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Complications related to surgically assisted rapid palatal expansion
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Complications related to surgically assisted rapid palatal expansion Guhan Dergin, DDS, PhD, Sertac Aktop, DDS, PhD, Altan Varol, DDS, PhD, Faysal Ugurlu, DDS, PhD, and Hasan Garip, DDS, PhD Objective. The goals of this retrospective clinical study were to identify surgically assisted rapid palatal expansion (SARPE) complications and assess their incidence, with the aim of informing surgeons and orthodontists of the risks of this widely used procedure before they recommend it to patients. Study Design. Between June 2008 and July 2010, 60 patients (23 women and 37 men) underwent SARPE according to a defined multidisciplinary protocol at the University of Marmara, Istanbul, Turkey. Results. Twelve patients (20%) suffered from nasal bleeding. Of these 12, 2 patients suffered late-onset bleeding beginning on postoperative day 8, and in the other 10, nasal bleeding was insignificant. Three patients reported excessive lacrimation postoperatively. Minor problems related to pain and numbness were all temporary. Conclusions. SARPE procedures have traditionally been reported to be associated with low morbidity, especially in comparison with other orthognathic surgical procedures. However, many complications have been reported. (Oral Surg Oral Med Oral Pathol Oral Radiol 2015;-:1-7)
Transverse maxillomandibular discrepancy is a major component of several types of malocclusion.1 Maxillary construction can be corrected surgically or nonsurgically via orthodontic rapid palatal expansion (RPE) using a tooth-borne expander, surgically assisted rapid palatal expansion (SARPE), or segmental Le Fort osteotomy.2 The general indications for SARPE include skeletal maturity, (extreme) transverse maxillary hypoplasia, unilateral or bilateral anterior crowding, and the presence of buccal corridors (“black corridors”) when smiling and when orthodontic maxillary expansion has failed.3 Although the mid-palatal suture is an area of resistance in symmetric widening of the constricted maxilla, it is only one of many areas of resistance in the facial skeleton, such as the zygomaticomaxillary buttress, pterygoid junction, and piriform aperture.4,5 Brown first described the use of the mid-palatal split technique for maxillary expansion, and SARPE has become the preferred approach for correcting maxillary transverse deficiency in skeletally mature individuals.6 Shetty et al. concluded that the exclusive use of bilateral zygomaticomaxillary buttress osteotomy to facilitate SARPE was inadequate and stated that complete midpalatal and pterygomaxillary osteotomies were
essential to achieve predictable maxillary expansion in adults.7 SARPE procedures have traditionally been reported to be associated with low morbidity, especially in comparison with other orthognathic surgical procedures.8 However, many complications have been reported, ranging from life-threatening epistaxis to cerebrovascular accidents, including skull base fracture with reversible oculomotor nerve paralysis and orbital compartment syndrome.9-13 The goals of this retrospective clinical study were to identify SARPE complications and assess their incidence, with the aim of informing surgeons and orthodontists of the risks of this widely used procedure before they recommend it to patients.
The work was previously presented at the 4th ACBID International Oral and Maxillofacial Surgery Society Congress, 2010, at Antalya, Turkey. Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Marmara University, Istanbul, Turkey. Received for publication Oct 10, 2014; returned for revision Jan 6, 2015; accepted for publication Jan 16, 2015. Ó 2015 Elsevier Inc. All rights reserved. 2212-4403/$ - see front matter http://dx.doi.org/10.1016/j.oooo.2015.01.008
Surgically assisted rapid palatal expansion procedures have traditionally been reported to be associated with low morbidity, especially in comparison with other orthognathic surgical procedures. However, many complications have been reported. Two patients suffered late-onset bleeding beginning on postoperative day 8. Three patients reported excessive lacrimation.
MATERIALS AND METHODS Between June 2008 and July 2010, 60 patients (23 women and 37 men) underwent SARPE according to a defined multidisciplinary protocol at the University of Marmara, Istanbul, Turkey. The age of the participants ranged from 17 to 26 years. All patients presented with a total transverse maxillary deficiency greater than
Statement of Clinical Relevance
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ORAL AND MAXILLOFACIAL SURGERY 2 Dergin et al.
5 mm and a closed mid-palatal suture. This project was approved by the Ethics Committee of the Faculty of Dentistry, University of Marmara, and informed consent was obtained from all patients. Computed tomography (CT) was performed to evaluate the preoperative anatomy and to exclude inflammation of the maxillary sinus. All patients underwent similar treatment regimes. Each patient’s orthodontist inserted a Haas-type expander, with an acrylic splint cemented to the first premolars and molars.14 The patients selected for this study were all American Society of Anaesthesiologists (ASA) I group of patients to determine the complications related to surgery, rather than predisposing systemic-related complications, such as bleeding. SARPE was performed with the patient under general anesthesia with nasotracheal intubation. All of the surgeries were performed by the same surgical team, comprising the authors of this paper. A modified Le Fort I maxillary osteotomy, including separation of the pterygomaxillary suture, was performed. A horizontal incision was made through the mucoperiosteum above the mucogingival junction in the deepest part of the buccal vestibular space, extending from the canine region to the mesial surface of the first molar. The nasal mucosae were elevated gently from the lateral nasal wall. A horizontal low-level osteotomy was performed through the lateral wall of the maxilla, 6 mm superior to the apices of the anteroposterior teeth, by using tiny rounded burs and then a microsaw. Cuts were made on the level of the occlusal plane, extending posteriorly from the inferolateral aspect of the piriform rim to the inferior aspect of the junction of the maxillary tuberosity and pterygoid plate. The maxilla was separated from the pterygoid plate with a curved osteotome. In conjunction with this procedure, sagittal palatal osteotomy was performed from the midline of the alveolar bone, passing between the central incisors, to the posterior nasal spine. An osteotome was positioned in the interradicular space between the central incisors and manipulated to achieve equal and symmetric mobilization of the anterior maxilla. The surgeon placed a forefinger on the incisive papilla to feel the redirected osteotome as it transected the deeper portion of the mid-palatal suture. After the osteotomies were complete, the Hyrax appliance was activated to check whether it functioned properly. Immediate regression was then performed, leaving a 1-mm gap. All patients received prophylactic antibiotics for 7 days postoperatively. On postoperative day 3, the orthodontic team initiated SARPE by effecting 0.25-mm expansion. The patient was instructed to perform additional 0.5-mm expansions (0.25-mm expansion two times per day) until the total expansion was deemed satisfactory. The study follow-up was discontinued after the expansion procedure was complete, and the patients’
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orthodontists provided orthodontic treatment. The expander was kept in place for a total of 6 months to minimize the potential for relapse. The type and level of discomfort were monitored objectively in all patients, and all complications arising from the early postoperative period to the end of the expansion period were recorded.
