khyaati Vinod Gidwani
Department of Pedodontics and Preventive Dentistry, Dr. D.Y. Patil Vidyapeeth, Dr. D.Y. Patil Dental College and Hospital, Pimpri - 411 018, Pune, Maharashtra
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JISPPD.JISPPD_85_17

Rights and Permissions



Objective: The present review was conducted to compare the effectiveness of Quad Helix (QH) appliance with other slow maxillary expanders in children with posterior crossbite. Materials and Methods: Randomized controlled clinical trials and retrospective studies published between January 1, 1995, and December 31, 2016, were identified from MEDLINE, the Cochrane Central Register of Controlled Trials, the National Institutes of Health Trials, Clinical Trials Registry India, Google Scholar and major journals. After a comprehensive search, the articles were independently screened for eligibility by two reviewers. All cross-reference lists of the selected studies were screened for any additional papers. Results: The preliminary screening consisted of 608 articles, of which 33 articles were selected. A final total of only 9 articles were included as they met the inclusion and exclusion criteria. Of the nine papers, four articles clearly state that QH appliance was a more effective appliance, while the remaining five studies suggest that the maxillary expansion caused by QH is comparable to other slow maxillary expansion appliances. Of the nine included articles, four articles also describe the complications of QH in comparison to other slow maxillary expansion devices. Conclusion: The QH appliance is a viable alternative for the correction of posterior crossbite. The QH appliance is comparable to or even better than other slow maxillary expanders in terms of maxillary expansion while being cost-effective with very few complications.

Keywords: Maxillary arch expansion, posterior crossbite, Quad Helix, slow maxillary expansion

How to cite this article:
Gidwani KV, Bendgude VD, Kokkali VV, Mehta V. Comparison of effectiveness of quad helix appliance with other slow maxillary expanders in children with posterior crossbite: A systematic review. J Indian Soc Pedod Prev Dent 2018;36:225-33

How to cite this URL:
Gidwani KV, Bendgude VD, Kokkali VV, Mehta V. Comparison of effectiveness of quad helix appliance with other slow maxillary expanders in children with posterior crossbite: A systematic review. J Indian Soc Pedod Prev Dent [serial online] 2018 [cited 2022 Oct 4];36:225-33. Available from: http://www.jisppd.com/text.asp?2018/36/3/225/241975

   Introduction Top

Crossbite is characterized by an abnormal buccolingual or labiolingual relationship of the teeth when in occlusion. It can be further classified as anterior/posterior or both, unilateral/bilateral or both, and skeletal/dental.

Posterior crossbite is one of the frequently observed malocclusions of deciduous and mixed dentition, with a prevalence of 8% in deciduous dentition and 7.2% in mixed dentition.[1] However, spontaneous self-correction of 45% of the posterior crossbite is observed. Thus, the recommendation for treatment is to be postponed until the early mixed dentition.[2]

It has been observed that untreated posterior crossbite may lead to craniofacial asymmetry and risk of damage to the temporomandibular joint (TMJ), the symptoms of which could include pain, clicking or locking of the TMJ.[2] Electromyographic studies have also shown disturbed activity of the temporal and masseter muscles in children with posterior crossbite. It is therefore recommended that an appropriate treatment for the correction of posterior crossbite should be performed.[3],[4]

The treatment option for the correction of posterior crossbite includes both rapid and slow maxillary expansion techniques. Despite the extensive use of rapid maxillary expanders, few complications such as bite opening, relapse, microtrauma of the TMJ and the midpalatal suture, root resorption, tissue impingement and pain, and excessive tipping of the tooth/teeth providing anchorage could occur along with the desired expansion.[5],[6],[7],[8],[9] On the other hand, slow maxillary expanders produce less tissue resistance around the circummaxillary structures and improve bone formation in the intermaxillary sutures.[8],[10],[11] Thus, slow maxillary expansion is preferred over rapid maxillary expansion.

Some commonly used appliances for slow maxillary expansion are Quad Helix (QH) appliance, W arch appliance, and jack screw with expansion plate (EP). Although QH is a more conventional device, and less frequently used, it also has a number of advantages such as better muscle adaptation and low chances of relapse.[12],[13],[14],[15] Hence, there is a need to revisit the QH appliance.

Systematic reviews are designed to locate, appraise, and synthesize the evidence from scientific studies to provide informative answers to scientific questions by including a comprehensive summary of the available evidence.[16] This systematic review was undertaken to answer the following question:

How effective is the QH appliance for arch expansion in children with posterior crossbite as compared to other slow maxillary expansion appliances?

