Surgically assisted rapid maxillary expansion: feasibility of not releasing the nasal septum

Comparison of Tooth- and Bone-Borne Appliances on the Stress Distributions and Displacement Patterns in the Facial Skeleton in Surgically Assisted Rapid Maxillary Expansion-A Finite Element Analysis (FEA) Study

The aim of this study was to compare the reduced stresses according to Huber’s hypothesis and the displacement pattern in the region of the facial skeleton using a tooth- or bone-borne appliance in surgically assisted rapid maxillary expansion (SARME). In the current literature, the lack of updated reports about biomechanical effects in bone-borne appliances used in SARME is noticeable. Finite element analysis (FEA) was used for this study. Six facial skeleton models were created, five with various variants of osteotomy and one without osteotomy. Two different appliances for maxillary expansion were used for each model. The three-dimensional (3D) model of the facial skeleton was created on the basis of spiral computed tomography (CT) scans of a 32-year-old patient with maxillary constriction. The finite element model was built using ANSYS 15.0 software, in which the computations were carried out. Stress distributions and displacement values along the 3D axes were found for each osteotomy variant with the expansion of the tooth- and the bone-borne devices at a level of 0.5 mm. The investigation showed that in the case of a full osteotomy of the maxilla, as described by Bell and Epker in 1976, the method of fixing the appliance for maxillary expansion had no impact on the distribution of the reduced stresses according to Huber’s hypothesis in the facial skeleton. In the case of the bone-borne appliance, the load on the teeth, which may lead to periodontal and orthodontic complications, was eliminated. In the case of a full osteotomy of the maxilla, displacements in the buccolingual direction for all the variables of the bone-borne appliance were slightly bigger than for the tooth-borne appliance.

Linear analysis of the nasal septum in patients treated with surgically assisted rapid maxillary expansion

INTRODUCTION

Surgically assisted rapid maxillary expansion is a widely used surgical procedure for resolving transverse maxillary occlusal changes in patients with bone maturity. However, few studies about the postoperative morphologic alterations in the nasal cavity in its inferior portion and the nasal septum positioning exist.

METHODS

The linear nasal septum measurements of 26 adult patients treated with surgically assisted rapid maxillary expansion from 2009 to 2013 were assessed through a retrospective analysis of cone-beam computed tomographies, in Digital Imaging and Communications in Medicine files, through the Dolphin Imaging program (Dolphin Imaging and Management Solutions, Chatsworth, Calif), aimed to identify significant changes during 3 time periods of the treatment: preoperative, immediately after the palatal expansion device locking (immediate postoperative), and 6-months postoperative (late postoperative). The analyses were performed in the inferior third of the nasal septum, from 4 equidistant points in anteroposterior position and height, using fixed cranial references for lateral measures of displacement.

RESULTS

No significant difference was found between preoperative, immediate postoperative, and late postoperative measurements in the 4 fixed nasal septum measurements, applying the analysis of variance test with a significance level of 5%. Comparing the surgical times alone, we found no statistically significant difference between the right and left sides applying the Student t test, which also showed symmetry in the nasal septum.

CONCLUSIONS

The measurements of the nasal septum did not change in the different surgical times throughout their inferior extension, and they remained symmetrical throughout patients' follow-up period.

Surgically assisted rapid maxillary expansion: a systematic review of complications

A systematic review of the literature on the complications of surgically assisted maxillary expansion (SARME) was performed. The search strategy was based on the PRISMA guidelines. The PubMed, SCOPUS, and Cochrane Library databases were searched. Data were extracted from the full texts after screening of the abstracts and titles. Human clinical studies encompassing 'maxillary expansion', 'palatal expansion', 'SARME', or 'SARPE' and that reported sufficient data for 'complication' were included. In vitro studies, case reports, meta-analyses, reviews, book chapters, animal studies, and studies with missing or insufficient data were excluded. The final selection included 12 articles for data extraction. A total of 851 patients underwent SARME, with 187 reported complications (21.97%). Epistaxis (2.47%) and postoperative pain (2.00%) were the most often reported minor complications, and asymmetric or inadequate expansion presented an occurrence rate of 4.47%. Minor complications were equally distributed between surgical (49.30%) and orthodontic complications (50.70%). The technique without pterygomaxillary disjunction increased the occurrence of minor complications (29.95% vs. 16.87%), and the expansion pattern with less than 0.5 mm/day increased the occurrence of orthodontic complications (30.93% vs. 1.83%), i.e. asymmetric expansion. In conclusion, SARME procedures mostly present minor complications. Although several types of complication are described in the literature, occurrence rates are low, and technical issues such as pterygomaxillary disjunction and the pattern of distraction can be predictors of the complication risk.

