Conservative surgical orthodontic adult rapid palatal expansion: Sixteen cases

Conservative surgical orthodontic adult rapid palatal expansion: Sixteen eases Andrew S. Glassman, D.D.S.,* Stephen J. Nahigian, Jerald M. Medway, D.D.S.,*** and Harry I. Aronowitz, Los Angeles, Calif.

D.D.S.,** D.M.D.****

A conservative surgical orthodontic technique that facilitates the widening of the adult maxilla at the midpalatal suture is presented. This procedure uses only lateral maxillary corticotomies and a maxillary Hyrax split-palate appliance. In all sixteen cases attempted, separation of the midpalatal suture was confirmed by occlusal radiographs and a diastema between the maxillary central incisors.

Key words: Adult,

rapid palatal expansion,

surgical, orthodontic

appliance, malocclusion

S

urgical facilitation of rapid palatal expansion (RPE) in adults has been reported previously. Although the techniques have varied in the reported procedures, surgical treatment of the midpalatal suture and pterygomaxillary junction was described.‘, x 3-8, “-‘L ‘O* 21 Initially, the midpalatal suture was identified as a significant area of osseous resistance to palatal expansion in patients beyond their late teens. *, ‘*, I43 15, i9, *I More recently, important contributions to the problem of palatal expansion have indicated that the zygomaticomaxillary buttress and the pterygomaxillary junction are critical areas of resistance to palatal expansion.2%3, I13 l4 It is evident that controversy still exists in that recent contributions to the literature continue to contemplate palatal surgery in many cases.a* *ix I9321 We would like to present a series of cases in which successful RPE was achieved without midpalatal or pterygomaxillary surgery. This simplified technique can be used safely in an office setting, with minimal morbidity and postoperative complications. The contents of the incisive canal are preserved, and there is no risk of surgical dehiscence of nasal or palatal tissue or *In private practice of oral and maxillofacial surgery, Beverly Hills, Calif.; Chief, Section of Oral and Maxillofacial Surgery, Cedars-Sinai Medical Center, Los Angeles, Calif. **In private practice of oral and maxillofacial surgery, Beverly Hills, Calif.; Attending Staff, Cedars-Sinai Medical Center, Los Angeles, Calif. ***In private practice of orthodontics, West Los Angeles, Calif.; Clinical Instructor, Department of Orthodontics, University of California, Los Angeles School of Dentistry. ****In private practice of orthodontics, Beverly Hills, Calif.; Assistant Clinical Rofessor, Department of Orthodontics, University of Southern California School of Dentistry.

Fig. 1. Diagram of osteotomy. piriform rim to pterygoid plates.

Made

from

lateral

aspect

of

of possible hemorrhage in the area of the pterygomaxillary fissure. Maxillary arch-width discrepancies in children have been corrected with relatively straightforward orthodontic techniques. Various rapid and slow palatal appliances have been advocated with good, predictable success,“-7’ 10. 22 Expansion was confirmed radiographically in both deciduous and mixed dentitions by opening of the median palatal suture.gs lo With the increased interest in adult orthodontics, maxillary width problems in the nongrowing patient have been encountered with greater frequency. Successful RPE has proved to be less predictable in the adult than in a child. Resistance, relapse, and pain associated with palatal 207

20% Classman et al

Fig. 2. Patient L.H. prior posterior crossbite.

to rapid

palatal

Fig.

in place

prior

3. Hyrax

appliance

expansion

with bilateral

to surgery

expansion have been attributed to several factors, including increased rigidity of the facial bones, especially the zygomatic buttress and other circummaxillary sutures. 3, 6. 7, 9-12, 22 Fusion at the midpalatal suture was also cited as a contributing factor to the poor prognosis for adult RpE

12.

REVIEW

15,

19.

?I

OF THE LITERATURE

In 1959 Kale’” advocated selective dentoalveolar osteotomies to section cortical bone and eliminate resistance to orthodontic movement. Converse and Horowitz suggested both labial and palatal cortical osteotomies for their expansion technique in 1969. In 1976 Kennedy and associates’” studied the effects of selected maxillary osteotomies as an adjunct to RPE in mature rhesus monkeys. Their results revealed a strong statistical difference between two groups; one group was treated with lateral maxillary, pterygomaxillary, and palatal osteotomy or simply lateral maxillary

Fig.