What are the complications seen while using the appliance?

   Materials and Methods Top

Search strategy

Two electronic databases were used to search for appropriate studies that would satisfy the study purpose: PubMed-MEDLINE, and the Cochrane Central Register of Controlled Trials from January 1, 1995, up to December 31, 2016, using MeSH terms [Table 1]. Additional sources such as Google Scholar and major journals were explored. Ongoing trial registries such as The National Institutes of Health Trials and Clinical Trial Registry India were searched. Contact with authors was done for any unpublished studies. Detailed search strategy is shown in [Table 2].
Table 1: Keywords

Click here to view
Table 2: Search strategy

Click here to view

Inclusion criteria

  1. Randomized controlled trials (RCTs), controlled clinical trials (CCT), and retrospective studies with essential data on posterior unilateral/bilateral crossbite treatment with QH
  2. Studies conducted in children with mixed dentition essentially maxillary first permanent molars with both unilateral or bilateral crossbite without skeletal Class III malocclusion
  3. Studies in which method of measurement of arch expansion was using study of dental casts
  4. Only papers in English were accepted.

Exclusion criteria

  1. Reviews, case reports, abstracts, editorials, letters, and historical reviews were not included in the search
  2. Studies that give a previous history of orthodontic treatment performed on the subjects were excluded
  3. Studies in which the subjects provide a history of nonnutritive sucking habits prior or during the appliance therapy were excluded
  4. Studies which accepted subjects with cleft lip and cleft palate defects or other syndrome with associated craniofacial anomalies were excluded
  5. Studies that utilized surgically assisted rapid maxillary expansion, mayofunctional appliance, and headgear appliance along with appliance therapy were excluded
  6. Studies in which the type of appliance for correction of crossbite was not clearly mentioned or results of “the QH appliance” correction were not separately mentioned
  7. Studies in which children were only with primary dentition and maxillary permanent first molars remained unerupted.

Screening and selection

The papers were independently scanned by two reviewers (KG and VB), first by the title and abstract. If the search keywords were present in the title and/or the abstract, the papers were selected for full-text reading. Papers without abstracts but with titles suggesting that they were related to the objectives of this review were also selected to screen the full text for eligibility. After selection, full-text papers were read in detail by two reviewers (KG and VB). Those papers that fulfilled all of the selection criteria were processed for data extraction. Two reviewers (KG and VB) hand searched the reference lists of all selected studies for additional relevant articles. Disagreements between the two reviewers were resolved by discussion. If a disagreement persisted, the judgment of a third reviewer (VM) was considered decisive.

Data extraction

From the collection of papers that met the inclusion criteria, data were extracted with respect to the effectiveness of QH compared to other slow maxillary expansion appliances.

   Results Top

Search and selection results

The PubMed-MEDLINE, Cochrane Central, and other sources identified 608 unique records which were screened by titles and abstracts [Figure 1]. After full-text reading, 563 records were excluded. This exclusion resulted in 33 full-text articles. The remaining nine studies[2],[16],[17],[18],[19],[20],[21],[22],[24] that fulfilled the selection criteria were processed for data extraction. Additional hand searching of the reference lists of the selected studies yielded no additional records. An overview of the selected studies[2],[16],[17],[18],[19],[20],[21],[22],[24] and their characteristics are presented in [Table 3] and [Table 4].
Figure 1: Flowchart summarizing article selection process

Click here to view
Table 3: Data extraction sheet (1)

Click here to view
Table 4: Data extraction sheet (2)

Click here to view

Study design and modalities

The study design of the selected articles was either RCTs or controlled CCT's. All of the studies were prospective studies except two that were retrospective studies.[17],[18]

The treatment modalities of all the selected studies contained one separate group of QH appliance therapy and the other group comprised the remaining slow maxillary expansion device/devices and/or a control group.

Six[2],[18],[20],[21],[22],[23] studies compared QH appliance to a slow maxillary EP, while one compared it to the NiTi tandem loop.[19]

Rate of attrition

Three[18],[20],[21] studies out of the nine showed no rate of attrition of the sample size. The remaining studies did show some attrition from the original sample size.

Amount of expansion

The amount of expansion was measured using intermolar width between the two permanent molars on study casts.

In all the studies, QH showed greater amount of expansion than any other appliance used.

The amount of expansion seen using QH appliance ranged between 3.6[2] and 5.7 mm[21] was seen immediately after removal of the appliance while amount of expansion retained ranged between 3.4[23] and 5.1 mm.[20]

The amount of expansion seen by other slow maxillary expansion appliances ranged as low as 2.9 mm[2] for EP and 0.5 mm[22] for composite onlays.


