Surgically Assisted Rapid Maxillary Expansion Research Articles

Pterygopalatine disjunction-associated SARME and the nasal cavity - A systematic literature review.

This study aimed to evaluate the effect of surgically assisted rapid maxillary expansion (SARME) with pterygopalatine disjunction (PD) on the nasomaxillary complex structures. A systematic two-phase review, recorded in the PROSPERO database, was conducted. Search strategies were performed using PubMed, Scopus, Web of Science, COCHRANE, LILACS and DOSS databases, including gray literature (Open Grey, Google Scholar, and ProQuest). The methodological quality and evidence of the included studies were assessed. Out of 1017 studies, 10 met the inclusion criteria. Generally, a moderate risk of bias was noted. The studies involved 236 adults evaluated preoperatively and postoperatively. Key outcomes assessed included nasal cavity volume, minimum cross-sectional area (MCSA), nasal septum positioning, nasal cavity width, and nose volume (soft tissues). Although findings indicated increased MCSA, nasal cavity, and nasopharynx volumes, and no changes in nasal septum post-SARME + PD, the current evidence is insufficient for definitive clinical recommendations due to study limitations, particularly the small number of included studies. More clinical studies with robust methodologies and low risk of bias are needed. Key words:Nasal septum, nasal cavity, palatine expansion technique.

Major clinical outcomes of rapid maxillary expansion in bucomaxillofacial surgery: a systematic review

Introduction: The techniques of surgically assisted rapid maxillary expansion (SARME) and non-surgically assisted rapid maxillary expansion (NSARME) are used to correct maxillary development through palatal disjunction. Objective: It was analyzed using a systematic review of the literature on the main considerations of the rapid expansion of the maxilla, evidencing its main indications, contraindications, types of expanders, as well as the main dental and skeletal alterations by them produced. Methods: The PRISMA Platform systematic review rules were followed. The search was carried out from February to April 2024 in the Scopus, PubMed, Science Direct, Scielo, and Google Scholar databases. The quality of the studies was based on the GRADE instrument and the risk of bias was analyzed according to the Cochrane instrument. Results and Conclusion: 110 articles were found, 34 articles were evaluated in full and 22 were included and developed in the present systematic review study. Considering the Cochrane tool for risk of bias, the overall assessment resulted in 18 studies with a high risk of bias and 23 studies that did not meet GRADE and AMSTAR-2. Most studies did not show homogeneity in their results, with X2=73.8%>50%. It was concluded there is still no consensus on which is the best jaw-breaker, and it is necessary to increase the number of clinical and randomized studies, with eligibility criteria that can homogenize the participants. In addition, the literature has clearly shown that bucomaxillofacial surgeons must have the knowledge and clinical experience to be able to indicate the best procedure for each patient, that is, the rapid expansion of the non-surgical or surgical maxilla.

Evaluation of Treatment Protocols in Surgically Assisted Rapid Maxillary Expansion by Finite Element Analysis.

Background and Objectives: Transverse maxillary deficiency is an important maxillary anomaly that is very common in society and remains current in orthodontics. The maxillary expansion has been used in treatment for a long time. While maxillary expansion can be performed with rapid maxillary expansion in young adults, it is performed with surgically assisted rapid maxillary expansion (SARME) in individuals who have reached skeletal maturity. No consensus has been reached on the most successful surgical technique or the ideal appliance for treating transverse maxillary deficiency. Accordingly, we aimed to evaluate various surgical techniques and orthodontic appliances for treating transverse maxillary deficiency using the finite element method (FEM) to identify the treatment protocol that minimizes stress on the maxillary bone and teeth. Materials and Methods: On the virtual models obtained from the cone beam computed tomography of a patient, two different incisions (the pterygomaxillary junction is separated and not separated) were made and combined using three different orthodontic appliances (tooth, bone, and hybrid assisted). Then, stresses over the maxillary bone and maxillary teeth were calculated by FEM. Results: Our results showed that when the pterygomaxillary plates were separated, fewer stresses were observed on the bone and teeth. Although hybrid-supported appliances created less stress on the teeth than tooth-supported appliances and no difference was found between bone-supported appliances, it was found that hybrid-supported appliances created less stress on the bone than the other appliances. Conclusions: The separation of the pterygomaxillary junction in the SARME operation and the use of a bone-supported or hybrid-supported appliance would place less stress on the bone and teeth.

