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Short-term complications after surgically assisted rapid palatal expansion: a retrospective cohort study
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Int. J. Oral Maxillofac. Surg. 2016; xxx: xxx–xxx http://dx.doi.org/10.1016/j.ijom.2016.11.016, available online at http://www.sciencedirect.com
Clinical Paper Orthognathic Surgery
Short-term complications after surgically assisted rapid palatal expansion: a retrospective cohort study
M. Verquin, L. Daems, C. Politis Department of Oral and Maxillofacial Surgery, Faculty of Medicine, Catholic University Leuven, Leuven, Belgium
M. Verquin, L. Daems, C. Politis: Short-term complications after surgically assisted rapid palatal expansion: a retrospective cohort study. Int. J. Oral Maxillofac. Surg. 2016; xxx: xxx–xxx. # 2016 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Abstract. Surgically assisted rapid palatal expansion (SARPE) has been considered a safe procedure with minimal patient morbidity. The aim of this study was to identify short-term complications encountered after tooth-borne expansion with a standardized approach to inform surgeons and orthodontists of the patient risk. In this retrospective cohort study, 55 patients (35 female, 20 male) undergoing SARPE between January 2013 and December 2014 were evaluated. Twenty-eight patients developed one or more complications. Postoperative haemorrhage was seen in six patients. Sixteen patients presented with injury to the infraorbital nerve, five had dental complications, and four had severe postoperative pain. A prolonged hospital stay was necessary for six patients and additional surgery was required in two cases. It is concluded that the short-term complications after tooth-borne SARPE are generally mild; however, the number of complications encountered indicates that SARPE is not free of risk and should be preceded by careful patient selection and planning.
Transverse maxillary deficiency is among the most common types of skeletal dysplasia observed in clinical practice and is often characterized by a unilateral or bilateral crossbite, as well as anterior crowding.1,2 A possible approach, depending on the level of skeletal maturity and the desired amount of expansion, is surgically assisted rapid palatal expansion (SARPE). The concept of correcting a 0901-5027/000001+06
transverse discrepancy in the maxilla was first described by Angell in 1860.3,4 Following the introduction of a mid-palatal split technique by Brown,5 Shetty et al. added a pterygomaxillary osteotomy to achieve predictable expansion of the maxilla,6 and SARPE quickly became a procedure of choice for widening of the maxilla in skeletally mature patients. It has been performed frequently ever since.
Key words: retrospective cohort study; palatal expansion technique; distraction osteogenesis; maxilla; tooth-borne; complications. Accepted for publication 29 November 2016
As SARPE is considered a relatively safe procedure in comparison to a segmental Le Fort I osteotomy, data concerning complications are limited. The current literature commonly reports pain, haemorrhage, infection, nerve injury, apical root resorption, and discolouration and devitalization of teeth. Inadequate or asymmetrical expansion and infection of the maxillary sinus are rare, while flaring of
# 2016 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Verquin M, et al. Short-term complications after surgically assisted rapid palatal expansion: a retrospective cohort study, Int J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/j.ijom.2016.11.016
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Verquin et al.
the alar base, tinnitus, lacrimation, lifethreatening epistaxis, and skull base fracture are extremely rare.7–14 With a growing number of adults seeking orthodontic treatment, an increase in the indications for SARPE can be expected. It is important to identify complications associated with SARPE to enable patient-specific treatment plans to be drawn up and to provide accurate information concerning the surgery-related risks. The purpose of this retrospective study was to investigate the presence/absence, nature, frequency, and timing of short-term complications presenting after tooth-borne SARPE in a group of consecutively treated patients at a single centre. Patients and methods Patients
All 56 patients undergoing tooth-borne SARPE between January 2013 and December 2014 were evaluated retrospectively for postoperative complications following a standardized multidisciplinary protocol at the Catholic University Leuven, Belgium. Exclusion criteria were prior trauma and craniofacial syndromes involving the maxilla. Fifty-five patients remained after applying the exclusion criteria; 35 were female and 20 were male, and they ranged in age from 13 to 47 years. This study was conducted in accordance with the principles stated in the Declaration of Helsinki and was approved by the Research Ethics Committee of the Faculty of Medicine, University of Leuven. Technique
Prior to surgery, all patients were screened for any relevant medical and surgical history. Baseline radiographic and clinical imaging was obtained for all patients. All surgeries were performed by one of the authors (CP) following a standardized protocol. All patients underwent SARPE under general anaesthesia with nasotracheal intubation combined with a local anaesthetic (lidocaine), with a vasoconstrictor (epinephrine 1:100,000) given for haemostatic purposes before incision. A semi-lunar horizontal incision was made using a scalpel and was completed with monopolar diathermy in the upper buccal fold from the canine up to the infrazygomatic crest bilaterally. A corticotomy according to Le Fort I was made from the posterior aperture to the maxillary tuberosity with a Hall drill, 4-mm above the apex of the upper canine, whilst holding the soft tissue of the upper jaw in a
cranial direction with a Le Fort I hook, protecting the infraorbital nerve. Disengagement of the pterygomaxillary suture was performed using a curved osteotome. In conjunction with this procedure, a vertical incision was made over the labial frenulum of the maxilla, the anterior nasal spine was loosened, and the transpalatal osteotomy was completed with a spatula osteotome whilst placing a forefinger on the palate for guidance of the osteotome as it transected the mid-palatal suture. Transverse mobility of the maxillary halves was checked by manipulating a chisel in-between the central diastema. Disengagement of the nasal septum then followed using a septum osteotome. Antibiotics (amoxicillin) were administered intraoperatively and given as prophylaxis for up to 5 days postoperatively. No standard distraction device was used; each patient’s orthodontist inserted a Hyrax-type expander prior to surgery. A latency period of 7 days between surgery and expansion was respected to allow new callus to be formed. The device was activated 0.25 mm twice daily to achieve a daily expansion of 0.5 mm. All patients were assessed for complications clinically and with peri-apical X-rays of the central incisors on a weekly basis by residents at the university hospital under the supervision of one of the authors (CP). This was done for up to 4 weeks postoperatively or until the desired maxillary expansion had been achieved. The continuation