RESULTS Separation of the mid-palatal suture, mobilization of the segment(s), and subsequent expansion and stabilization during consolidation were successfully achieved in all 60 patients. Most difficulties encountered were related to protocol parameters. Bleeding Nasal bleeding occurred in 12 of 60 patients (20%). Nine patients experienced bleeding only on postoperative day 1, whereas one patient reported insignificant nasal bleeding while sniffing during postoperative week 1. However, two patients suffered late-onset bleeding beginning on postoperative day 8; one of these cases was severe and was accompanied by postnasal bleeding and vomiting of blood clots (Table I). Paresthesia Eleven patients reported paresthesia of the infraorbital nerve and related branches. Eight of these patients experienced paresthesia for less than 1 week, during which four patients reported numbness of teeth, and the remaining four reported paresthesia of teeth and lips. Seven of the eight patients with paresthesia for less than 1 week also reported infraorbital paresthesia; six patients experienced this symptom unilaterally and one bilaterally. Three patients suffered from unilateral infraorbital paresthesia for up to 2 weeks, but no patient experienced permanent damage. All these minor problems are related to postoperative edema and traction of tissues during surgery (Table II). Pain Seven patients suffered prolonged pain during the distraction procedure. Eight patients suffered from headaches, two of whom experienced pain for less than 1 week and five for less than 2 to 3 days postoperatively. One patient reported headache and pain at the surgical site when exposed to loud noise during the distraction period (Table III). Rare complications One patient developed a large hematoma in the cheek, one patient complained of tinnitus, and three patients
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Table I. Bleeding First day First week Late onset Total
9/60 1/60 2/60 12/60
15% 1.66% 3.33% 20%
reported excessive lacrimation. Of those experiencing excessive lacrimation, one patient show unilateral effects for 1 day, and two patients reported bilateral effects for 1 and 4 days, respectively. Complaints lasting less than 1 week were not counted as complications (Table IV).
DISCUSSION SARPE is a commonly used procedure for the correction of maxillary transversal deficiency. Conventional orthodontic RPE before closure of the mid-palatal suture has been reported to be highly successful in young patients,2,15,16 but this technique is not indicated in skeletally mature individuals because suture closure and the completion of transverse growth limit the range of maxillary expansion.17 Furthermore, RPE can produce unwanted effects in skeletally mature patients, including lateral tipping of posterior teeth,15,18 extrusion,19-21 periodontal membrane compression, buccal root resorption,22-24 alveolar bone bending,15 fenestration of the buccal cortex,7,22,25,26 palatal tissue necrosis,27 inability to open the mid-palatal suture, pain, and instability of the expansion.15,20,28-30 Bell and Epker showed that attempting orthodontic expansion with a palatal appliance in a skeletally mature patient may lead to pain and necrosis of the palatal mucosa.31 Mommaerts outlined an age-based treatment strategy for patients with maxillary constriction and stated that RPE should be used to treat maxillary constriction in patients younger than 12 years, whereas SARPE is indicated in patients older than 14 years to release areas of bony resistance in the midface.21 Most methods consider the zygomaticomaxillary junction to be a major site of resistance and recommend corticotomy through the zygomaticomaxillary buttress from the piriform rim to the maxillopterygoid junction to release this resistance. The mid-palatal suture has historically been considered the primary site of resistance. The pterygoid plates are also sites of considerable resistance, but because osteotomy carries an increased risk of injuring the pterygoid plexus, some surgeons choose not to address this resistance, without losing much mobility. When the pterygoid junction is not released, the opening of the maxillary halves is more V-shaped, with the apex of the V pointing dorsally.3-5,14
Reported complications of SARPE include significant hemorrhage, gingival recession,32 root resorption,21,33 injury to the branches of the maxillary nerve, infection, pain, devitalization of teeth and altered pulpal blood flow,34-36 periodontal breakdown,36,37 sinus infection,38 alar base flaring,39 extrusion of the teeth attached to the appliance,40 relapse, and unilateral expansion.12,13,41,42 Postoperative hemorrhage, pain, sinusitis, palatal tissue irritation or ulceration, asymmetric expansion, nasal septum deviation, periodontal problems, and relapse have been reported as minor complications.9-11 Although SARPE is considered to be associated with little risk of serious complications, several additional complications were encountered in the present study. Asymmetric expansion Verlinden et al. found asymmetric expansion in 5 of 73 cases and all required additional surgery.43 In clinical and experimental studies, Koudstaal et al. noted asymmetric expansion in 2 of 46 patients.44 Williams et al. mentioned an incidence of 8.33%,45 as we experienced in two of our patients (3.33%). Asymmetric expansion results from uncompleted osteotomies and frequently missed lateral nasal wall osteotomies. In our surgeries, we made sure that the lateral nasal wall osteotomy and nasal septum osteotomy were completed, and this might have decreased the rate of asymmetric expansion compared with the rates in the study by Verlinden et al. and Williams et al. but might have increased the incidence rate of bleeding in our cases. Soft-tissue necrosis One of the most frequently occurring complications is palatal tissue irritation caused by impingement of the expansion appliance against the palatal soft tissues,27,45 which may lead to aseptic pressure necrosis. Williams et al. reported one case of palatal soft tissue necrosis (0.83%) in their study on complications after SARPE.45 Lehman and Haas reported 3 cases (5.4%) of palatal mucosal ulceration,46 and Alpern and Yurosko reported 3 cases of palatal mucosal soft tissue aseptic necrosis.27 We did not observe this complication in our patients. Bleeding Major intraoperative or postoperative bleeding associated with maxillary surgery is an infrequent complication relative to the number of these procedures performed.13 Although intraoperative complications of SARPE are uncommon, the risk of bleeding increases when the pterygoid plates are separated from the maxilla. Betts et al. pointed out that bilateral release of the pterygoid plates from the maxilla was as
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Table II. Paresthesia <1 week of paresthesia
8/60
13.33%
1-2 weeks of unilateral infraorbital paresthesia Total
3/60
5%
11/60
18.33%
Only teeth Teeth þ unilateral infraorbital Teeth þ lips þ unilateral infraorbital Teeth þ lips þ bilateral infraorbital
1/60 3/60 3/60 1/60
1.66% 5% 5% 1.66%
Table III. Pain Prolonged pain during distraction
7/60
11.6%
Headache
8/60
13.33%
Table IV. Rare complications Hematoma Tinnitus Lacrimation
1/60 1/60 3/60
1.66% 1.66% 5%
Unilateral lacrimation Bilateral lacrimation
1/60 2/60
1.66% 3.33%