Bone Density of the Midpalatal Suture After Surgically Assisted Rapid Maxillary Expansion: A Retrospective Cohort Study

Objectives: To evaluate the bone density in the midpalatal suture after 10 months of surgically assisted rapid maxillary expansion (SARME) with the separation of the maxilla into 2 segments. Methods: Sixty multislice computed tomography (MCT) from 20 patients undergoing SARME were analyzed in 3 periods of time (1 MCT per patient on each occasion): (1) 1 week before surgery, (2) postsurgery immediately after completing the expander activation, and (3) 10 months after the expander activation. On all occasions, the bone density was measured in Hounsfield units on MCT scans in axial and coronal sections, in the anterior (A1), middle (A2), and posterior (A3) regions of the midpalatal suture. Results: The mean percentage values of bone density in Hounsfield units, from the 10-month postactivation period to preoperative in the A1, A2, and A3 regions were 68.38%, 38.21%, and 55.90%, respectively, in the axial norm, and 64.06%, 36.81%, and 55.50% in coronal norm (A1 = A3>A2), with no significant difference in the tomographic cuts (P >0.05). There was no correlation between patient age or amount of expansion in the expander and bone density. Conclusions: The bone density in the midpalatal suture 10 months after SARME is lower than preexpansion. A denser new bone formation along the suture concentrates closer to the extremities rather than in the central region. Although the maturation of the new bone formation in the midpalatal suture is lower 10 months after SARME, it appears to be sufficient for satisfactory clinical results, regardless of patient age or the amount of expansion in the expander.

The effects of pterygomaxillary disjunction in surgically assisted rapid maxillary expansion: A systematic review and meta-analysis.

This study aims to assess the expansive effects of pterygomaxillary disjunction (PMD) in surgically assisted rapid maxillary expansion (SARME) surgery using a meta-analysis approach. The study conducted a comprehensive literature search across five databases: PubMed, Scopus, Medline, Embase, and Cochrane, adhering to the PRISMA 2020 guidelines. Dental alterations were assessed using either cone-beam computed tomography (CBCT) or dental casts, while skeletal changes were exclusively measured from CBCT scans. We analysed the dentoskeletal changes between PMD +/- groups and conducted a within-group comparison. The primary focus of the results was on the mean differences observed in pre- and post-operative measurements. Dental expansion was larger in the PMD+ group but not statistically significant. Skeletal expansion showed a significantly larger expansion in the posterior region in the PMD+ group (P = .033). Without PMD, anterior palatal expansion was significantly larger (P = .03), and the buccal tipping of posterior teeth was also significantly larger (P = .011) to achieve acceptable dental expansion outcomes. Both PMD +/- groups of SARME surgery can achieve satisfactory dental expansion outcomes. However, bone expansion and tooth inclination are also important factors that influence orthodontic treatment and post-expansion stability. By reducing the bony resistance with PMD, larger posterior palatal expansion and more parallel bony expansion are observed. In contrast, without PMD, there is smaller palatal expansion and greater tooth inclination in the posterior region. This could potentially lead to compromised periodontal conditions following expansion.

Impact of Non-Surgical and Surgically Assisted Rapid Maxillary Expansion Procedures upon the Periodontium: A Systematic Review

Background: Scarce evidence is available regarding the occurrence and prevalence of hard/soft tissue deficiencies among patients undergoing surgically assisted rapid maxillary expansion (SARME) as compared to non-surgical rapid maxillary expansion (NSRME) approaches. The purpose of this study is to evaluate the effect of NSRME and SARME upon the periodontal structures. Methods: A literature search was performed to identify studies that fulfilled pre-established eligibility criteria, evaluating changes in the periodontium (e.g., probing depths) and hard/soft tissue deficiencies (e.g., bone levels, gingival recession) within patients undergoing NSRME and SARME procedures. Results: A total of 21 articles were included in the present review. Four of them evaluated the outcomes of both NSRME and SARME procedures, while six and eleven studies analyzed NSRME alone and SARME alone, respectively. The incidence of hard (e.g., changes in buccal bone width/height) and soft tissue deficiencies (e.g., gingival recession, keratinized tissue, and clinical attachment level) is slightly increased among patients undergoing maxillary expansion with worsened outcomes during NSRME procedures. Conclusions: The impact of NSRME and SARME upon the periodontium remains inconclusive.