4. Initial

Fig.

dissection

5. Osteotomy

with exposure

made

through

of lateral

lateral

maxillary

maxillary

wall.

wall.

and pterygomaxillary osteotomy, while the second group was either an unoperated control or had palatal osteotomy alone. Their conclusion was that “true movement of basal bone of the maxilla by RPE could be accomplished by reduced resistance to lateral movement via osteotomy through the zygomatic buttress, nasomaxillary, and pterygomaxillary areas. “I2 In 1975 LinesI and in 1976 Bell and Epke? brought clinical relevance to the question of adult RPE when they advocated these same selected osteotomies in their skeletally mature patients. However, the latter still recommended placement of a chisel in the midpalatal suture from the nasal side, while the former made a palatal incision and with a bur cut through the midpalatal suture. Jacobs and his colleagues” reported in an article in March, 1980, that “once a diagnosis of absolute transverse maxillary deficiency has been made, and it is ascertained that the need for expansion of the maxillary arch does exist, other factors must be considered to

Conservative surgical

Volume 86 Number 3

Fig.

6. Primary

Fig. 7. Patient on sixteenth appliance expanded.

closure

postoperative

of incision.

day

Fig.

showing

Hyrax

determine whether such expansion should be achieved through lateral maxillary osteotomies and rapid maxillary expansion, as an integral part of the presurgical orthodontic therapy, or by segmentalizing the maxilla at the time of the surgery to achieve transverse correction, concomitantly with ultimate vertical and/or sagittal treatment objectives.” They also stated that “if nonextraction orthodontic therapy is desired, then, lateral maxillary osteotomies and rapid maxillary expansion is the treatment of choice.” In that article, they also refer to reports of maxillary expansion via lateral maxillary, pterygomaxillary, and palatal osteotomies to achieve their expansion. Most recently (in 1981) Timms,21 basing his approach on the findings of Persson and ThilanderlY who had reported various degrees of midpalatal ossifications in different age groups, sought to establish a conservative and definitive staging sequence to provide a “modus operandi” for the oral surgeon and orthodontist to employ the maximal amount of expansion with

adult rapid palatal

8. Frontal

view

with

expansion

209

diastema

Fig. 9. Patient with posterior crossbite and diastema months after beginning orthodontic treatment.

closed

5

the minimal amount of surgery. Timms advocated a surgical palatal split in his technique. We have found that uniform palatal expansion can be achieved in either extraction or nonextraction cases without sectioning of either the palate or the pterygomaxillary fissure. A technique of lateral corticotomy from the piriform rim anteriorly and posteriorly, to and through the zygomaticomaxillary buttress, was used exclusively in the cases reported in this study, which included nonextraction, simultaneous extraction, unilateral, and bilateral cases in patients from 14 to 44 years of age. DESCRIPTION

Upon perceiving unilateral or bilateral buccal crossbite in the adult patient, the orthodontist can consider RPE in his treatment plan. A Hyrax* appliance is cemented to the first premolar and to the first molar. If *Registered

trademark

of O.I.S.,

Wilmington,

Del

210

Glasman

Fig.

10. Patient

et al.

Am. J. Orthod. Srptember 1984

R.M.

with

bilateral

posterior

crossbite.

Fig. 12. Maxillary midpalatal

Fig.

Table

11. Patient

R.M.

after

rapid

palatal

expansion

therapy.

I. Unilateral

Case No. 1 2 3 4 5 6 7 8 9 10 II 12 13 14 15 16

Patient’s initials

Sex

Age

D.R. R.G. K.M. L.H. C.F. D.K. B.G. A.B. M.H. M.V. R.M. M.T. R.P. K.D. K.A. P.B.

M M F F F M M M M F F M F F F M

35 22 25 22 29 18 19 34 26 14 21 18 15 22 44 20

*Key to symbols: 1 = Sinus infection. abutment tooth. 3 = F’re-existing cleft terior collapse. 4 = Transient epistaxis.

bilayeral B B B B B B B B B B B U U B B U

Complications*

4 4 2 4 I

4 3

2 = Transient extrusion of palate with unilateral pos-

occlusal

radiograph

showing

separation

at

suture.