important as the release of the palatal sutures to allow posterior maxillary expansion.47 However, when the pterygoid plates are separated from the maxilla, the most common sources of hemorrhage after SARPE are the terminal branches of the maxillary artery, in particular the posterosuperior alveolar artery and the pterygoid venous plexus.48,49 Turvey and Fonseca showed that the mean distance from the most inferior part of the pterygomaxillary junction to the most inferior part of the internal maxillary artery is 25 mm.48 Thus, during pterygomaxillary separation, the pterygoid osteotomes must be correctly positioned, and anatomic variance should be taken into account to avoid direct damage to vascular structures. Turvey and Fonseca also recommended the use of an osteotome with an approximate width of 10 mm in adult patients and noted that the descending palatine artery is particularly vulnerable to damage when SARPE is performed with pterygomaxillary separation or lateral nasal wall osteotomy.48 Damage to the descending palatine artery can be minimized by limiting the extent of the osteotomy posterior to the piriform rim to 35 mm in men and 30 mm in women.47 Among our patients who underwent pterygoid plate separation, we observed no intraoperative or postoperative severe bleeding requiring blood transfusion, emergency intervention, or prolonged hospitalization. Another source of bleeding after SARPE is injury to the nasal mucosa, which is primarily observed after mid-palatal suture separation and lateral nasal wall
With asymmetric expansion <2-3 days <1 week When exposed to loud noise
2/60 5/60 2/60 1/60
3.33% 21.66% 3.33% 1.66%
osteotomy.50,51 We observed postoperative nasal bleeding in 12 patients (20%). Nine of these bleeding complications were observed on postoperative day 1. This type of bleeding may have been caused by severe postoperative inflammation and trauma to the nasal mucosa during mid-palatal separation. Because SARPE is not a down-fracture procedure, nasal bleeding can be easily controlled with nasal tamponade and should therefore be considered a minor complication if the patient does not suffer from coagulopathy. Williams et al. reported 4 bleeding complications (3.33%), and the incidence seems very low according to our cases (20%). Williams et al. did not mention lateral nasal wall osteotomy that may affect symmetric expansion and adequate distraction.45 Bays and Greco reported one case of nasal bleeding with minor posterior epistaxis among 19 patients (5.26%), and the bleeding was controlled with packing.8 One of our patients suffered postoperative nasal bleeding, which occurred when inhaling sharply (i.e., sniffing), for 1 week, although the patient had been advised against acts such as sniffing. Nasal bleeding began in another of our patients on postoperative day 8 and was controlled with simple nasal tamponade. It is generally agreed that bleeding after Le Fort type I osteotomy occurs most commonly within 2 weeks of surgery. Such bleeding usually presents as epistaxis, which can be anterior, posterior, or both. Bleeding from pseudoaneurysms is generally more delayed and tends to be recurrent.48 Mehra et al.13 presented a case in which significant delayed postoperative hemorrhage occurred after a routine and uncomplicated SARPE procedure. The case was successfully managed with exploration and prolonged nasal packing. The authors suggested that abnormal bleeding during maxillary orthognathic procedures can be caused by mechanical disruption of an artery or vein or secondary to a bleeding diathesis.13 Alpern and Yurosko reported
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two cases, in which the patients experienced sufficient bleeding to require an extra day in hospital. The Caldwell Luc approach was used to ligate an arteriole with sutures in one of these cases.27 In our retrospective study, one patient showed more severe postoperative nasal bleeding accompanied by postnasal bleeding on postoperative day 8. The volume of bleeding was not excessive, but bleeding was continuous and thus difficult to control. Control was finally achieved via anterior and posterior nasal packing. Furthermore, there was no sign of intraoperative or postoperative bleeding until postoperative day 8. Accordingly, bleeding was attributed to the rupture of the greater palatinal artery, rupture of the inferior nasal mucosae, or damage to the venous plexus during the expansion procedure. Segments or sharp prominences of bone in the intrapalatinal region may have abraded or lacerated these tissues while the expansion procedure was underway. Pain Although SARPE is generally an easy procedure associated with minimal postoperative pain, the amount of pain may increase with the patient’s age, as resistance to expansion increases with suture interdigitation. Inadequate bony release is usually the cause of excessive pain and pressure during activation of the appliance.41 This situation can lead to a more involved procedure in which a larger number of maxillary articulations must be released, and this may necessitate further postoperative surgery or cause distraction-related pain. Although distraction-related pain has rarely been reported, insufficient release of bony sutures or buttress resistance may underlie subjectively reported pain in adult patients.43 In our study, seven patients complained of pain (1.66%). Two patients reported pain accompanying asymmetric expansion (3.33%), which may indicate that the pain was related to insufficient release of the bony buttress. Dental and periodontal problems Williams et al. noted dental and periodontal problems in 18 of 120 patients (15%). They found gingival recession in 12 cases, most seen within 2 months of surgery (%10), 75% of which were between central incisors. Among their patients, 5.83% suffered from periodontal bone loss between central incisors.45 Gauthier et al.52 studied the periodontal effects of SARPE, which were evaluated clinically and with cone beam CT during 6 months of follow-up. They concluded that SARPE has little detrimental effect on the periodontium when measured clinically. However, they claimed that radiographic data demonstrated some statistically significant changes during 6 months.52 Seeberger et al.55 have evaluated the changes caused by tooth-
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borne distraction devices to the anchoring teeth, the hard palate, and the lower nasal passage in 31 patients. They reported no signs of gingival recession or bony fenestration during the 3-month follow-up period.53 Sygouros et al.54 evaluated different surgical techniques and their effects on the maxillary dentoskeletal complex on 20 patients. They recommended pterygomaxillary disjunction, particularly in periodontally compromised patients.54 In our study, no gingival recession or bone loss was observed during the 3-month follow-up period as in the study by Seeberger et al. This might be related to the performance of full osteotomy that included the lateral nasal wall and the pterygoid plates, as Sygouros et al. reported. Tinnitus Auditory system dysfunction in association with orthognathic surgery has rarely been reported. Most cases have been related to maxillary and bimaxillary procedures and were typically mild and transient, requiring no intervention.55-58 One of our patients complained of tinnitus for 1 week postoperatively (1.66%). This condition was attributed to the performance of pterygoid plate osteotomy, in which vibrations and sounds can be directly transmitted via bone to the auditory canal system. Headache Eight of our patients suffered from headache postoperatively (13.33%) but not for more than 1 week. One of our patients reported headache and pain at the surgical site when exposed to loud noise (1.66%), which we attributed to vibrations of the bony segments caused by highintensity sounds. The headaches may also have been related to resistance of the bony buttress to expansion.43 Postoperative numbness Altered postsurgical pulpal blood flow in the surgical area has been reported to cause devitalization or hypoesthesia of related teeth. Altered blood flow and injury to the branches of the maxillary nerve have been reported to cause numbness of teeth and paresthesia of the lips and the infraorbital region.34,35 Four of our patients reported temporary numbness of teeth (1.66%), which may have been caused by postsurgical shock of the pulpal tissue. Eleven patients suffered temporary mild facial paresthesia (18.33%), attributed to pressure exerted by postoperative edema on the surgical area and infraorbital nerve or mild transient intraoperative trauma to the infraorbital nerve exerted by tissue retractors. We had not observed prolonged numbness of teeth or nerve-related complications when we accomplished the osteotomy line 5 to 6 mm above the apices of maxillary teeth.