Facial soft tissue changes and volumetric analysis of upper airways in patients undergoing surgically assisted rapid maxillary expansion using a transpalatal distractor

ObjectiveTo verify changes in facial soft tissue using the RadiANT-DICOM-viewer and Dolphin Imaging software, through linear measurements of tomographic points in a 3D reconstruction of the face and volumetric evaluation with three-dimensional measurements of the upper airways of patients with transverse maxillary discrepancy undergoing Surgically Assisted Rapid Maxillary Expansion (SARME). MethodsRetrospective, transverse, and descriptive study, through the analysis of computed tomography scans of the face of patients with transverse maxillary discrepancy, treated from July 2019 to December 2022. The sample consisted of 15 patients of both sexes, aged 21–42 years old, who underwent surgically assisted rapid maxillary expansion using the transpalatal distractor. Analysis was performed through linear, angular, and three-dimensional measurements in millimeters, in the preoperative and late four-month postoperative period, in frontal 3D tomographic images of the face, in the region of the width of the nose and alar base and also angular measurement in the lateral tomography for the angle nasolabial and upper airways of rhinopharynx, oropharynx and hypopharynx. ResultsThere was an increase in nasal width with an average of 1.3467mm and an increase in the alar base with an average of 1.7333mm. A significant difference was found in the pre- and postoperative assessments of the measurements of nasal width, alar base and nasolabial angle, as well as the upper airways in all their extension. The results favour a better understanding of the professional and the patient regarding the diagnosis and management of patients with transverse maxillary width discrepancies. ConclusionAlthough our study shows an increase in soft tissues after SARME, no aesthetic changes are observed clinically, and all patients report significant respiratory improvement. SARME may therefore contribute to the improvement of professionals working in the field of oral and maxillofacial surgery and orthodontics. Level of evidenceLevel 4.

Facial recognition by cloud-based APIs following surgically assisted rapid maxillary expansion.

This study aimed to investigate whether the facial soft tissue changes of individuals who had undergone surgically assisted rapid maxillary expansion (SARME) would be detected by three different well-known facial biometric recognition applications. To calculate similarity scores, the pre- and postsurgical photographs of 22patients who had undergone SARME treatment were examined using three prominent cloud computing-based facial recognition application programming interfaces (APIs): AWS Rekognition (Amazon Web Services, Seattle, WA, USA), Microsoft Azure Cognitive (Microsoft, Redmond, WA, USA), and Face++ (Megvii, Beijing, China). The pre- and post-SARME photographs of the patients (relaxed, smiling, profile, and semiprofile) were used to calculate similarity scores using the APIs. Friedman's two-way analysis of variance and the Wilcoxon signed-rank test were used to compare the similarity scores obtained from the photographs of the different aspects of the face before and after surgery using the different programs. The relationship between measurements on lateral and posteroanterior cephalograms and the similarity scores was evaluated using the Spearman rank correlation. The similarity scores were found to be lower with the Face++ program. When looking at the photo types, it was observed that the similarity scores were higher in the smiling photos. Astatistically significant difference in the similarity scores (P < 0.05) was found between the relaxed and smiling photographs using the different programs. The correlation between the cephalometric and posteroanterior measurements and the similarity scores was not significant (P > 0.05). SARME treatment caused asignificant change in the similarity scores calculated with the help of three different facial recognition programs. The highest similarity scores were found in the smiling photographs, whereas the lowest scores were found in the profile photographs.