of follow-up was then performed by the treating orthodontist. The weekly clinical examination consisted of adequate anamnesis including an assessment of pain on a visual analogue scale (VAS), extraoral examinations including sensory deficits in the maxillary nerve (V2) region (light touch, pin-prick, and two-point discrimination tests) and an evaluation of the symmetry of expansion, and intraoral examinations including measurement of the central diastema, tooth colour, pocket measurement and mobility of the anchoring teeth (hyrax device) and central incisors using a Periotest M device (DentiSystem, Budapest, Hungary), and inspection of the intraoral wound healing. The weekly examination was concluded with clinical imaging (intraoral and extraoral) to allow comparisons to be made. Additional radiographic images were obtained when indicated after aberrant findings during clinical examination; for example, posterior–anterior films were obtained in the case of asymmetric expansion to allow proper follow-up, and tooth discolouration or mobility was investigated with additional peri-apical images or
cone beam computed tomography (CBCT) to exclude direct damage from the burr or the osteotomy. After expansion, the device was blocked and either left in place or replaced with a transpalatal arch for a consolidation period of 6 months. Outcome
Short-term complications after SARPE refer to unattended and unwanted conditions presenting intraoperatively, during the distraction phase, or postoperatively within 4 weeks after the SARPE procedure. Patients were systematically evaluated for pain, infection, haemorrhage, dental and periodontal changes, nerve injury, and symmetry of expansion, but other complications were also taken into account. Severe postoperative pain was defined as a VAS pain score >7 during the first week after surgery, affecting daily functioning, with only a limited effect of paracetamol and non-steroidal antiinflammatory drugs (NSAIDs) at the maximum dose allowed. The term ‘haemorrhage’ was used to describe all cases of postoperative bleeding presenting via the emergency or maxillofacial surgery department, with the exception of regular weekly follow-up after discharge from the hospital. All patients in whom the subjective findings of altered sensitivity in the trigeminal region could be confirmed clinically were categorized under ‘nerve injury’. Deviations in the symmetry of expansion were diagnosed based on the comparison of successive extraoral and intraoral images. Results
Fifty-six patients undergoing SARPE during the study period were identified. One patient had solitary median maxillary central incisor (SMMCI) syndrome and was excluded. Thus, the study cohort consisted of 55 patients. Thirty-five of the patients were female and 20 were male, and they ranged in age from 13 to 47 years (median age 22 years). All patients were skeletally mature and in the permanent dentition phase. Mobilization of the maxillary halves, subsequent expansion, and stabilization was achieved in all patients. Nerve injury
Paresthesia of the infraorbital nerve and related branches was observed in 16 patients (29.1%). Eight of these patients experienced bilateral involvement of the nerve. Of the unilaterally affected patients, two complained of paresthesia
Please cite this article in press as: Verquin M, et al. Short-term complications after surgically assisted rapid palatal expansion: a retrospective cohort study, Int J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/j.ijom.2016.11.016
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Short-term complications after SARPE of the incisors only, three had involvement of the infraorbital region, and another three patients had numbness of the upper lip in addition to the teeth and the infraorbital region. Four cases of paresthesia resolved within 2 weeks postoperative. After 4 weeks, three patients continued to suffer from unilateral paresthesia. There was no report of dysesthesia or complete anaesthesia (Table 1). Haemorrhage
A total of six patients presented with postoperative bleeding (10.9%). Intraoral bleeding was observed in one patient on the first evening after surgery. Epistaxis was seen in five patients. Four patients experienced a nosebleed on the day of surgery, whereas one presented with severe late-onset bleeding beginning on postoperative day 8 (Table 1). Dental and periodontal problems
Dental complications were seen in a total of five patients (9.1%). Two patients presented with increased tooth mobility of the
central incisors during the first week postoperative. Discolouration of a central incisor was observed in one patient during distraction. External apical root resorption of the upper central incisors was seen in two patients. None of these complications resulted in tooth loss during follow-up (Table 1). Pain
Of all 55 patients, four (7.3%) suffered from severe postoperative pain at the surgical site. One patient was hospitalized overnight due to limited oral intake, and lost up to 12 kg during the subsequent 2 weeks. No cases of distraction-related pain were observed (Table 1). Inadequate/asymmetrical expansion
In this study, three cases of asymmetrical expansion were encountered (5.5%). Two were noticed early on during expansion and were only temporary due to trapping of the upper molars between the buccal cusps of their antagonists. One patient presented with true asymmetrical
3
expansion after finishing the distraction phase. There were no reports of inadequate or unsuccessful expansion in this study cohort (Table 1). Appliance-related problems
Appliance-related complications were seen in three patients (5.5%). The Hyrax appliance had not been placed prior to surgery in one patient, therefore additional surgical time was required as the appliance had yet to be placed. Two patients had difficulties activating the device resulting in a lag of expansion of 1 week after starting the activation (Table 1). Other complications
Seven patients encountered complications that could not be classified into the above categories. Four patients reported postoperative nausea and vomiting. Two patients complained of a large, aesthetically disturbing cheek haematoma. A third patient was hospitalized due to iatrogenic gastric bleeding caused by NSAIDs (Table 1). Discussion
Table 1. Summary of short-term complications encountered. Pain Severe postoperative pain Haemorrhage Intraoral Epistaxis First week (4/55) Late onset (1/55) Total Dental Dental complications Mobile central incisors (2/55) Discolouration (1/55) Blunting of the apices (2/55) Appliance Appliance-related problems Hyrax placement (1/55) Device activation (2/55) Paresthesia Week 1 Front teeth only (2/55) Front teeth + unilateral infraorbital (3/55) Front teeth + lips + unilateral infraorbital (3/55) Front teeth + lips + bilateral infraorbital (8/55) Week 2 Week 3 Week 4 Front teeth only (1/55) Front teeth + unilateral infraorbital (0/55) Front teeth + lips + unilateral infraorbital (2/55) Front teeth + lips + bilateral infraorbital (0/55) Expansion Asymmetrical expansion Other Cheek haematoma Iatrogenic gastric bleeding Nausea and/or vomiting
4/55
7.3%
1/55 5/55
1.8% 9.1%
6/55
10.9%
5/55
9.1%
3/55
5.5%
16/55
29.1%
12/55 9/55 3/55
21.8% 16.4% 5.5%
3/55
5.5%
2/55 1/55 4/55
3.6% 1.8% 7.3%