A number of complications have been seen using slow maxillary expansion appliances. These vary from appliance to appliance.

For QH appliance, the following are the complications seen: patient discomfort on activation of the appliance, loose bands and breakage of the appliance, soft tissue trauma,[19],[20],[21] and dental tipping.[2]

For NiTi tandem loop, the following complications were seen: patient discomfort on activation, dislodged appliance, loose bands, soft tissue trauma, and fracture of the appliance.[19]

For EP, the following complications were seen: loss of appliance, breakage of appliance,[20],[21] and lack of patient cooperation[22] leading to treatment failure.

Primary outcome

Different authors had various comments to give about the QH appliance. These comments serve as a final verdict and summarize the results of their paper. Four[2],[20],[22],[24] authors have clearly stated that QH group proved to be a more effective slow maxillary expander than the other expanders used, while the others state that QH was as effective as other slow maxillary expanders used. There are no authors who stated a negative result with the QH appliance.

Time taken for expansion

Different authors stated different amounts of time used for the treatment of crossbite with QH appliance. These treatment times had a variety of range which ranged from 2[20] to 7.7 months,[2] while EP ranged for about 1.2 years.[2]

   Discussion Top

Quad Helix: The appliance used

The QH appliance, as described by Ricketts in 1975, is a modification of the earlier transpalatal Coffin spring.[25],[26],[27],[28] It has four helical loops, each of which comprises an extra 25-mm wire which lightens the force magnitude. This helps in providing continuous action during expansion because of greater range of activation provided by the longer wire.[29]

A QH appliance is not only used for arch expansion but also can be activated to de-rotate the molar on one side of the arch, thus providing a distalizing force on the opposite side of the same arch. Thus, it is a multifunctional multipurpose appliance.[29]

Also by extending the palatal arms of the appliance on one side, the appliance can be used to involve more teeth to act as anchorage in the distal movement of a single molar on the opposite side of the arch, therefore adding more credit to its usage.[29]

Effectiveness of Quad Helix appliance versus other slow maxillary expanders

In this systematic review, the QH appliance has been compared with other slow maxillary expanding appliances (EP with jack screw and NiTi tandem loop) in its ability to expand arches. The studies included in this review compared the difference between the intermolar widths to judge the arch expansion observed with different appliances.

The QH appliance produced an expansion which ranged from 4.1[21] to 8.4 mm,[19] with an average of 5.45 mm. This was more than the other appliances compared in this study. The most common appliance which was compared with QH was EP with jack screw. The expansion observed with EP ranged from 2.9[2] to 4.5 mm,[24] with an average of 3.78 mm. Hence, only a fraction of the expansion was observed when compared with the QH appliance.

In a study conducted by Bell and LeCompte,[31] a significant increase in maxillary intermolar and intercanine arch width was produced by the QH appliance which was sufficient to allow normal vertical closure and correct the functional posterior crossbite. Erdinç et al.[18] showed that not only was the amount of expansion attained by QH greater than the other slow maxillary expander, but the treatment time of QH appliance was also shorter. The QH appliance presented with maximum amount of arch expansion (5.6 mm) as compared to the other appliances in just 0.6 years.

In addition to achieve the desired maxillary expansion, the QH appliance presented no significant patient tolerance problems while offering the advantages of continuous force application and eliminating adjustment responsibility from the parents. The continuous nature of force application produced by the QH appliance apparently reduces the need for appliance adjustments during maxillary expansion.[30] This further helps in reducing the number of visits, shortening the period of treatment, and decreasing the dependability on patient cooperation. These advantages were distinctly observed in a study conducted by Hermanson et al., in which 16 out of 17 patients were treated with QH successfully. However, there was severe attrition in the experimental group, in which EP was used for crossbite correction.[31]

In terms of expansion, few authors have observed that other slow maxillary expanders were comparable to QH. Godoy et al.[21] compared the effectiveness of QH appliance and removable EP among 99 patients for crossbite correction. They noted that the success rates were similar for both the appliances; however, the treatment cost and duration were higher for the group in which EP was used. Thus, making QH appliance was a better choice of treatment.

Considering the important features about slow maxillary expansion, it can be stated that QH appliance effectively produces a greater amount of maxillary expansion, in a shorter period with better patient compliance.