simultaneous first-premolar extraction is indicated, the appliance may be cemented to the second premolar and second molar without compromising treatment objectives. The orthodontist may elect to attempt expansion without surgery, as placement of the appliance will not interfere with any proposed surgery. If the RPE is unsuccessful, or is deemed inappropriate by virtue of the patient’s advanced age or skeletal maturity, the patient is referred to the oral surgeon. After adequate consultation, the patient is prepared for surgery and given light anesthetic sedation which is supplemented by local anesthetic nerve block. An incision is then made in the height of the buccal vestibule from the mesial aspect of the first molar to the distal aspect of the canine. The lateral maxillary wall is exposed by mucoperiosteal elevation from the piriform anteriorly across the zygomatic maxillary buttress, then posterior to the pterygomaxillary fissure via a subperiosteal tunneling technique. A fissure bur is used to effect an osteotomy approximately 5 mm above the apices of the teeth from the piriform rim to the zygomatic maxillary buttress, ending just anterior to the pterygoid fissure (Fig. 1). Care is taken at the anterior aspect of the osteotomy to avoid tearing the nasal mucoperiosteum by using a freer elevator as a tissue guard. The wound is then closed with a Vicryl3-0 dyed

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Fig. 13. crossbite.

Patient

R.G.

with

severe

crowding

and

posterior

Fig.

14. Patient

surgical

R.G.

adult

after

rapid

rapid

palutal

palatal

211

expansion

expansion

therapy.

suture. Prophylactic antibiotics, nasal decongestants, and analgesics are prescribed. The appliance is activated four turns (1 mm) at the time of surgery to absorb some of the elastic properties of the appliance. On the third postoperative day, the patient is instructed to activate one turn in the morning and then one turn in the evening, until adequate expansion has been achieved. The appliance is left in place for 12 weeks in a passive position, after which time routine orthodontic procedures can be initiated or continued. CASE

REPORT

Patient L.H., a 24-year-old woman, sought orthodontic treatment in May. 1982. Oral examination revealed significant bilateral posterior maxillary crossbite(Fig. 2). There was a Class I molar relationship with an open-bite tendency. Anterior maxillary crowding was evident, as was anterior mandibular crowding to a Iesser extent. To correct the crossbite and create additional arch width, RPE was considered. An oral surgical consultation was obtained in July, 1982. History and physical examination revealed a healthy woman with no contraindication for surgery. Radiographic evaluation revealed normal dental and osseous structures, no gross decay or periapical pathoses, and normal sinus configuration. The third molars were partial bony, mesial angular. Surgical re-

moval of the third molars and a lateral maxillary corticotomy were scheduled for August, 1982. The patient returned to her orthodontist for placement of the Hyrax RPE device (Fig. 3). In August, 1982, the patient underwent the previously described surgical procedure. Initial incision and maxillary

exposure (Fig. 4) were followed by lateral maxillary corticotomy (Fig. 5). The wound was closed (Fig. 6), the procedure was repeated on the opposite site, and the third molars were then removed. The Hyrax appliance was activated 1 mm (four turns) at the time of surgery, then one turn in the morning and evening after the third postoperative day. Expansion of 5.5 mm was seen on the sixteenth postoperative day (Figs. 7 and 8).

Fig. 15. Maxillary midpalatal suture.

occlusal

radiograph

showing

separation

of

When seen in February, 1983, the patient had maintained the Class I molar relationship, but the crossbite was eliminated and the diastema was closed (Fig. 9). Orthodontic treatment continues. iXCUSSlON

Rapid palatal expansion with lateral corticotomy only has been successful in all sixteen cases in which it has been attempted (Table I). The technique has several apparent advantages over the previously described

212

Glassrnan

et ul

Am. J. Orthod. 1984

Sr@vnber

Fig. 16. Patient tion of maxillary

E.G. first

with posterior premolar.

crossbite

and recent

extrac-

Fig. 16. Maxillary midpalatal suture.

Fig.

17. Patient

E.G.

after

rapid

palatal

expansion

treatment.

techniques. As no palatal approach is contemplated, the Hyrax appliance can be placed prior to surgery, and nonsurgical RPE can be attempted by the orthodontist. Should nonsurgical RPE fail or be associated with significant pain, then surgery can be performed without removing the appliance. Moreover, the pain associated with palatal osteotomy, whether by bur or chisel, is avoided. Operative bleeding and trauma to the incisive canal are minimized by avoiding the surgical split of the palate. As the maxillary expansion proceeds, a diastema is produced between the central incisors, similar to RPE in children (Figs. 10 to 18). The procedure may be performed safely in an office environment and postexpansion relapse has not been observed. Possible postoperative complications include sinus infection, devitalization of the teeth (if osteotomy is performed too close to the apices of the teeth), extrusion of teeth fixed to the Hyrax appliance, or nasal bleeding.