Of the total 55 patients undergoing toothborne SARPE between January 2013 and December 2014, 28 developed one or more complications. In general, most complications were minor and resolved spontaneously. Two patients, however, required an unanticipated surgical intervention and six required an unintended or prolonged hospital stay. The primary site of resistance when widening the midface is the subject of discussion. It is generally accepted that both the mid-palatal suture – historically – and the zygomaticomaxillary junction play an important role.7,15 Closure of the midpalatal suture limits the possible range of maxillary expansion with orthodontic devices and increases the opposing effects, rendering SARPE the treatment of choice.16,17 This has also been outlined by Mommaerts in an age-based treatment strategy for patients with a transverse maxillary deficiency.18 This strategy recommends that rapid palatal expanders should be used in patients aged <12 years, whereas SARPE should be used for those aged >14 years, to release areas of bony resistance in the midface.18 It should be noted, however, that the ossification of the bone sutures is critical to the indication for SARPE, rather than the patient’s chronological age. In addition to the mid-palatal suture and the zygomaticomaxillary junction,
Please cite this article in press as: Verquin M, et al. Short-term complications after surgically assisted rapid palatal expansion: a retrospective cohort study, Int J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/j.ijom.2016.11.016
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the nasal septum and the pterygoid plates are areas of considerable resistance. Many surgeons consider pterygomaxillary disjunction a risk not worth taking due to injury to the pterygoid plexus or branches of the maxillary artery resulting in significant bleeding.19 In addition to this, a recent meta-analysis by Hamedi Sangsari et al. could not identify a meaningful difference between the disjunction and non-disjunction groups in anterior and posterior expansion.20 However, it has consistently been stated that when the pterygoid plates are not released, the widening of the maxillary segments tends to be V-shaped, with the apex pointing dorsally, lacking expansion in the molar region.15 Since a lateral nasal wall corticotomy is likely to increase the risk of postoperative nasal bleeding, and a release of the pterygoid plates carries an increased risk of intraoperative and postoperative intraoral bleeding, the authors believe that the decision of whether or not to release certain bony sutures should depend on the patient’s history and the purpose of SARPE. The current trend is for procedures to be as minimally invasive as possible; however, not disengaging areas of major resistance decreases the mobility of the maxillary halves and leads to a greater risk of asymmetrical, inadequate, or unsuccessful expansion and an increased risk of periodontal damage, since the distraction forces are not evenly distributed. Numbness of the teeth, lips, and the infraorbital region originates from an altered blood flow and injury to the branches of the maxillary nerve.21,22 In the present study, over 80% of patients who presented altered sensitivity of the infraorbital nerve postoperatively experienced a full recovery within 4 weeks after surgery. At the last follow-up time, three patients had mild altered sensitivity (5.5%) with a limited impact on daily functioning. Remarkably all patients with bilateral injury to the infraorbital nerve experienced a full recovery, whereas only 62.5% of those with a unilateral injury recovered fully. The bilateral involvement was attributed to transient pressure exerted by postoperative oedema. Unilateral numbness is more likely to be related to the intraoperative trauma due to stretching and blunt injury with tissue retractors (Le Fort I hooks), hence the worse prognosis. No long-term prediction of nerve recovery can be made based on these results due to the limited duration of follow-up. The number of bleeding complications found in this study is within the same range as the numbers reported previously
by Bays and Greco23 (one case of minor nasal bleeding, 5.3%) and Dergin et al.8 (epistaxis in 12 patients, 20%). Williams et al. observed four bleeding complications in their study (3.3%); however, there was no mention of whether or not a lateral nasal wall osteotomy was performed.24 Neyt et al. reported one case of epistaxis (1.8%) without mentioning a lateral nasal wall osteotomy or transection of the pterygoid plates, which may in turn affect symmetry and the adequacy of expansion.25 The present authors have found that the use of haemostatic measures such as electrocoagulation and tamponade with absorbable haemostatic gelatin sponges decreases the amount of intraoperative blood loss and postoperative bleeding. All cases of postoperative bleeding in the present cohort were managed successfully with either local or systemic tranexamic acid or nasal packing. Bleeding following a SARPE procedure can be considered a mild complication, since only one case of postoperative life-threatening haemorrhage has been reported so far, which could be controlled with anterior and posterior nasal packing.14 Politis reported no life-threatening haemorrhage after 376 SARPE procedures and stated that for SARPE, in contrast to the Le Fort I osteotomy, nasal packing is sufficient to stop heavy bleeding even in the worst-case scenario.26 In this study, tooth mobility resolved spontaneously or was addressed orthodontically, and all cases were managed successfully. Discolouration of a central incisor adjacent to the interdental osteotomy was seen in one patient during follow-up (1.8%). Imaging showed a symmetrical midline osteotomy without separation of the alveolar bone from the incisor root. Failure to identify an unusual midline osteotomy before appliance activation may result in an exacerbated periodontal injury and, in severe cases, even tooth loss.27 Williams et al. reported discolouration of a central incisor in 4.2%,24 and Koudstaal et al. reported discolouration of a central incisor 3 weeks after surgery in one patient (2.4%).28 Tooth discolouration after interdental osteotomies has been found to be the result of direct intraoperative insult, transient hypoperfusion, or a combination of both, with resulting pulpal haemorrhage, death, and necrosis, and leakage of the pulpal degeneration products into the adjacent dentine layer. Blunting and resorption of the apices was seen in two patients (3.6%). Due to the retrospective nature of this study, it is unclear whether the SARPE procedure or the concurrent orthodontic