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Lacrimation The nasolacrimal duct carries tears from the lacrimal sac into the nasal cavity. Excess tears flow through this duct, which opens into the nose.59,60 The anatomic basis of bloody tearing lies in the intimate connection of the nose and eye via the lacrimal apparatus.61 In our study, three patients reported temporary lacrimation that persisted for less than 1 week. This lacrimation was attributed to lateral wall osteotomy and subsequent trauma to the lacrimal canal orifice or soft tissue edema of the orifice, which may be caused by temporary obstruction of nasolacrimal canal.60,62 All of our lateral nasal wall osteotomies were performed below the inferior nasal concha and thus could not have caused direct trauma to the lacrimal canal. This report is the first to describe lacrimation as a complication of SARPE, likely because more typically reported complications, such as temporary edema, pain, and bleeding, are usually the first of the patient’s complaints and lacrimation can be easily overlooked or may be hidden by the patient unless the surgeon asks about it specifically.
CONCLUSIONS In conclusion, maxillary Le Fort I osteotomies to assist maxillary expansion is a widely used and effective procedure for the correction of maxillary transverse deficiency in skeletally mature patients. The use of bilateral osteotomy combined with interradicular osteotomy ensures proper expansion of the palatal segments. Although it is relatively simple procedure and is associated with minimal morbidity in comparison with orthognathic surgery (including down-fracture of the maxilla), some unusual postprocedural complications have been reported. Lacrimation is a rarely seen and unusually reported complication that may be observed in patients who have undergone lateral nasal wall osteotomy. In combination with reported cases in the literature, our results emphasize that SARPE, like any other surgical procedure, is not free of risks, and careful planning and execution of treatment are necessary to ensure an acceptable outcome. If this operation is undertaken with careful planning and, in particular, careful surgical techniques applied by appropriately trained surgeons, morbidity is minimal and it can be a relatively safe surgical procedure with good outcome. REFERENCES 1. Suri L, Taneja P. Surgically assisted rapid palatal expansion: a literature review. Am J Orthodont Dentofac Orthoped. 2008;133: 290-302. 2. McNamara JA Jr, Baccetti T, Franchi L, et al. Rapid maxillary expansion followed by fixed appliances: a long-term evaluation of changes in arch dimensions. Angle Orthod. 2003;73: 344-353.
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27. Alpern MC, Yurosko JJ. Rapid palatal expansion in adults with and without surgery. Angle Orthod. 1987;57:245-263. 28. Moss JP. Rapid expansion. Int J Orthod. 1976;14:15-19. 29. Haas AJ. Long-term post-treatment evaluation of rapid palatal expansion. Angle Orthod. 1980;50:189-217. 30. Greenbaum KR, Zachrisson BU. The effect of palatal expansion therapy on the periodontal supporting tissues. Am J Orthod. 1982;81:12-21. 31. Bell WH, Epker BN. Surgical-orthodontic expansion of the maxilla. Am J Orthod. 1976;70:517-528. 32. Carmen M, Marcella P, Giuseppe C, et al. Periodontal evaluation in patients undergoing maxillary expansion. J Craniofac Surg. 2000;11:491-494. 33. Vardimon AD, Graber TM, Pitaru S. Repair process of external root resorption subsequent to palatal expansion treatment. Am J Orthod Dentofacial Orthop. 1993;103:120-130. 34. Ozturk M, Doruk C, Ozec I, et al. Pulpal blood flow: Effects of corticotomy and midline osteotomy in surgically assisted rapid palatal expansion. J Craniomaxillofac Surg. 2003;31:97-100. 35. Harada K, Sato M, Omura K. Blood-flow change and recovery of sensibility in the maxillary dental pulp during and after maxillary distraction: a pilot study. Oral Surg Oral Med Oral Patho Oral Radiol Endod. 2004;98:528-532. 36. Goddard R, Witherow H. Surgically assisted rapid palatal expansion (SARPE): technical note. Br J Oral and Maxillofac Surg. 2011;49:65-66. 37. Cureton SL, Cuenin M. Surgically assisted rapid palatal expansion: orthodontic preparation for clinical success. Am J Orthod Dentofacial Orthop. 1999;116:46-59. 38. Schimming R, Feller KU, Herzmann K, et al. Surgical and orthodontic rapid palatal expansion in adults using Glassman’s technique: retrospective study. Br J Oral Maxillofac Surg. 2000;38:66-69. 39. Woods M, Wiesenfeld D, Probert T. Surgically-assisted maxillary expansion. Aust Dent J. 1997;42:38-42. 40. Glassman AS, Nahigan SJ, Medway JM, et al. Conservative surgical orthodontic adult rapid maxillary expansion: sixteen cases. Am J Orthod. 1984;86:207-213. 41. Lanigan DT, Hey JH, West RA. Major vascular complications of orthognathic surgery: hemorrhage associated with Le Fort 1 osteotomies. J Oral Maxillofac Surg. 1990;48:561-573. 42. Lanigan DT, Mintz SM. Complications of surgically assisted rapid palatal expansion: review of the literature and report of a case. J Oral Maxillofac Surg. 2002;60:104-110. 43. Verlinden CRA, Gooris PG, Becking AG. Complications in transpalatal distraction osteogenesis: a retrospective clinical study. J Oral Maxillofac Surg. 2011;69:899-905. 44. Koudstaal MJ, Smeets JB, Kleinrensink GJ, et al. Stability, tipping and relapse of bone-borne versus tooth-borne surgically assisted rapid maxillary expansion: a prospective randomized patient trial. Int J Oral Maxillofac Surg. 2009;38:308. 45. Williams BJD, Currimbhoy S, Silva A, O’Ryan FS. Complications following surgically assisted rapid palatal expansion: a retrospective cohort study. J Oral Maxillofac Surg. 2012;70: 2394-2402. 46. Lehman JA, Haas AJ. Surgical-orthodontic correction of transverse maxillary deficiency. Dent Clin North Am. 1990;34: 385-395. 47. Betts NJ, Vanarsdall RL, Barber HD, Higgins-Barber K, Fonseca RJ. Diagnosis and treatment of transverse maxillary deficiency. Int J Adult Orthodon Orthognath Surg. 1995;10(2): 75-96.