Is There a Difference in Mid-Palatal Suture Density after Rapid Maxillary Expansion, Surgically Assisted Rapid Maxillary Expansion, and Miniscrew-Assisted Rapid Palatal Expansion? A Systematic Review and Meta-Analysis

The aim of this systematic review and meta-analysis was to evaluate the density of the midpalatal suture (MPS) of individuals with maxillary expansion (rapid maxillary expansion, RME), surgically assisted rapid maxillary expansion (SARPE), and miniscrew-assisted rapid palatal expansion (MARPE) through computed tomography. An electronic search was performed in four databases, MEDLINE via PubMed, SCOPUS, Web of Science, and Cochrane Central Register of Controlled Trials (CENTRAL) in February 2023 and updated in April 2023, using previously established search strategies. Studies were retrieved without restrictions in terms of data, language, or publication status. The risk of bias assessment was based on a quality assessment tool for before-and-after studies. Ten studies were included in our systematic review, and nine studies were included for our quantitative analysis. The analyses were performed by subgroup according to the evaluation of the region, anterior, middle, and posterior, including the three types of treatment: RME, SARPE, and MARPE. Heterogeneity was high for the three regions (anterior 95%, medium 97%, and posterior 84%) and a statistical difference was found in two of the three regions (anterior p = 0.06, medium p = 0.031, and posterior p &lt; 0.001). There is not enough evidence to state that the MPS density is different after 6 months of RME in the anterior and middle regions; the bone density values for SARPE and MARPE suggest that 6 or 7 months after expansion, there is still no bone density similar to the initial one in the three regions.

Randomized clinical trial of surgically assisted rapid maxillary expansion with two and three segments for nasal breathing.

To evaluate surgically assisted rapid maxillary expansion (SARME), with osteotomies separating the maxilla into two segments (SARME-2S) and three segments (SARME-3S), on obstruction symptoms and nasal cavity dimensions in patients with maxillary transverse skeletal deficiency (MTSD). Sixteen patients with MTSD of 7mm or above were evaluated in each group, for a total of 32 patients. All patients were evaluated pre- and postoperatively up to 10months after the expander activations. The minimum cross-sectional area (MCA) and the volume of the nasal cavities were identified by acoustic rhinometry. The Nasal Obstruction Symptom Evaluation (NOSE) scale questionnaire was applied. The palate surface area (PSA) was measured, via digitized maxillary models, as a criterion for comparison with the other variables studied. There was no difference between the groups (p = 0.370) and was verified a significant increase in PSA postoperatively. MCA showed a small increase without statistical significance, and together with the volume of the nasal cavities remained constant during the study. NOSE scale scores decreased significantly in the postoperative periods, implying a decrease in nasal obstruction symptoms in both groups. SARME with two and three segments show similar results, and both may improve nasal obstruction symptoms when present in patients with MTSD. SARME, regardless of the chosen surgical technique, should follow the recommendation to correct just the MTSD. While an improvement in nasal breathing is expected, this must be understood as likely, but not certain.

Dental, Skeletal, and Soft Tissue Changes after Bone-Borne Surgically Assisted Rapid Maxillary Expansion: A Systematic Review and Meta-Analysis.

(1) Background: For non-growing patients with marked transverse maxillary deficiency, bone-borne surgically assisted rapid maxillary expansion (SARME) has been proposed as an effective treatment option. Objective: To evaluate the dental, skeletal, and soft tissue changes following bone-borne SARME. (2) Methods: An unrestricted systematic electronic search of six databases, supplemented by manual searches, was performed up to April 2023. The eligibility criteria included prospective/retrospective clinical studies with outcomes pertaining to objective measurements of dental/skeletal/soft tissue effects of bone-borne SARME in healthy patients. (3) Results: Overall, 27 studies satisfied the inclusion criteria. The risk of bias of the non-randomized trials ranged between moderate (20) and serious (4). For the two RCTs, there were some concerns of bias. Trials with outcomes measured at the same landmarks within the scope of the prespecified timeframe were deemed eligible for quantitative synthesis. Eventually, five trials were included in the meta-analysis. SARME was associated with a statistically significant lengthening of the dental arch perimeter immediately after expansion, along with a marginally significant decrease in palatal depth during the post-SARME retention period. Post-treatment SNA values exhibited no statistically significant change. (4) Conclusion: Current evidence indicates that bone-borne SARME constitutes an effective treatment option for adult patients with maxillary transverse deficiency. Further long-term randomized clinical trials with robust methodology, large sample sizes, and 3D evaluation of the outcomes are needed.