treatment was the reason for these results. Verlinden et al. reported on the subject of external apical root resorption using Sharpe’s classification and found extreme external apical root resorption in 1.6%.29,30 No gingival recession or bone loss was seen during follow-up in this study. In contrast, Williams et al. reported 12 cases (10%) of gingival recession, of which nine involved the central incisors, and seven cases (5.8%) of periodontal bone loss between the maxillary central incisors.24 Removal of the central incisors was required in two of the cases following severe interdental bone loss. Dergin et al. reported no gingival recession or bone loss during their 3-month follow-up period.8 Seeberger et al. evaluated changes after surgically assisted maxillary expansion to the dentoalveolar, palatal, and nasal structures using tooth-borne distraction devices and saw no signs of gingival recession or periodontal loss in 31 patients.31 Different surgical techniques and their effects on the maxillary dentoalveolar complex were evaluated using computed tomography by Sygouros et al.32 The results reported on the pattern of expansion and periodontal findings are similar to those found by Laudemann et al.33 suggesting that without separation of the pterygoid plates, an adequate transverse dimension can be achieved; however, putting additional strain on the periodontal apparatus, especially in the premolar area. Pterygoid disjunction should therefore be performed in patients over the age of 20 years and in periodontally compromised patients. The cases of severe postoperative pain presented in this study are likely related to the extended loosening of bony sutures during surgery, leading to increased intraoperative and postoperative oedema and therefore pain. Although rarely reported, insufficient release of the bony sutures may underlie subjective reported pain during distraction, suggesting that good intraoperative mobilization of the maxillary halves decreases distraction-related pain. In this study cohort, no patient presented with distraction-related pain, giving strength to this hypothesis.28,29 In extension to this, inadequate expansion did not occur and true asymmetrical expansion was seen in only one patient (1.8%). This problem was managed successfully by the treating orthodontist. No additional segmental maxillary surgery was required for correction of the asymmetry. A wide variation in incidence of asymmetrical expansion has been reported after SARPE, ranging from 3.3% up to 18%.34–36
Please cite this article in press as: Verquin M, et al. Short-term complications after surgically assisted rapid palatal expansion: a retrospective cohort study, Int J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/j.ijom.2016.11.016
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Short-term complications after SARPE Verlinden et al. found asymmetrical expansion in five out of 73 cases, all needing additional surgery.29 Koudstaal et al. reported asymmetrical expansion in two of 46 patients.28 Williams et al. encountered 16 cases of asymmetrical or inadequate expansion (13.3%).24 Dergin et al. observed an incidence of 3.3%.8 Asymmetrical expansion can be seen as a result of incomplete osteotomies and missed lateral nasal wall osteotomies. This has also been suggested by Koudstaal et al.15 and Dergin et al.8 The meticulous release of all areas of major resistance during the surgical technique likely decreased the rate of asymmetrical and inadequate expansion in comparison to Verlinden et al.29 and Williams et al.24; however, postoperative pain, haemorrhage, and swelling tend to increase. Although SARPE is considered a relatively simple procedure associated with minimal morbidity when compared to orthognathic surgery, over half of the patients in this study cohort presented with one or multiple complications within 4 weeks after surgery. Although these complications are rather mild and many resolve on their own, the results of this study emphasize that like any other surgical procedure, SARPE is not free of risks and should be preceded by careful patient selection and planning. When comparing these results with those of other authors, it seems that the incidence and severity of postoperative pain, haemorrhage, and swelling increase with extended loosening of the bony sutures in the areas of resistance, whereas pain during distraction, periodontal breakdown, and asymmetrical expansion tend to decrease. Considering the prognosis of nerve injury to the infraorbital branch of the trigeminal nerve, unilateral involvement tends to have a worse outcome, most likely due to intraoperative stretching and blunt trauma, rather than postoperative pressure secondary to tissue oedema. Funding
There are no sources of funding to declare. Competing interests
The authors have no proprietary or commercial interest to declare. Ethical approval
Ethical approval was obtained from the Research Ethics Committee of the University Hospital of Leuven (OBC) (registration number mp01384).
Patient consent
Not required. 15.
Acknowledgements. Special thanks to the medical staff and residents at the Catholic University Leuven for the adequate follow-up and documentation of the patients included in this cohort study. Many thanks also to the co-operating orthodontists for the treatment of these patients and support in multidisciplinary decision-making. References 1. McNamara JA. Maxillary transverse deficiency. Am J Orthod Dentofac Orthop 2000;117:567–70. 2. Howe RP, McNamara JA, O’Connor KA. An examination of dental crowding and its relationship to tooth size and arch dimension. Am J Orthod 1983;83:363–73. 3. Baccetti T, Franchi L, Cameron CG, McNamara Jr JA. Treatment timing for rapid maxillary expansion. Angle Orthod 2001;71: 343–50. 4. Angell E. Treatment of irregularity of permanent adult teeth. Dent Cosmos 1860. 5. Brown GV. The surgery of oral and facial diseases and malformations. fourth ed. London: Kimpton; 1938: 507. 6. Shetty V, Caridad JM, Caputo AA, Chaconas SJ. Biomechanical rationale for surgical-orthodontic expansion of the adult maxilla. JOral Maxillofac Surg 1994;52:742–9. [discussion 750–751]. 7. 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;60:104–10. 8. Dergin G, Aktop S, Varol A, Ugurlu F, Garip H. Complications related to surgically assisted rapid palatal expansion. Oral Surg Oral Med Oral Pathol Oral Radiol 2015;119:601–7. 9. Schimming R, Feller KU, Herzmann K, Eckelt U. Surgical and orthodontic rapid palatal expansion in adults using Glassman’s technique: retrospective study. Br J Oral Maxillofac Surg 2000;38:66–9. 10. Woods M, Wiesenfeld D, Probert T. Surgically-assisted maxillary expansion. Aust Dent J 1997;42:38–42. 11. Messer EJ, Bollinger TE, Keller JJ. Surgicalmechanical maxillary expansion. Quintessence Int Dent Dig 1979;10:13–6. 12. Kraut RA. Surgically assisted rapid maxillary expansion by opening the midpalatal suture. J Oral Maxillofac Surg 1984;42: 651–5. 13. Pogrel MA, Kaban LB, Vargervik K, Baumrind S. Surgically assisted rapid maxillary expansion in adults. Int J Adult Orthodon Orthognath Surg 1992;7:37–41. 14. Mehra P, Cottrell DA, Caiazzo A, Lincoln R. Life-threatening, delayed epistaxis after
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evaluation of different surgical techniques and their effects on the maxillary dentoskeletal complex. Am J Orthod Dentofac Orthop 2014;146:748–57. 33. Laudemann K, Petruchin O, Mack MG, Kopp S, Sader R, Landes CA. Evaluation of surgically assisted rapid maxillary expansion with or without pterygomaxillary disjunction based upon preoperative and post-expansion 3D computed tomography data. Oral Maxillofac Surg 2009;13:159–69. 34. Ramieri GA, Spada MC, Austa M, Bianchi SD, Berrone S. Transverse maxillary distraction with a bone-anchored appliance: dento-periodontal effects and clinical and radiological results. Int J Oral Maxillofac Surg 2005;34:357–63. 35. Verstraaten J, Kuijpers-Jagtman AM, Mommaerts MY, Berge´ SJ, Nada RM, Schols JG, et al. A systematic review of the effects of bone-borne surgical assisted rapid maxillary