occlusal

radiograph

showing

separation

of

In all cases thus far completed, there was only one incident of postoperative sinus infection. This patient was found to have, at a later date, a calcified nasal antral ostium. In the one case of extrusion of the teeth cemented to the Hyrax appliance, removal of the buccal aspect of the cemented Hyrax band allowed intrusion without loss of palatal expansion. In our series of cases extending over a period of 5 years, there has been no visual relapse, either immediately following removal of the expansion device or after case completion. The postorthodontic series of cases have been followed 2 years after band removal without any observable relapse. SUMMARY

A conservative approach for surgical facilitation of rapid palatal expansion has been presented. It provides greater flexibility on the part of the orthodontist and decreases time and morbidity from a surgical approach. The elimination of the palatal osteotomy in this technique has proved successful in all sixteen cases thus treated. REFERENCES 1. Bell RA, LeCompte EJ: The effect of maxillary expansion a quad-helix appliance during the deciduous and mixed tions. AM J ORTHOD 79: 152-161, 1981.

using denti-

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2. Bell WH. Epker BN: Surgical-orthodontic expansion of the maxilla. AM J ORTHOD 70: 517-528, 1976. 3. Bell WH, Jacobs JD: Surgical orthodontic correction of horizontal maxillary deficiency. J Oral Surg 37: 897-902, 1979. 4. Ellenberg DC: An evaluation of relapse changes following rapid maxillary expansion, University of Minnesota Dental School, 1969. 5. Haas AJ: Rapid expansion of the maxillary dental arch and nasal cavity by opening of the mid-palatal suture. Angle Orthod 31: 73-90, 1961. 6. Haas AJ: The treatment of maxillary deficiency by opening the mid-palatal suture. Angle Orthod 35: 200-217, 1965. 7. Haas AJ: Palatal expansion: Just the beginning of dentofacial orthopedics. AM J ORTHOD 57: 219-255, 1970. 8. Haas AJ: Long-term post treatment evaluation of rapid palatal expansion. Angle Orthod SO: 189-217, 1980. 9. Harberson VA, Meyers DR: Midpalatal suture opening during functional posterior cross-bite correction. AM J ORTHOD 74: 310-313, 1978. 10. Hicks EP: Slow maxillary expansion. AM J ORTHOD 73: 121. 141.

1978.

11. Jacobs JD, et al: Control of the transverse dimension with surgery and orthodontics. AM J ORTHOD 77: 284-306, 1980. 12. Kennedy JW, et al: Osteotomy as an adjunct to rapid maxillary expansion. AM J ORTHOD 70: 123-137, 1976. 13. Kole H: Surgical operations on the alveolar ridge to correct occlusal abnormalities. Oral Surg 12: 515-528, 1959.

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14. Lines PA: Adult rapid maxillary expansion with corticotomy. AM J ORTHOD 67: 44-56, 1975. 15. Melsen B: Palatal growth studied on human autopsy material. AM J ORTHOD 68: 42-54, 1975. 16. Moss JP: Rapid expansion of the maxillary arch. Part I. J Pratt Orthod 2: 165-171, 1968. 17. Moss JP: Rapid expansion of the maxillary arch. Part II. J Pratt Orthod 2: 215-223, 1968. 18. Muguerza OE, Shapiro PA: Palatal mucoperiostomy: an attempt to reduce relapse after slow maxillary expansion. AM J ORTHOD 78: 548-558, 1980. 19. Persson M, Thilander B: Palatal suture closure in man from 15 35 years of age. Aivi J ORTHOD 72: 42-52, 1977 20. Timms D: An occlusal analysis of lateral maxillary expansion. Trans Br Sot Study Orthod, pp. 13-78, 1967. 21. Timms D: The relationship of rapid maxillary expansion to surgery with special reference to mid-palatal synostosis. Br J Oral Surg 19: 180-196, 1981. 22. Zimring JF, Isaacson RJ: Forces produced by rapid maxillary expansion; forces present during retention. Angle Orthod 35: 178-186, 1978. Reprint

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Dr. Andrew S. Glassman 9735 Wilshire Blvd., Suite 232 Beverly Hills, CA 90212