48. Turvey TA, Fonseca RJ. The anatomy of the internal maxillary artery in the pterygopalatine fossa: its relationship to maxillary surgery. J Oral Surg. 1980;38:92-95. 49. Apinhasmit W, Methathrathip D, Ploytubtim S, et al. Anatomic study of the maxillary artery at the pterygomaxillary fissure in a Thai population: its relationship to maxillary osteotomy. J Med Assoc Thai. 2004;87:1212-1217. 50. Chrcanovic BR, Custódio ALN. Orthodontic or surgically assisted rapid maxillary expansion. Oral Maxillofac Surg. 2009;13: 123-137. 51. Drew SJ. Orthognathic surgery. In: Miloro M, Kolokythas A, eds. Management of Complications in Oral and Maxillofacial Surgery, Chapter 5. London, UK: Wiley-Blackwell; 2012: 109-137. 52. Gauthier C, Voyer R, Paquette M, Rompre P, Papadakise A. Periodontal effects of surgically assisted rapid palatal expansion evaluated clinically and with cone-beam computerized tomography: 6-month preliminary results. Am J Orthod Dentofacial Orthop. 2011;139:117-128. 53. Seeberger R, Kater W, Schulte-Geers M, Davids R, Freier K, Thiele O. Changes after surgically-assisted maxillary expansion (SARME) to the dentoalveolar, palatal and nasal structures by using tooth-borne distraction devices. Br J Oral Maxillofac Surg. 2011;49:381-385. 54. Sygouros A, Motro M, Ugurlu F, Acar A. Surgically assisted rapid maxillary expansion: cone-beam computed tomography evaluation of different surgical techniques and their effects on the maxillary dentoskeletal complex. Am J Orthod Dentofacial Orthop. 2014;146:748-757. 55. Klemm E, Stösslein F, Mürbe B. Arteriovenous fistula of the maxillary artery, eustachian tube dysfunction and tinnitus after Le Fort I osteotomy. HNO. 2001;49:216-219. 56. Kim S, Park S. Incidence of Complications and problems related to orthognathic surgery. J Oral Maxillofac Surg. 2007;65:24382444. 57. Yaghmaei M, Ghoujeghi A, Sadeghinejad A, et al. Auditory changes in patients undergoing orthognathic surgery. Int J Oral Maxillofac Surg. 2009;38:1148-1153. 58. Bayram B, Deniz K, Aydin E, et al. Is auditory function affected after Le Fort I osteotomy? IntJ Oral Maxillofac Surg. 2012;41: 709-712. 59. Bhaskaran AA, Courtney DJ, Anand P, et al. A complication of Le Fort I osteotomy. Int J Oral Maxillofac Surg. 2010;39: 292-294. 60. Humber CC, Lanigan DT, Hohn FI. Retrograde hemorrhage (hemolacria) from the lacrimal puncta after a Le Fort 1 osteotomy: a report of 2 cases and a review of the literature. J Oral Maxillofac Surg. 2011;69:520-527. 61. Wiese MF. Bloody tears, and more! An unusual case of epistaxis. Br J Ophthalmol. 2003;87:1051. 62. Chrcanovic BR, Nunes FCF, Freire-Maia B. Bloody tears after miniplate osteosynthesis for Le Fort I osteotomy. J Oral Maxillofac Surg Med Pathol. 2013;25:32-34. Reprint requests: Sertac Aktop, DDS, PhD Marmara University Dentistry Faculty Department of Oral and Maxillofacial Surgery Guzelbahce Buyukciftlik sok. No:6 Nisantasi Sisli, Istanbul Turkey [email protected]
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Complications related to surgically assisted rapid palatal expansion Guhan Dergin, DDS, PhD, Sertac Aktop, DDS, PhD, Altan Varol, DDS, PhD, Faysal Ugurlu, DDS, PhD, and Hasan Garip, DDS, PhD Objective. The goals of this retrospective clinical study were to identify surgically assisted rapid palatal expansion (SARPE) complications and assess their incidence, with the aim of informing surgeons and orthodontists of the risks of this widely used procedure before they recommend it to patients. Study Design. Between June 2008 and July 2010, 60 patients (23 women and 37 men) underwent SARPE according to a defined multidisciplinary protocol at the University of Marmara, Istanbul, Turkey. Results. Twelve patients (20%) suffered from nasal bleeding. Of these 12, 2 patients suffered late-onset bleeding beginning on postoperative day 8, and in the other 10, nasal bleeding was insignificant. Three patients reported excessive lacrimation postoperatively. Minor problems related to pain and numbness were all temporary. Conclusions. SARPE procedures have traditionally been reported to be associated with low morbidity, especially in comparison with other orthognathic surgical procedures. However, many complications have been reported. (Oral Surg Oral Med Oral Pathol Oral Radiol 2015;-:1-7)
Transverse maxillomandibular discrepancy is a major component of several types of malocclusion.1 Maxillary construction can be corrected surgically or nonsurgically via orthodontic rapid palatal expansion (RPE) using a tooth-borne expander, surgically assisted rapid palatal expansion (SARPE), or segmental Le Fort osteotomy.2 The general indications for SARPE include skeletal maturity, (extreme) transverse maxillary hypoplasia, unilateral or bilateral anterior crowding, and the presence of buccal corridors (“black corridors”) when smiling and when orthodontic maxillary expansion has failed.3 Although the mid-palatal suture is an area of resistance in symmetric widening of the constricted maxilla, it is only one of many areas of resistance in the facial skeleton, such as the zygomaticomaxillary buttress, pterygoid junction, and piriform aperture.4,5 Brown first described the use of the mid-palatal split technique for maxillary expansion, and SARPE has become the preferred approach for correcting maxillary transverse deficiency in skeletally mature individuals.6 Shetty et al. concluded that the exclusive use of bilateral zygomaticomaxillary buttress osteotomy to facilitate SARPE was inadequate and stated that complete midpalatal and pterygomaxillary osteotomies were
essential to achieve predictable maxillary expansion in adults.7 SARPE procedures have traditionally been reported to be associated with low morbidity, especially in comparison with other orthognathic surgical procedures.8 However, many complications have been reported, ranging from life-threatening epistaxis to cerebrovascular accidents, including skull base fracture with reversible oculomotor nerve paralysis and orbital compartment syndrome.9-13 The goals of this retrospective clinical study were to identify SARPE complications and assess their incidence, with the aim of informing surgeons and orthodontists of the risks of this widely used procedure before they recommend it to patients.