Three-dimensional dento-skeletal effects of mandibular midline distraction and surgically assisted rapid maxillary expansion: A retrospective study

It was the aim of the study to provide a three-dimensional evaluation of dento-skeletal effects following bone-borne vs tooth-borne mandibular midline distraction (MMD) and tooth-borne surgically assisted rapid maxillary expansion (SARME). A retrospective observational study was conducted. Cone beam computed tomography (CBCT) records were taken pre-operatively (T1), immediately post-distraction (T2) and 1 year post-operatively (T3). All included 30 patients had undergone MMD (20 bone-borne MMD; 10 tooth-borne MMD). A total of 20 bone-borne MMD and 8 tooth-borne MMD patients had simultaneously undergone tooth-borne SARME. At T1 vs T3, canine (p = 0.007; 26.0 ± 2.09 vs 29.2 ± 2.02) and first premolar (p = 0.005; 33.8 ± 2.70 vs 37.0 ± 2.43) showed significant expansion on the tip level for tooth-borne MMD. This was no significant on the apex level, indicating tipping. Bone-borne MMD showed a parallel distraction gap, whereas tooth-borne MMD showed a V-shape. There was a significant (p = 0.017; 138 ± 17.8 vs 141 ± 18.2) inter-condylar axes increase for bone-borne MMD. In conclusion, bone-borne vs tooth-borne MMD and tooth-borne SARME showed stable dento-skeletal effects at 1 year post-operatively. Bone-borne and tooth-borne MMD seemed not to be superior to each other. The choice of distractor type therefore depends more on anatomical and comfort factors.

Comparison of the effects of different rapid maxillary expansion techniques on craniofacial structures: a finite element analysis study

AimTo compare the effects of three different maxillary expansion appliances with five different types of expansion modalities on stress distribution and displacement on the maxilla and its adjacent craniofacial structures using the finite element method (FEM).Materials and methodsCone-beam computed tomography data of a patient with maxillary transverse deficiency were rendered into a three-dimensional model of craniomaxillary structures. The expansion appliances included tooth-borne, hybrid, and bone-borne expanders. Five different expansion modalities were applied to each expander [conventional Rapid Maxillary Expansion (RME) (type 1), midpalatal suture cortico-puncture-assisted RME (type 2), LeFort l cortico-puncture-assisted RME (type 3), surgically assisted RME (SARME) without pterygomaxillary junction (PMJ) separation (type 4), and SARME with bilateral PMJ separation (type 5)]. The numerical and visual data were analyzed.ResultsThe highest amount of stress accumulation on teeth was found in the tooth-borne and hybrid groups. On the other hand, more stress concentration on the maxilla was observed in the bone-borne group. SARME cuts with PMJ separation increased total movement by reducing the stress on the midpalatal suture in all groups. While types 1, 2, and 3 were similar in terms of the amounts of displacement, types 4 and 5 increased the total amount of displacement in all groups. The total amounts of displacements from the highest value to the lowest value for the anterior and posterior maxilla were in the bone-borne, tooth-borne, and hybrid groups.ConclusionsSARME cuts were effective in reducing stress on the teeth, but the cortico-puncture application affected neither the stress values on the teeth nor the transverse displacement in the tooth-borne expanders. Surgical procedures such as SARME and corticotomy should be used with bone-borne devices to improve the outcomes of maxillary expansion procedures.

Effects of different distractor positions on the formation of expansion, stress and displacement patterns in surgically assisted rapid maxillary expansion without pterygomaxillary disjunction: a finite element analysis study