Complications with Quad Helix appliance versus other slow maxillary expanders

There are different slow maxillary expanders used by different authors. A number of complications have been seen with QH appliance; these included dental tipping, ulcerations at the area of the helix, loose bands, and breakage of the appliance.

Donhue et al.[19] in their found the percentage of these complications to be 50% for QH appliance and 57% for NiTi tandem loop that was the other slow expander used.

Godoy et al.[21] stated that there was maximum of breakage and displacement of QH appliance, 18.2% and 33.3%, respectively, while EP had maximum complication seen as loss of the appliance, 24.2%.

However, most of the complications are easily avoidable by careful chairside and laboratory practices such as proper band pinching and adaptation, adequate adaptation of the wire components of the appliance, and appropriate selection of wire gauge.

   Conclusion Top

The meticulous investigation of this review concludes that QH appliance is a viable alternative for the correction of posterior crossbite. The amount of arch expansion produced by QH appliance is equal to or better than other slow maxillary expanders. Moreover, the expansion is brought about in a shorter duration, does not heavily depend on the compliance of the patient, and is extremely cost-effective with few complications which are avoidable.


  1. Other methods for the measurement such as lateral and posteroanterior cephalometric radiographs were not taken into consideration for expansion of skeletal component with the appliance
  2. There was a large variation in sample size between the studies ranging from 312 to 30 subjects at a time.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Kutin G, Hawes RR. Posterior cross-bites in the deciduous and mixed dentitions. Am J Orthod 1969;56:491-504.  Back to cited text no. 1
Bjerklin K. Follow-up control of patients with unilateral posterior cross-bite treated with expansion plates or the quad-helix appliance. J Orofac Orthop 2000;61:112-24.  Back to cited text no. 2
Troelstrup B, Moller E. Electromyography of the temporalis and masseter muscles in children with unilateral cross-bite. Scand J Dent Res 1970;78:425-30.  Back to cited text no. 3
Ingervall B, Thilander B. Activity of temporal and masseter muscles in children with a lateral forced bite. Angle Orthod 1975;45:249-58.  Back to cited text no. 4
McNamara JA Jr., Baccetti T, Franchi L, Herberger TA. Rapid maxillary expansion followed by fixed appliances: A long-term evaluation of changes in arch dimensions. Angle Orthod 2003;73:344-53.  Back to cited text no. 5
Chang JY, McNamara JA Jr., Herberger TA. A longitudinal study of skeletal side effects induced by rapid maxillary expansion. Am J Orthod Dentofacial Orthop 1997;112:330-7.  Back to cited text no. 6
Ciambotti C, Ngan P, Durkee M, Kohli K, Kim H. A comparison of dental and dentoalveolar changes between rapid palatal expansion and nickel-titanium palatal expansion appliances. Am J Orthod Dentofacial Orthop 2001;119:11-20.  Back to cited text no. 7
Garib DG, Henriques JF, Carvalho PE, Gomes SC. Longitudinal effects of rapid maxillary expansion. Angle Orthod 2007;77:442-8.  Back to cited text no. 8
Akkaya S, Lorenzon S, Uçem TT. Comparison of dental arch and arch perimeter changes between bonded rapid and slow maxillary expansion procedures. Eur J Orthod 1998;20:255-61.  Back to cited text no. 9
Proffit WR, Fields HW, Sarver DM. Contemporary Orthodontics. 4th ed. St. Louis: Mosby Elsevier; 2007.  Back to cited text no. 10
Henry RJ. Slow maxillary expansion: A review of quad-helix therapy during the transitional dentition. ASDC J Dent Child 1993;60:408-13.  Back to cited text no. 11
Duarte MS. Quad-helix appliance and its modalities. R Dental Press Ortodon Ortop Facial 2006;11:128-56.  Back to cited text no. 12
Hicks EP. Slow maxillary expansion. A clinical study of the skeletal versus dental response to low-magnitude force. Am J Orthod 1978;73:121-41.  Back to cited text no. 13
Ricketts RM. Logic and Keys to Bio Philosophy and Treatment Mechanics. Scottsdale AZ: American Institute for Bioprogresive Education; 1986. p. 98.  Back to cited text no. 14
Boysen B, La Cour K, Athanasiou AE, Gjessing PE. Three-dimensional evaluation of dentoskeletal changes after posterior cross-bite correction by quad-helix or removable appliances. Br J Orthod 1992;19:97-107.  Back to cited text no. 15