The work was previously presented at the 4th ACBID International Oral and Maxillofacial Surgery Society Congress, 2010, at Antalya, Turkey. Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Marmara University, Istanbul, Turkey. Received for publication Oct 10, 2014; returned for revision Jan 6, 2015; accepted for publication Jan 16, 2015. Ó 2015 Elsevier Inc. All rights reserved. 2212-4403/$ - see front matter http://dx.doi.org/10.1016/j.oooo.2015.01.008
Surgically assisted rapid palatal expansion procedures have traditionally been reported to be associated with low morbidity, especially in comparison with other orthognathic surgical procedures. However, many complications have been reported. Two patients suffered late-onset bleeding beginning on postoperative day 8. Three patients reported excessive lacrimation.
MATERIALS AND METHODS Between June 2008 and July 2010, 60 patients (23 women and 37 men) underwent SARPE according to a defined multidisciplinary protocol at the University of Marmara, Istanbul, Turkey. The age of the participants ranged from 17 to 26 years. All patients presented with a total transverse maxillary deficiency greater than
Statement of Clinical Relevance
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ORAL AND MAXILLOFACIAL SURGERY 2 Dergin et al.
5 mm and a closed mid-palatal suture. This project was approved by the Ethics Committee of the Faculty of Dentistry, University of Marmara, and informed consent was obtained from all patients. Computed tomography (CT) was performed to evaluate the preoperative anatomy and to exclude inflammation of the maxillary sinus. All patients underwent similar treatment regimes. Each patient’s orthodontist inserted a Haas-type expander, with an acrylic splint cemented to the first premolars and molars.14 The patients selected for this study were all American Society of Anaesthesiologists (ASA) I group of patients to determine the complications related to surgery, rather than predisposing systemic-related complications, such as bleeding. SARPE was performed with the patient under general anesthesia with nasotracheal intubation. All of the surgeries were performed by the same surgical team, comprising the authors of this paper. A modified Le Fort I maxillary osteotomy, including separation of the pterygomaxillary suture, was performed. A horizontal incision was made through the mucoperiosteum above the mucogingival junction in the deepest part of the buccal vestibular space, extending from the canine region to the mesial surface of the first molar. The nasal mucosae were elevated gently from the lateral nasal wall. A horizontal low-level osteotomy was performed through the lateral wall of the maxilla, 6 mm superior to the apices of the anteroposterior teeth, by using tiny rounded burs and then a microsaw. Cuts were made on the level of the occlusal plane, extending posteriorly from the inferolateral aspect of the piriform rim to the inferior aspect of the junction of the maxillary tuberosity and pterygoid plate. The maxilla was separated from the pterygoid plate with a curved osteotome. In conjunction with this procedure, sagittal palatal osteotomy was performed from the midline of the alveolar bone, passing between the central incisors, to the posterior nasal spine. An osteotome was positioned in the interradicular space between the central incisors and manipulated to achieve equal and symmetric mobilization of the anterior maxilla. The surgeon placed a forefinger on the incisive papilla to feel the redirected osteotome as it transected the deeper portion of the mid-palatal suture. After the osteotomies were complete, the Hyrax appliance was activated to check whether it functioned properly. Immediate regression was then performed, leaving a 1-mm gap. All patients received prophylactic antibiotics for 7 days postoperatively. On postoperative day 3, the orthodontic team initiated SARPE by effecting 0.25-mm expansion. The patient was instructed to perform additional 0.5-mm expansions (0.25-mm expansion two times per day) until the total expansion was deemed satisfactory. The study follow-up was discontinued after the expansion procedure was complete, and the patients’
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orthodontists provided orthodontic treatment. The expander was kept in place for a total of 6 months to minimize the potential for relapse. The type and level of discomfort were monitored objectively in all patients, and all complications arising from the early postoperative period to the end of the expansion period were recorded.
RESULTS Separation of the mid-palatal suture, mobilization of the segment(s), and subsequent expansion and stabilization during consolidation were successfully achieved in all 60 patients. Most difficulties encountered were related to protocol parameters. Bleeding Nasal bleeding occurred in 12 of 60 patients (20%). Nine patients experienced bleeding only on postoperative day 1, whereas one patient reported insignificant nasal bleeding while sniffing during postoperative week 1. However, two patients suffered late-onset bleeding beginning on postoperative day 8; one of these cases was severe and was accompanied by postnasal bleeding and vomiting of blood clots (Table I). Paresthesia Eleven patients reported paresthesia of the infraorbital nerve and related branches. Eight of these patients experienced paresthesia for less than 1 week, during which four patients reported numbness of teeth, and the remaining four reported paresthesia of teeth and lips. Seven of the eight patients with paresthesia for less than 1 week also reported infraorbital paresthesia; six patients experienced this symptom unilaterally and one bilaterally. Three patients suffered from unilateral infraorbital paresthesia for up to 2 weeks, but no patient experienced permanent damage. All these minor problems are related to postoperative edema and traction of tissues during surgery (Table II). Pain Seven patients suffered prolonged pain during the distraction procedure. Eight patients suffered from headaches, two of whom experienced pain for less than 1 week and five for less than 2 to 3 days postoperatively. One patient reported headache and pain at the surgical site when exposed to loud noise during the distraction period (Table III). Rare complications One patient developed a large hematoma in the cheek, one patient complained of tinnitus, and three patients
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Table I. Bleeding First day First week Late onset Total
9/60 1/60 2/60 12/60
15% 1.66% 3.33% 20%
reported excessive lacrimation. Of those experiencing excessive lacrimation, one patient show unilateral effects for 1 day, and two patients reported bilateral effects for 1 and 4 days, respectively. Complaints lasting less than 1 week were not counted as complications (Table IV).