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Address: Constantinus Politis Department of Oral and Maxillofacial Surgery Faculty of Medicine Catholic University Leuven Kapucijnenvoer 33 Leuven 3000 Belgium Tel: +32 16 3 32462 Fax: +32 16 3 32437 E-mail: [email protected]
Please cite this article in press as: Verquin M, et al. Short-term complications after surgically assisted rapid palatal expansion: a retrospective cohort study, Int J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/j.ijom.2016.11.016
Int. J. Oral Maxillofac. Surg. 2016; xxx: xxx–xxx http://dx.doi.org/10.1016/j.ijom.2016.11.016, available online at http://www.sciencedirect.com
Clinical Paper Orthognathic Surgery
Short-term complications after surgically assisted rapid palatal expansion: a retrospective cohort study
M. Verquin, L. Daems, C. Politis Department of Oral and Maxillofacial Surgery, Faculty of Medicine, Catholic University Leuven, Leuven, Belgium
M. Verquin, L. Daems, C. Politis: Short-term complications after surgically assisted rapid palatal expansion: a retrospective cohort study. Int. J. Oral Maxillofac. Surg. 2016; xxx: xxx–xxx. # 2016 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Abstract. Surgically assisted rapid palatal expansion (SARPE) has been considered a safe procedure with minimal patient morbidity. The aim of this study was to identify short-term complications encountered after tooth-borne expansion with a standardized approach to inform surgeons and orthodontists of the patient risk. In this retrospective cohort study, 55 patients (35 female, 20 male) undergoing SARPE between January 2013 and December 2014 were evaluated. Twenty-eight patients developed one or more complications. Postoperative haemorrhage was seen in six patients. Sixteen patients presented with injury to the infraorbital nerve, five had dental complications, and four had severe postoperative pain. A prolonged hospital stay was necessary for six patients and additional surgery was required in two cases. It is concluded that the short-term complications after tooth-borne SARPE are generally mild; however, the number of complications encountered indicates that SARPE is not free of risk and should be preceded by careful patient selection and planning.
Transverse maxillary deficiency is among the most common types of skeletal dysplasia observed in clinical practice and is often characterized by a unilateral or bilateral crossbite, as well as anterior crowding.1,2 A possible approach, depending on the level of skeletal maturity and the desired amount of expansion, is surgically assisted rapid palatal expansion (SARPE). The concept of correcting a 0901-5027/000001+06
transverse discrepancy in the maxilla was first described by Angell in 1860.3,4 Following the introduction of a mid-palatal split technique by Brown,5 Shetty et al. added a pterygomaxillary osteotomy to achieve predictable expansion of the maxilla,6 and SARPE quickly became a procedure of choice for widening of the maxilla in skeletally mature patients. It has been performed frequently ever since.
Key words: retrospective cohort study; palatal expansion technique; distraction osteogenesis; maxilla; tooth-borne; complications. Accepted for publication 29 November 2016
As SARPE is considered a relatively safe procedure in comparison to a segmental Le Fort I osteotomy, data concerning complications are limited. The current literature commonly reports pain, haemorrhage, infection, nerve injury, apical root resorption, and discolouration and devitalization of teeth. Inadequate or asymmetrical expansion and infection of the maxillary sinus are rare, while flaring of
# 2016 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Verquin M, et al. Short-term complications after surgically assisted rapid palatal expansion: a retrospective cohort study, Int J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/j.ijom.2016.11.016
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the alar base, tinnitus, lacrimation, lifethreatening epistaxis, and skull base fracture are extremely rare.7–14 With a growing number of adults seeking orthodontic treatment, an increase in the indications for SARPE can be expected. It is important to identify complications associated with SARPE to enable patient-specific treatment plans to be drawn up and to provide accurate information concerning the surgery-related risks. The purpose of this retrospective study was to investigate the presence/absence, nature, frequency, and timing of short-term complications presenting after tooth-borne SARPE in a group of consecutively treated patients at a single centre. Patients and methods Patients
All 56 patients undergoing tooth-borne SARPE between January 2013 and December 2014 were evaluated retrospectively for postoperative complications following a standardized multidisciplinary protocol at the Catholic University Leuven, Belgium. Exclusion criteria were prior trauma and craniofacial syndromes involving the maxilla. Fifty-five patients remained after applying the exclusion criteria; 35 were female and 20 were male, and they ranged in age from 13 to 47 years. This study was conducted in accordance with the principles stated in the Declaration of Helsinki and was approved by the Research Ethics Committee of the Faculty of Medicine, University of Leuven. Technique
Prior to surgery, all patients were screened for any relevant medical and surgical history. Baseline radiographic and clinical imaging was obtained for all patients. All surgeries were performed by one of the authors (CP) following a standardized protocol. All patients underwent SARPE under general anaesthesia with nasotracheal intubation combined with a local anaesthetic (lidocaine), with a vasoconstrictor (epinephrine 1:100,000) given for haemostatic purposes before incision. A semi-lunar horizontal incision was made using a scalpel and was completed with monopolar diathermy in the upper buccal fold from the canine up to the infrazygomatic crest bilaterally. A corticotomy according to Le Fort I was made from the posterior aperture to the maxillary tuberosity with a Hall drill, 4-mm above the apex of the upper canine, whilst holding the soft tissue of the upper jaw in a
cranial direction with a Le Fort I hook, protecting the infraorbital nerve. Disengagement of the pterygomaxillary suture was performed using a curved osteotome. In conjunction with this procedure, a vertical incision was made over the labial frenulum of the maxilla, the anterior nasal spine was loosened, and the transpalatal osteotomy was completed with a spatula osteotome whilst placing a forefinger on the palate for guidance of the osteotome as it transected the mid-palatal suture. Transverse mobility of the maxillary halves was checked by manipulating a chisel in-between the central diastema. Disengagement of the nasal septum then followed using a septum osteotome. Antibiotics (amoxicillin) were administered intraoperatively and given as prophylaxis for up to 5 days postoperatively. No standard distraction device was used; each patient’s orthodontist inserted a Hyrax-type expander prior to surgery. A latency period of 7 days between surgery and expansion was respected to allow new callus to be formed. The device was activated 0.25 mm twice daily to achieve a daily expansion of 0.5 mm. All patients were assessed for