Skeletal orthopedic expansion of maxilla is accepted as a reliable method for the treatment of transverse maxillar deficiency in growing patients. The aim of the study was to evaluate the effects of different palatal distractor positions on the expansion, stress and displacement patterns of the structures of craniofacial complex in surgical assisted rapid maxillary expansion without pterygomaxillary disjunction (PTMD) with the help of finite element analysis(FEA). Four facial skeleton models with different distractor positions (first premolar, second premolar, first molar, second molar regions) were created. In all finite element models median and lateral osteotomies were performed, without PTMD. Stress distribution was evaluated after 5 mm activation of the transpalatal distraction in all models using the nonlinear solution method in FEA. Unilateral displacement(mm) and stress distribution(MPa) were measured in three directions (x, y, and z axes) of craniofacial and maxillofacial structures in the symmetrical finite element models. In all models, the unilateral transverse displacements of the anterior teeth were greater than those of the posterior teeth, and the greatest displacement was at the central incisor level. The greatest displacement values at the central incisor level, at the anterior nasal spine(ANS) and at the posterior nasal spine(PNS) levels was measured in Model-IV, III, II and I, respectively. Mean elemental stress(von Mises stress) in the medial pterygoid plate, screw and lateral pterygoid plate regions from highest to lowest was measured in Model-IV, III, II and I, respectively. The maxilla performed outward rotation and tipping movement in all models during the expansion period. Among the distractor positions, the second molar region was found to be the most advantageous one in terms of expansion pattern. Considering the patient’s anatomy and clinical conditions, placing the palatal distractor as posteriorly as possible will result in more effective maxillary expansion.

Maxillary Expansion and Its Effects on Circummaxillary Structures: A Review.

Transverse maxillary discrepancies are the most common. The narrowed upper arch is the most prevalent problem an orthodontist encounter while treating adolescent and adult patients.Maxillary expansion is a technique used to increase the upper arch's transverse dimension to apply forces to widen the upper arch. For young children, a narrow maxillary arch has to be corrected using orthopedic and orthodontic treatments. In an orthodontic treatment plan, it is crucial to update transverse maxillary defeat. There are various clinical manifestations associated with a transverse maxillary deficiency which include a narrow palate, crossbite mainly seen in posteriors (unilateral or bilateral), severe crowding in anterior teeth, and cone-shaped hypertrophy can be seen. Some frequently used therapies for constricted upper arch include slow maxillary expansion, rapid maxillary expansion, and surgically assisted rapid maxillary expansion. Slow maxillary expansion requires light and constant force, whereas rapid maxillary expansion needs heavy pressure for activation. The surgical-assisted rapid maxillary expansion has gradually become popular to correct transverse maxillary hypoplasia. The maxillary expansion has various consequences on the nasomaxillary complex. There are multiple effects of maxillary expansion on the nasomaxillary complex. Mainly, the effect is seen on the mid-palatine suture along with the palate, maxilla, mandible, temporomandibular joint, soft tissue, and anterior and posterior upper teeth. It also affects functions like speech and hearing. Information on maxillary expansion is provided in depth in the following review article, along with its various effects on the surrounding structure.

Evaluation of Masticatory Muscles in Adult Patients with Maxillary Hypoplasia Treated with Surgically Assisted Rapid Maxillary Expansion (SARME): A Retrospective Study.

Aim: The aim of the present study was to investigate modifications in electromyographic activity of temporal and masseter muscles before and after surgically assisted rapid maxillary expansion (SARME) in adult subjects. Materials and Methods: Data from 20 patients with unilateral posterior crossbite were selected retrospectively from the Orthodontics Department of the University of Genoa and the Department of Biomedical Surgical and Dental Sciences of the University of Milan, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico Milan. Inclusion criteria were set as skeletal class I; adult patients (age > 18); good general health; patients with a transverse maxillary deficiency with unilateral posterior crossbite and maxillary constriction ≥ 5 mm; Superficial electromyographic (EMG) examinations at T0 and T1. Exclusion criteria were smoking, metabolic bone diseases (e.g., hyperparathyroidism, vitamin C deficiency), chronic use of corticoids before or during treatment, parafunctional habits (e.g., bruxism), and temporomandibular joint dysfunction. The Shapiro−Wilk test was performed to check whether the data were normally distributed. Differences for each variable before and after SARME were analyzed with a paired t-test (p < 0.05). Results: The statistical analysis demonstrated no statistically significant differences between the EMG values taken before and after SARME regarding the standardized electrical activity of the masticatory muscles (masseter and anterior temporalis (p > 0.05)). Conclusions: Considering the specific conditions of this study, it can be concluded that SARME did not alter the EMG activity of the masseter and temporal muscles. The present study has shown that the masticatory musculature evaluated after approximately 8 months of therapy can adapt well to SARME.