DISCUSSION SARPE is a commonly used procedure for the correction of maxillary transversal deficiency. Conventional orthodontic RPE before closure of the mid-palatal suture has been reported to be highly successful in young patients,2,15,16 but this technique is not indicated in skeletally mature individuals because suture closure and the completion of transverse growth limit the range of maxillary expansion.17 Furthermore, RPE can produce unwanted effects in skeletally mature patients, including lateral tipping of posterior teeth,15,18 extrusion,19-21 periodontal membrane compression, buccal root resorption,22-24 alveolar bone bending,15 fenestration of the buccal cortex,7,22,25,26 palatal tissue necrosis,27 inability to open the mid-palatal suture, pain, and instability of the expansion.15,20,28-30 Bell and Epker showed that attempting orthodontic expansion with a palatal appliance in a skeletally mature patient may lead to pain and necrosis of the palatal mucosa.31 Mommaerts outlined an age-based treatment strategy for patients with maxillary constriction and stated that RPE should be used to treat maxillary constriction in patients younger than 12 years, whereas SARPE is indicated in patients older than 14 years to release areas of bony resistance in the midface.21 Most methods consider the zygomaticomaxillary junction to be a major site of resistance and recommend corticotomy through the zygomaticomaxillary buttress from the piriform rim to the maxillopterygoid junction to release this resistance. The mid-palatal suture has historically been considered the primary site of resistance. The pterygoid plates are also sites of considerable resistance, but because osteotomy carries an increased risk of injuring the pterygoid plexus, some surgeons choose not to address this resistance, without losing much mobility. When the pterygoid junction is not released, the opening of the maxillary halves is more V-shaped, with the apex of the V pointing dorsally.3-5,14
Reported complications of SARPE include significant hemorrhage, gingival recession,32 root resorption,21,33 injury to the branches of the maxillary nerve, infection, pain, devitalization of teeth and altered pulpal blood flow,34-36 periodontal breakdown,36,37 sinus infection,38 alar base flaring,39 extrusion of the teeth attached to the appliance,40 relapse, and unilateral expansion.12,13,41,42 Postoperative hemorrhage, pain, sinusitis, palatal tissue irritation or ulceration, asymmetric expansion, nasal septum deviation, periodontal problems, and relapse have been reported as minor complications.9-11 Although SARPE is considered to be associated with little risk of serious complications, several additional complications were encountered in the present study. Asymmetric expansion Verlinden et al. found asymmetric expansion in 5 of 73 cases and all required additional surgery.43 In clinical and experimental studies, Koudstaal et al. noted asymmetric expansion in 2 of 46 patients.44 Williams et al. mentioned an incidence of 8.33%,45 as we experienced in two of our patients (3.33%). Asymmetric expansion results from uncompleted osteotomies and frequently missed lateral nasal wall osteotomies. In our surgeries, we made sure that the lateral nasal wall osteotomy and nasal septum osteotomy were completed, and this might have decreased the rate of asymmetric expansion compared with the rates in the study by Verlinden et al. and Williams et al. but might have increased the incidence rate of bleeding in our cases. Soft-tissue necrosis One of the most frequently occurring complications is palatal tissue irritation caused by impingement of the expansion appliance against the palatal soft tissues,27,45 which may lead to aseptic pressure necrosis. Williams et al. reported one case of palatal soft tissue necrosis (0.83%) in their study on complications after SARPE.45 Lehman and Haas reported 3 cases (5.4%) of palatal mucosal ulceration,46 and Alpern and Yurosko reported 3 cases of palatal mucosal soft tissue aseptic necrosis.27 We did not observe this complication in our patients. Bleeding Major intraoperative or postoperative bleeding associated with maxillary surgery is an infrequent complication relative to the number of these procedures performed.13 Although intraoperative complications of SARPE are uncommon, the risk of bleeding increases when the pterygoid plates are separated from the maxilla. Betts et al. pointed out that bilateral release of the pterygoid plates from the maxilla was as
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Table II. Paresthesia <1 week of paresthesia
8/60
13.33%
1-2 weeks of unilateral infraorbital paresthesia Total
3/60
5%
11/60
18.33%
Only teeth Teeth þ unilateral infraorbital Teeth þ lips þ unilateral infraorbital Teeth þ lips þ bilateral infraorbital
1/60 3/60 3/60 1/60
1.66% 5% 5% 1.66%
Table III. Pain Prolonged pain during distraction
7/60
11.6%
Headache
8/60
13.33%
Table IV. Rare complications Hematoma Tinnitus Lacrimation
1/60 1/60 3/60
1.66% 1.66% 5%
Unilateral lacrimation Bilateral lacrimation
1/60 2/60
1.66% 3.33%
important as the release of the palatal sutures to allow posterior maxillary expansion.47 However, when the pterygoid plates are separated from the maxilla, the most common sources of hemorrhage after SARPE are the terminal branches of the maxillary artery, in particular the posterosuperior alveolar artery and the pterygoid venous plexus.48,49 Turvey and Fonseca showed that the mean distance from the most inferior part of the pterygomaxillary junction to the most inferior part of the internal maxillary artery is 25 mm.48 Thus, during pterygomaxillary separation, the pterygoid osteotomes must be correctly positioned, and anatomic variance should be taken into account to avoid direct damage to vascular structures. Turvey and Fonseca also recommended the use of an osteotome with an approximate width of 10 mm in adult patients and noted that the descending palatine artery is particularly vulnerable to damage when SARPE is performed with pterygomaxillary separation or lateral nasal wall osteotomy.48 Damage to the descending palatine artery can be minimized by limiting the extent of the osteotomy posterior to the piriform rim to 35 mm in men and 30 mm in women.47 Among our patients who underwent pterygoid plate separation, we observed no intraoperative or postoperative severe bleeding requiring blood transfusion, emergency intervention, or prolonged hospitalization. Another source of bleeding after SARPE is injury to the nasal mucosa, which is primarily observed after mid-palatal suture separation and lateral nasal wall
With asymmetric expansion <2-3 days <1 week When exposed to loud noise
2/60 5/60 2/60 1/60
3.33% 21.66% 3.33% 1.66%
osteotomy.50,51 We observed postoperative nasal bleeding in 12 patients (20%). Nine of these bleeding complications were observed on postoperative day 1. This type of bleeding may have been caused by severe postoperative inflammation and trauma to the nasal mucosa during mid-palatal separation. Because SARPE is not a down-fracture procedure, nasal bleeding can be easily controlled with nasal tamponade and should therefore be considered a minor complication if the patient does not suffer from coagulopathy. Williams et al. reported 4 bleeding complications (3.33%), and the incidence seems very low according to our cases (20%). Williams et al. did not mention lateral nasal wall osteotomy that may affect symmetric expansion and adequate distraction.45 Bays and Greco reported one case of nasal bleeding with minor posterior epistaxis among 19 patients (5.26%), and the bleeding was controlled with packing.8 One of our patients suffered postoperative nasal bleeding, which occurred when inhaling sharply (i.e., sniffing), for 1 week, although the patient had been advised against acts such as sniffing. Nasal bleeding began in another of our patients on postoperative day 8 and was controlled with simple nasal tamponade. It is generally agreed that bleeding after Le Fort type I osteotomy occurs most commonly within 2 weeks of surgery. Such bleeding usually presents as epistaxis, which can be anterior, posterior, or both. Bleeding from pseudoaneurysms is generally more delayed and tends to be recurrent.48 Mehra et al.13 presented a case in which significant delayed postoperative hemorrhage occurred after a routine and uncomplicated SARPE procedure. The case was successfully managed with exploration and prolonged nasal packing. The authors suggested that abnormal bleeding during maxillary orthognathic procedures can be caused by mechanical disruption of an artery or vein or secondary to a bleeding diathesis.13 Alpern and Yurosko reported