complications clinically and with peri-apical X-rays of the central incisors on a weekly basis by residents at the university hospital under the supervision of one of the authors (CP). This was done for up to 4 weeks postoperatively or until the desired maxillary expansion had been achieved. The continuation of follow-up was then performed by the treating orthodontist. The weekly clinical examination consisted of adequate anamnesis including an assessment of pain on a visual analogue scale (VAS), extraoral examinations including sensory deficits in the maxillary nerve (V2) region (light touch, pin-prick, and two-point discrimination tests) and an evaluation of the symmetry of expansion, and intraoral examinations including measurement of the central diastema, tooth colour, pocket measurement and mobility of the anchoring teeth (hyrax device) and central incisors using a Periotest M device (DentiSystem, Budapest, Hungary), and inspection of the intraoral wound healing. The weekly examination was concluded with clinical imaging (intraoral and extraoral) to allow comparisons to be made. Additional radiographic images were obtained when indicated after aberrant findings during clinical examination; for example, posterior–anterior films were obtained in the case of asymmetric expansion to allow proper follow-up, and tooth discolouration or mobility was investigated with additional peri-apical images or
cone beam computed tomography (CBCT) to exclude direct damage from the burr or the osteotomy. After expansion, the device was blocked and either left in place or replaced with a transpalatal arch for a consolidation period of 6 months. Outcome
Short-term complications after SARPE refer to unattended and unwanted conditions presenting intraoperatively, during the distraction phase, or postoperatively within 4 weeks after the SARPE procedure. Patients were systematically evaluated for pain, infection, haemorrhage, dental and periodontal changes, nerve injury, and symmetry of expansion, but other complications were also taken into account. Severe postoperative pain was defined as a VAS pain score >7 during the first week after surgery, affecting daily functioning, with only a limited effect of paracetamol and non-steroidal antiinflammatory drugs (NSAIDs) at the maximum dose allowed. The term ‘haemorrhage’ was used to describe all cases of postoperative bleeding presenting via the emergency or maxillofacial surgery department, with the exception of regular weekly follow-up after discharge from the hospital. All patients in whom the subjective findings of altered sensitivity in the trigeminal region could be confirmed clinically were categorized under ‘nerve injury’. Deviations in the symmetry of expansion were diagnosed based on the comparison of successive extraoral and intraoral images. Results
Fifty-six patients undergoing SARPE during the study period were identified. One patient had solitary median maxillary central incisor (SMMCI) syndrome and was excluded. Thus, the study cohort consisted of 55 patients. Thirty-five of the patients were female and 20 were male, and they ranged in age from 13 to 47 years (median age 22 years). All patients were skeletally mature and in the permanent dentition phase. Mobilization of the maxillary halves, subsequent expansion, and stabilization was achieved in all patients. Nerve injury
Paresthesia of the infraorbital nerve and related branches was observed in 16 patients (29.1%). Eight of these patients experienced bilateral involvement of the nerve. Of the unilaterally affected patients, two complained of paresthesia
Please cite this article in press as: Verquin M, et al. Short-term complications after surgically assisted rapid palatal expansion: a retrospective cohort study, Int J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/j.ijom.2016.11.016
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Short-term complications after SARPE of the incisors only, three had involvement of the infraorbital region, and another three patients had numbness of the upper lip in addition to the teeth and the infraorbital region. Four cases of paresthesia resolved within 2 weeks postoperative. After 4 weeks, three patients continued to suffer from unilateral paresthesia. There was no report of dysesthesia or complete anaesthesia (Table 1). Haemorrhage
A total of six patients presented with postoperative bleeding (10.9%). Intraoral bleeding was observed in one patient on the first evening after surgery. Epistaxis was seen in five patients. Four patients experienced a nosebleed on the day of surgery, whereas one presented with severe late-onset bleeding beginning on postoperative day 8 (Table 1). Dental and periodontal problems
Dental complications were seen in a total of five patients (9.1%). Two patients presented with increased tooth mobility of the
central incisors during the first week postoperative. Discolouration of a central incisor was observed in one patient during distraction. External apical root resorption of the upper central incisors was seen in two patients. None of these complications resulted in tooth loss during follow-up (Table 1). Pain
Of all 55 patients, four (7.3%) suffered from severe postoperative pain at the surgical site. One patient was hospitalized overnight due to limited oral intake, and lost up to 12 kg during the subsequent 2 weeks. No cases of distraction-related pain were observed (Table 1). Inadequate/asymmetrical expansion
In this study, three cases of asymmetrical expansion were encountered (5.5%). Two were noticed early on during expansion and were only temporary due to trapping of the upper molars between the buccal cusps of their antagonists. One patient presented with true asymmetrical
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expansion after finishing the distraction phase. There were no reports of inadequate or unsuccessful expansion in this study cohort (Table 1). Appliance-related problems
Appliance-related complications were seen in three patients (5.5%). The Hyrax appliance had not been placed prior to surgery in one patient, therefore additional surgical time was required as the appliance had yet to be placed. Two patients had difficulties activating the device resulting in a lag of expansion of 1 week after starting the activation (Table 1). Other complications
Seven patients encountered complications that could not be classified into the above categories. Four patients reported postoperative nausea and vomiting. Two patients complained of a large, aesthetically disturbing cheek haematoma. A third patient was hospitalized due to iatrogenic gastric bleeding caused by NSAIDs (Table 1). Discussion
Table 1. Summary of short-term complications encountered. Pain Severe postoperative pain Haemorrhage Intraoral Epistaxis First week (4/55) Late onset (1/55) Total Dental Dental complications Mobile central incisors (2/55) Discolouration (1/55) Blunting of the apices (2/55) Appliance Appliance-related problems Hyrax placement (1/55) Device activation (2/55) Paresthesia Week 1 Front teeth only (2/55) Front teeth + unilateral infraorbital (3/55) Front teeth + lips + unilateral infraorbital (3/55) Front teeth + lips + bilateral infraorbital (8/55) Week 2 Week 3 Week 4 Front teeth only (1/55) Front teeth + unilateral infraorbital (0/55) Front teeth + lips + unilateral infraorbital (2/55) Front teeth + lips + bilateral infraorbital (0/55) Expansion Asymmetrical expansion Other Cheek haematoma Iatrogenic gastric bleeding Nausea and/or vomiting