York. National Health Service (NHS). Centre for Reviews and Dissemination. Undertaking Systematic Reviews of Research on Effectiveness. University of York; 2001.  Back to cited text no. 16
Huynh T, Kennedy DB, Joondeph DR, Bollen AM. Treatment response and stability of slow maxillary expansion using haas, hyrax, and quad-helix appliances: A retrospective study. Am J Orthod Dentofacial Orthop 2009;136:331-9.  Back to cited text no. 17
Erdinç AE, Ugur T, Erbay E. A comparison of different treatment techniques for posterior crossbite in the mixed dentition. Am J Orthod Dentofacial Orthop 1999;116:287-300.  Back to cited text no. 18
Donohue VE, Marshman LA, Winchester LJ. A clinical comparison of the quadhelix appliance and the nickel titanium (tandem loop) palatal expander: A preliminary, prospective investigation. Eur J Orthod 2004;26:411-20.  Back to cited text no. 19
Sandikçioğlu M, Hazar S. Skeletal and dental changes after maxillary expansion in the mixed dentition. Am J Orthod Dentofacial Orthop 1997;111:321-7.  Back to cited text no. 20
Godoy F, Godoy-Bezerra J, Rosenblatt A. Treatment of posterior crossbite comparing 2 appliances: A community-based trial. Am J Orthod Dentofacial Orthop 2011;139:e45-52.  Back to cited text no. 21
Petrén S, Bondemark L. Correction of unilateral posterior crossbite in the mixed dentition: A randomized controlled trial. Am J Orthod Dentofacial Orthop 2008;133:790.e7-13.  Back to cited text no. 22
Petrén S, Bjerklin K, Bondemark L. Stability of unilateral posterior crossbite correction in the mixed dentition: A randomized clinical trial with a 3-year follow-up. Am J Orthod Dentofacial Orthop 2011;139:e73-81.  Back to cited text no. 23
Shundo I, Kobayashi Y, Endo T. Short-term treatment effects of quad-helix on maxillomandibular expansion in patients with maxillary incisor crowding. Odontology 2012;100:76-86.  Back to cited text no. 24
Brandt S, Ricketts RM. Interview: Dr. Robert M. Ricketts on growth prediction 2. J Clin Orthod 1975;9:340-9, 352.  Back to cited text no. 25
Coffin WH. A generalized treatment of irregularities. Paper read to section XII of the International Medical Congress. Trans Int Cong Med 1881;3:542-7.  Back to cited text no. 26
Talbot ES. Irregularities of the Teeth. Philadelphia, PA: P. Blakiston; 1888. p. 121-5.  Back to cited text no. 27
Friel S, McKeag HT. The Design and Construction of Fixed Orthodontic Appliances in Stainless Steel, European Orthodontic Society, Report of the Twenty-Second Annual Congress. London, England: The Dental Manufacturing Company; 1038. p. 53-84.  Back to cited text no. 28
Bench RW. The quad helix appliance. Semin Orthod 1998;4:231-7.  Back to cited text no. 29
Bell RA, LeCompte EJ. The effects of maxillary expansion using a quad-helix appliance during the deciduous and mixed dentitions. Am J Orthod 1981;79:152-61.  Back to cited text no. 30
Hermanson H, Kurol J, Rönnerman A. Treatment of unilateral posterior crossbite with quad-helix and removable plates. A retrospective study. Eur J Orthod 1985;7:97-102.  Back to cited text no. 31


  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4]

This article has been cited by
1 Maxillary expansion in grafted alveolar arches in patients with cleft lip and palate: A literature review
Adriana Parra Barillas, Dimitrios Michelogiannakis, P. Emile Rossouw, Fawad Javed
Surgery in Practice and Science. 2021; 5: 100034
[Pubmed] | [DOI]
2 Is the Quad Helix more efficient to correct mandibular asymmetry before age 7? A retrospective comparative study
Manon Fourneron, Flora Morant, François Boutin, Laure Frapier
International Orthodontics. 2020; 18(3): 443
[Pubmed] | [DOI]


Print this article  Email this article


    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Article in PDF (461 KB)
    Citation Manager
    Access Statistics
    Reader Comments
    Email Alert *
    Add to My List *
* Registration required (free)  

    Materials and Me...
    Article Figures
    Article Tables

 Article Access Statistics
    PDF Downloaded682    
    Comments [Add]    
    Cited by others 2    

Recommend this journal

Contact us | Sitemap | Advertise | What's New | Copyright and Disclaimer | Privacy Notice
 © 2005 - Journal of Indian Society of Pedodontics and Preventive Dentistry | Published by Wolters Kluwer - Medknow 
Online since 1st May '05