Orthodontic Evaluation and Craniofacial Characteristics of a Patient with Dubowitz Syndrome: A Case Report

This case report presents the orthodontic evaluation and treatment planning of a patient with Dubowitz syndrome, an autosomal recessive inherited and rare genetic disorder characterized by microcephaly, growth retardation, high sloping forehead, facial asymmetry, micrognathia, deep palate, blepharophimosis, sparse hair and eyebrows, low ear and mental retardation. The male patient, with a chronological age of 8 years and 2 days, was referred to our clinic due to severe overjet and mandibular retrognathia. Radiographic and clinical evaluations revealed deep palate, narrowness of maxillary and mandibular arches, mandibular micrognathia, speech difficulties and mixed breathing. The patient's treatment planning was aimed at function and phonation and included the use of a twin block appliance with expansion screw in both parts and simultaneous use of occipital headgear (350 g force on one side). It was aimed to positively direct the growth in the craniofacial structure by making use of the continuation of the patient's growth and development period, and to prevent interventions such as surgical-assisted rapid maxillary expansion and orthognathic surgery, which are invasive approaches in adulthood.

Orthodontic and Orthognathic Treatment Combined withSurgically Assisted Rapid Maxillary Expansion in an Adult Patient with a Hyperdivergent Skeletal Pattern.

In this case study, we report the successful treatment of a 35-year-old woman with a hyperdivergent skeletal pattern, open bite and severe transverse deficiency, exhibiting a skeletal Class III malocclusion. The treatment plan included 3D correction of these issues with surgically assisted rapid maxillary expansion (SARME) to solve the transverse deficiency, presurgical orthodontic treatment including aligning and levelling of the teeth in both arches, LeFort I osteotomy and bilateral sagittal split ramus osteotomy, and postsurgical correction of malocclusion. Orthodontic treatment was performed with labial brackets, and the patient achieved satisfactory occlusion and a significantly improved facial profile. Retention at the 1-year follow-up showed stable occlusion and arch forms with a harmonious facial profile.

Evaluation of dentoskeletal effects of surgically assisted rapid maxillary expansion using computed tomography

Introduction: Patients with transverse maxillary deficiency may have unilateral or bilateral posterior crossbite, crowded and rotated teeth and narrow palate. The treatment for adults is surgically assisted rapid maxillary expansion, a procedure that results in changes not only to bones, but also to teeth, nasal cavity, air space, lips and surrounding soft tissues. Objective: This study evaluated dentoskeletal changes in patients that underwent surgically assisted rapid maxillary expansion (SARME). Methods: Cone beam computed tomography (CBCT) scans were obtained before and after SARME. The thickness of buccal and lingual cortical bone and the angle of the long axis of posterior maxillary teeth were measured. Data were analyzed statistically. Results showed changes in thickness of buccal and lingual cortical bone and tooth movement and tipping. Conclusion: Tooth tipping increased and buccal bone thickness decreased, although osteotomies were used.

Update of the classification of midpalatal suture behaviour after surgically assisted rapid maxillary expansion using computed tomography

The aim of this study was to update the midpalatal suture classification after surgically assisted rapid maxillary expansion (SARME) using computed tomography (CT). Thirty-five patients with a transverse maxillary deficiency and unilateral or bilateral posterior crossbite underwent SARME with osteotomy of the pterygoid apophysis of the sphenoid. CT was performed before installation of the Hyrax expander appliance and after the final activation. Opening of the midpalatal suture was classified into three types: type I, total midpalatal suture opening from anterior nasal spine (ANS) to posterior nasal spine (PNS); type II, partial midpalatal suture opening from ANS to the transverse palatine suture, with partial or non-existent opening of the midpalatal suture posterior to the transverse palatine suture; type III, complete maxillary opening from ANS, but not of PNS, because a paramedian fracture completed the opening of the hard palate. Type I was observed in 42.8% of the patients, type II in 40%, and type III in 17.2%. Opening of the transverse palatine suture was found in all midpalatal suture opening patterns and was more frequent in type III, followed by type II and type I. CT was used to update the classification of midpalatal suture patterns, with the inclusion of type III: total opening of the hard palate due partly to opening of the midpalatal suture and partly to a paramedian fracture.