4/55
7.3%
1/55 5/55
1.8% 9.1%
6/55
10.9%
5/55
9.1%
3/55
5.5%
16/55
29.1%
12/55 9/55 3/55
21.8% 16.4% 5.5%
3/55
5.5%
2/55 1/55 4/55
3.6% 1.8% 7.3%
Of the total 55 patients undergoing toothborne SARPE between January 2013 and December 2014, 28 developed one or more complications. In general, most complications were minor and resolved spontaneously. Two patients, however, required an unanticipated surgical intervention and six required an unintended or prolonged hospital stay. The primary site of resistance when widening the midface is the subject of discussion. It is generally accepted that both the mid-palatal suture – historically – and the zygomaticomaxillary junction play an important role.7,15 Closure of the midpalatal suture limits the possible range of maxillary expansion with orthodontic devices and increases the opposing effects, rendering SARPE the treatment of choice.16,17 This has also been outlined by Mommaerts in an age-based treatment strategy for patients with a transverse maxillary deficiency.18 This strategy recommends that rapid palatal expanders should be used in patients aged <12 years, whereas SARPE should be used for those aged >14 years, to release areas of bony resistance in the midface.18 It should be noted, however, that the ossification of the bone sutures is critical to the indication for SARPE, rather than the patient’s chronological age. In addition to the mid-palatal suture and the zygomaticomaxillary junction,
Please cite this article in press as: Verquin M, et al. Short-term complications after surgically assisted rapid palatal expansion: a retrospective cohort study, Int J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/j.ijom.2016.11.016
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the nasal septum and the pterygoid plates are areas of considerable resistance. Many surgeons consider pterygomaxillary disjunction a risk not worth taking due to injury to the pterygoid plexus or branches of the maxillary artery resulting in significant bleeding.19 In addition to this, a recent meta-analysis by Hamedi Sangsari et al. could not identify a meaningful difference between the disjunction and non-disjunction groups in anterior and posterior expansion.20 However, it has consistently been stated that when the pterygoid plates are not released, the widening of the maxillary segments tends to be V-shaped, with the apex pointing dorsally, lacking expansion in the molar region.15 Since a lateral nasal wall corticotomy is likely to increase the risk of postoperative nasal bleeding, and a release of the pterygoid plates carries an increased risk of intraoperative and postoperative intraoral bleeding, the authors believe that the decision of whether or not to release certain bony sutures should depend on the patient’s history and the purpose of SARPE. The current trend is for procedures to be as minimally invasive as possible; however, not disengaging areas of major resistance decreases the mobility of the maxillary halves and leads to a greater risk of asymmetrical, inadequate, or unsuccessful expansion and an increased risk of periodontal damage, since the distraction forces are not evenly distributed. Numbness of the teeth, lips, and the infraorbital region originates from an altered blood flow and injury to the branches of the maxillary nerve.21,22 In the present study, over 80% of patients who presented altered sensitivity of the infraorbital nerve postoperatively experienced a full recovery within 4 weeks after surgery. At the last follow-up time, three patients had mild altered sensitivity (5.5%) with a limited impact on daily functioning. Remarkably all patients with bilateral injury to the infraorbital nerve experienced a full recovery, whereas only 62.5% of those with a unilateral injury recovered fully. The bilateral involvement was attributed to transient pressure exerted by postoperative oedema. Unilateral numbness is more likely to be related to the intraoperative trauma due to stretching and blunt injury with tissue retractors (Le Fort I hooks), hence the worse prognosis. No long-term prediction of nerve recovery can be made based on these results due to the limited duration of follow-up. The number of bleeding complications found in this study is within the same range as the numbers reported previously
by Bays and Greco23 (one case of minor nasal bleeding, 5.3%) and Dergin et al.8 (epistaxis in 12 patients, 20%). Williams et al. observed four bleeding complications in their study (3.3%); however, there was no mention of whether or not a lateral nasal wall osteotomy was performed.24 Neyt et al. reported one case of epistaxis (1.8%) without mentioning a lateral nasal wall osteotomy or transection of the pterygoid plates, which may in turn affect symmetry and the adequacy of expansion.25 The present authors have found that the use of haemostatic measures such as electrocoagulation and tamponade with absorbable haemostatic gelatin sponges decreases the amount of intraoperative blood loss and postoperative bleeding. All cases of postoperative bleeding in the present cohort were managed successfully with either local or systemic tranexamic acid or nasal packing. Bleeding following a SARPE procedure can be considered a mild complication, since only one case of postoperative life-threatening haemorrhage has been reported so far, which could be controlled with anterior and posterior nasal packing.14 Politis reported no life-threatening haemorrhage after 376 SARPE procedures and stated that for SARPE, in contrast to the Le Fort I osteotomy, nasal packing is sufficient to stop heavy bleeding even in the worst-case scenario.26 In this study, tooth mobility resolved spontaneously or was addressed orthodontically, and all cases were managed successfully. Discolouration of a central incisor adjacent to the interdental osteotomy was seen in one patient during follow-up (1.8%). Imaging showed a symmetrical midline osteotomy without separation of the alveolar bone from the incisor root. Failure to identify an unusual midline osteotomy before appliance activation may result in an exacerbated periodontal injury and, in severe cases, even tooth loss.27 Williams et al. reported discolouration of a central incisor in 4.2%,24 and Koudstaal et al. reported discolouration of a central incisor 3 weeks after surgery in one patient (2.4%).28 Tooth discolouration after interdental osteotomies has been found to be the result of direct intraoperative insult, transient hypoperfusion, or a combination of both, with resulting pulpal haemorrhage, death, and necrosis, and leakage of the pulpal degeneration products into the adjacent dentine layer. Blunting and resorption of the apices was seen in two patients (3.6%). Due to the retrospective nature of this study, it is unclear whether the SARPE procedure or the concurrent orthodontic