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two cases, in which the patients experienced sufficient bleeding to require an extra day in hospital. The Caldwell Luc approach was used to ligate an arteriole with sutures in one of these cases.27 In our retrospective study, one patient showed more severe postoperative nasal bleeding accompanied by postnasal bleeding on postoperative day 8. The volume of bleeding was not excessive, but bleeding was continuous and thus difficult to control. Control was finally achieved via anterior and posterior nasal packing. Furthermore, there was no sign of intraoperative or postoperative bleeding until postoperative day 8. Accordingly, bleeding was attributed to the rupture of the greater palatinal artery, rupture of the inferior nasal mucosae, or damage to the venous plexus during the expansion procedure. Segments or sharp prominences of bone in the intrapalatinal region may have abraded or lacerated these tissues while the expansion procedure was underway. Pain Although SARPE is generally an easy procedure associated with minimal postoperative pain, the amount of pain may increase with the patient’s age, as resistance to expansion increases with suture interdigitation. Inadequate bony release is usually the cause of excessive pain and pressure during activation of the appliance.41 This situation can lead to a more involved procedure in which a larger number of maxillary articulations must be released, and this may necessitate further postoperative surgery or cause distraction-related pain. Although distraction-related pain has rarely been reported, insufficient release of bony sutures or buttress resistance may underlie subjectively reported pain in adult patients.43 In our study, seven patients complained of pain (1.66%). Two patients reported pain accompanying asymmetric expansion (3.33%), which may indicate that the pain was related to insufficient release of the bony buttress. Dental and periodontal problems Williams et al. noted dental and periodontal problems in 18 of 120 patients (15%). They found gingival recession in 12 cases, most seen within 2 months of surgery (%10), 75% of which were between central incisors. Among their patients, 5.83% suffered from periodontal bone loss between central incisors.45 Gauthier et al.52 studied the periodontal effects of SARPE, which were evaluated clinically and with cone beam CT during 6 months of follow-up. They concluded that SARPE has little detrimental effect on the periodontium when measured clinically. However, they claimed that radiographic data demonstrated some statistically significant changes during 6 months.52 Seeberger et al.55 have evaluated the changes caused by tooth-
ORIGINAL ARTICLE Dergin et al. 5
borne distraction devices to the anchoring teeth, the hard palate, and the lower nasal passage in 31 patients. They reported no signs of gingival recession or bony fenestration during the 3-month follow-up period.53 Sygouros et al.54 evaluated different surgical techniques and their effects on the maxillary dentoskeletal complex on 20 patients. They recommended pterygomaxillary disjunction, particularly in periodontally compromised patients.54 In our study, no gingival recession or bone loss was observed during the 3-month follow-up period as in the study by Seeberger et al. This might be related to the performance of full osteotomy that included the lateral nasal wall and the pterygoid plates, as Sygouros et al. reported. Tinnitus Auditory system dysfunction in association with orthognathic surgery has rarely been reported. Most cases have been related to maxillary and bimaxillary procedures and were typically mild and transient, requiring no intervention.55-58 One of our patients complained of tinnitus for 1 week postoperatively (1.66%). This condition was attributed to the performance of pterygoid plate osteotomy, in which vibrations and sounds can be directly transmitted via bone to the auditory canal system. Headache Eight of our patients suffered from headache postoperatively (13.33%) but not for more than 1 week. One of our patients reported headache and pain at the surgical site when exposed to loud noise (1.66%), which we attributed to vibrations of the bony segments caused by highintensity sounds. The headaches may also have been related to resistance of the bony buttress to expansion.43 Postoperative numbness Altered postsurgical pulpal blood flow in the surgical area has been reported to cause devitalization or hypoesthesia of related teeth. Altered blood flow and injury to the branches of the maxillary nerve have been reported to cause numbness of teeth and paresthesia of the lips and the infraorbital region.34,35 Four of our patients reported temporary numbness of teeth (1.66%), which may have been caused by postsurgical shock of the pulpal tissue. Eleven patients suffered temporary mild facial paresthesia (18.33%), attributed to pressure exerted by postoperative edema on the surgical area and infraorbital nerve or mild transient intraoperative trauma to the infraorbital nerve exerted by tissue retractors. We had not observed prolonged numbness of teeth or nerve-related complications when we accomplished the osteotomy line 5 to 6 mm above the apices of maxillary teeth.
ORAL AND MAXILLOFACIAL SURGERY 6 Dergin et al.
Lacrimation The nasolacrimal duct carries tears from the lacrimal sac into the nasal cavity. Excess tears flow through this duct, which opens into the nose.59,60 The anatomic basis of bloody tearing lies in the intimate connection of the nose and eye via the lacrimal apparatus.61 In our study, three patients reported temporary lacrimation that persisted for less than 1 week. This lacrimation was attributed to lateral wall osteotomy and subsequent trauma to the lacrimal canal orifice or soft tissue edema of the orifice, which may be caused by temporary obstruction of nasolacrimal canal.60,62 All of our lateral nasal wall osteotomies were performed below the inferior nasal concha and thus could not have caused direct trauma to the lacrimal canal. This report is the first to describe lacrimation as a complication of SARPE, likely because more typically reported complications, such as temporary edema, pain, and bleeding, are usually the first of the patient’s complaints and lacrimation can be easily overlooked or may be hidden by the patient unless the surgeon asks about it specifically.
CONCLUSIONS In conclusion, maxillary Le Fort I osteotomies to assist maxillary expansion is a widely used and effective procedure for the correction of maxillary transverse deficiency in skeletally mature patients. The use of bilateral osteotomy combined with interradicular osteotomy ensures proper expansion of the palatal segments. Although it is relatively simple procedure and is associated with minimal morbidity in comparison with orthognathic surgery (including down-fracture of the maxilla), some unusual postprocedural complications have been reported. Lacrimation is a rarely seen and unusually reported complication that may be observed in patients who have undergone lateral nasal wall osteotomy. In combination with reported cases in the literature, our results emphasize that SARPE, like any other surgical procedure, is not free of risks, and careful planning and execution of treatment are necessary to ensure an acceptable outcome. If this operation is undertaken with careful planning and, in particular, careful surgical techniques applied by appropriately trained surgeons, morbidity is minimal and it can be a relatively safe surgical procedure with good outcome. REFERENCES 1. Suri L, Taneja P. Surgically assisted rapid palatal expansion: a literature review. Am J Orthodont Dentofac Orthoped. 2008;133: 290-302. 2. McNamara JA Jr, Baccetti T, Franchi L, et al. Rapid maxillary expansion followed by fixed appliances: a long-term evaluation of changes in arch dimensions. Angle Orthod. 2003;73: 344-353.
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