treatment was the reason for these results. Verlinden et al. reported on the subject of external apical root resorption using Sharpe’s classification and found extreme external apical root resorption in 1.6%.29,30 No gingival recession or bone loss was seen during follow-up in this study. In contrast, Williams et al. reported 12 cases (10%) of gingival recession, of which nine involved the central incisors, and seven cases (5.8%) of periodontal bone loss between the maxillary central incisors.24 Removal of the central incisors was required in two of the cases following severe interdental bone loss. Dergin et al. reported no gingival recession or bone loss during their 3-month follow-up period.8 Seeberger et al. evaluated changes after surgically assisted maxillary expansion to the dentoalveolar, palatal, and nasal structures using tooth-borne distraction devices and saw no signs of gingival recession or periodontal loss in 31 patients.31 Different surgical techniques and their effects on the maxillary dentoalveolar complex were evaluated using computed tomography by Sygouros et al.32 The results reported on the pattern of expansion and periodontal findings are similar to those found by Laudemann et al.33 suggesting that without separation of the pterygoid plates, an adequate transverse dimension can be achieved; however, putting additional strain on the periodontal apparatus, especially in the premolar area. Pterygoid disjunction should therefore be performed in patients over the age of 20 years and in periodontally compromised patients. The cases of severe postoperative pain presented in this study are likely related to the extended loosening of bony sutures during surgery, leading to increased intraoperative and postoperative oedema and therefore pain. Although rarely reported, insufficient release of the bony sutures may underlie subjective reported pain during distraction, suggesting that good intraoperative mobilization of the maxillary halves decreases distraction-related pain. In this study cohort, no patient presented with distraction-related pain, giving strength to this hypothesis.28,29 In extension to this, inadequate expansion did not occur and true asymmetrical expansion was seen in only one patient (1.8%). This problem was managed successfully by the treating orthodontist. No additional segmental maxillary surgery was required for correction of the asymmetry. A wide variation in incidence of asymmetrical expansion has been reported after SARPE, ranging from 3.3% up to 18%.34–36
Please cite this article in press as: Verquin M, et al. Short-term complications after surgically assisted rapid palatal expansion: a retrospective cohort study, Int J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/j.ijom.2016.11.016
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Short-term complications after SARPE Verlinden et al. found asymmetrical expansion in five out of 73 cases, all needing additional surgery.29 Koudstaal et al. reported asymmetrical expansion in two of 46 patients.28 Williams et al. encountered 16 cases of asymmetrical or inadequate expansion (13.3%).24 Dergin et al. observed an incidence of 3.3%.8 Asymmetrical expansion can be seen as a result of incomplete osteotomies and missed lateral nasal wall osteotomies. This has also been suggested by Koudstaal et al.15 and Dergin et al.8 The meticulous release of all areas of major resistance during the surgical technique likely decreased the rate of asymmetrical and inadequate expansion in comparison to Verlinden et al.29 and Williams et al.24; however, postoperative pain, haemorrhage, and swelling tend to increase. Although SARPE is considered a relatively simple procedure associated with minimal morbidity when compared to orthognathic surgery, over half of the patients in this study cohort presented with one or multiple complications within 4 weeks after surgery. Although these complications are rather mild and many resolve on their own, the results of this study emphasize that like any other surgical procedure, SARPE is not free of risks and should be preceded by careful patient selection and planning. When comparing these results with those of other authors, it seems that the incidence and severity of postoperative pain, haemorrhage, and swelling increase with extended loosening of the bony sutures in the areas of resistance, whereas pain during distraction, periodontal breakdown, and asymmetrical expansion tend to decrease. Considering the prognosis of nerve injury to the infraorbital branch of the trigeminal nerve, unilateral involvement tends to have a worse outcome, most likely due to intraoperative stretching and blunt trauma, rather than postoperative pressure secondary to tissue oedema. Funding
There are no sources of funding to declare. Competing interests
The authors have no proprietary or commercial interest to declare. Ethical approval
Ethical approval was obtained from the Research Ethics Committee of the University Hospital of Leuven (OBC) (registration number mp01384).
Patient consent
Not required. 15.
Acknowledgements. Special thanks to the medical staff and residents at the Catholic University Leuven for the adequate follow-up and documentation of the patients included in this cohort study. Many thanks also to the co-operating orthodontists for the treatment of these patients and support in multidisciplinary decision-making. References 1. McNamara JA. Maxillary transverse deficiency. Am J Orthod Dentofac Orthop 2000;117:567–70. 2. Howe RP, McNamara JA, O’Connor KA. An examination of dental crowding and its relationship to tooth size and arch dimension. Am J Orthod 1983;83:363–73. 3. Baccetti T, Franchi L, Cameron CG, McNamara Jr JA. Treatment timing for rapid maxillary expansion. Angle Orthod 2001;71: 343–50. 4. Angell E. Treatment of irregularity of permanent adult teeth. Dent Cosmos 1860. 5. Brown GV. The surgery of oral and facial diseases and malformations. fourth ed. London: Kimpton; 1938: 507. 6. Shetty V, Caridad JM, Caputo AA, Chaconas SJ. Biomechanical rationale for surgical-orthodontic expansion of the adult maxilla. JOral Maxillofac Surg 1994;52:742–9. [discussion 750–751]. 7. 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;60:104–10. 8. Dergin G, Aktop S, Varol A, Ugurlu F, Garip H. Complications related to surgically assisted rapid palatal expansion. Oral Surg Oral Med Oral Pathol Oral Radiol 2015;119:601–7. 9. Schimming R, Feller KU, Herzmann K, Eckelt U. Surgical and orthodontic rapid palatal expansion in adults using Glassman’s technique: retrospective study. Br J Oral Maxillofac Surg 2000;38:66–9. 10. Woods M, Wiesenfeld D, Probert T. Surgically-assisted maxillary expansion. Aust Dent J 1997;42:38–42. 11. Messer EJ, Bollinger TE, Keller JJ. Surgicalmechanical maxillary expansion. Quintessence Int Dent Dig 1979;10:13–6. 12. Kraut RA. Surgically assisted rapid maxillary expansion by opening the midpalatal suture. J Oral Maxillofac Surg 1984;42: 651–5. 13. Pogrel MA, Kaban LB, Vargervik K, Baumrind S. Surgically assisted rapid maxillary expansion in adults. Int J Adult Orthodon Orthognath Surg 1992;7:37–41. 14. Mehra P, Cottrell DA, Caiazzo A, Lincoln R. Life-threatening, delayed epistaxis after
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Address: Constantinus Politis Department of Oral and Maxillofacial Surgery Faculty of Medicine Catholic University Leuven Kapucijnenvoer 33 Leuven 3000 Belgium Tel: +32 16 3 32462 Fax: +32 16 3 32437 E-mail: [email protected]
Please cite this article in press as: Verquin M, et al. Short-term complications after surgically assisted rapid palatal expansion: a retrospective cohort study, Int J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/j.ijom.2016.11.016