Bone changes on lateral cephalograms and CBCT during treatment of maxillary narrowing using palatal osteodistraction with bone-anchored appliances

The most common problem in surgical and orthodontic treatment involves abnormal transverse dimension of the maxilla. Behaviour of the facial skeleton in its anterior-posterior dimension during treatment of maxillary narrowing using surgical assist is interesting to observe. Assessment of bone changes of the maxillary location assessed on lateral cephalograms and CBCT during surgically assisted maxillary expansion with bone-anchored appliances. The analysed material included documentation of 78 patients, the mean age of 16.86±2.65, treated with transverse maxillary distraction using a bone-anchored appliance. The software (Dolphin Imaging) was used to measure parameters on lateral cephalograms. Results obtained analysis of correlation between planes, angles and diameters between teeth before and after treatment. Simple Regression - SNA vs. SN-OCCL change of the anterior height with regard to changes in the occlusal angle refer to the opening and dropping of the maxilla in the anterior section. Simple Regression - SNA vs. S-PNS-ANS describe changes in the anterior section such as opening of the S-PNS-ANS angle, and in a correlation with the SNA angle opening it indicates maxillary dropping and protrusion. Dropping and protrusion of the maxilla can be observed during surgically assisted maxillary expansion with bone-anchored appliances. Maxillary anterior movement may depend on a surgical procedure.

Wooden spatula sinusitis following maxillary expansion surgery

Sinusitis is a recognised rare complication of palatine expansion procedures and is usually caused by the presence of an oroantral fistula. We report the first case of unilateral sinusitis as a result of a retained foreign body (a wooden spatula) following a surgically assisted rapid palatine expansion procedure.

Skeletal changes following surgically assisted rapid maxillary expansion (SARME)

Purpose

Surgically assisted rapid maxillary expansion (SARME) is a common treatment technique in the correction of maxillary transverse deficiency. The purpose of this study was to evaluate nasal and palatal skeletal changes following SARME using Cone Beam Computed Tomography (CBCT) and posterior anterior (PA) cephalograms.

Materials and Methods

In this retrospective study, the radiographic images obtained from 14 patients with transverse maxillary deficiency before treatment and 6 months after SARME operations were evaluated. The changes in nasal bone width and palatal bone width were measured on CBCT. The changes in basal maxillary width, nasal cavity width and angular measurements were evaluated on PA cephalograms.

Results

Nasal floor width was measured at the levels of upper first premolar teeth and molar teeth which significantly increased following SARME (p=0.005 and 0.017 respectively). Palatal bone width between first premolar teeth and molar teeth also significantly increased (p=0.003 and 0.002 respectively). Basal maxillary width (p=0.026), nasal cavity width (p=0.024) and other angular measurements also significantly increased (p<0.05).

Conclusion

Nasal and palatal skeletal transverse dimensions increased following SARME. Due to the enlargement of the nasal floor and nasal cavity, it is likely to improve air pass through the nose.

The value of cone beam computed tomography imaging in surgically assisted rapid palatal expansion: a systematic review of the literature

This study aimed to evaluate the reliability of cone-beam computed tomography (CBCT) imaging of the maxillary structures and the postoperative dentoskeletal, nasal airway, periodontal, and facial soft tissue changes after surgically assisted rapid palatal expansion (SARPE). A systematic review of the literature on CBCT analysis of SARPE was performed. The PubMed, Embase, and Cochrane Library databases were searched. Nine articles were included, involving a total of 228 patients. The general trend was tooth-borne distraction with pterygomaxillary dysjunction. A systematic increase in all transverse dimensions at the dentoalveolar and dental levels, as well as a certain degree of tipping and extrusion of the anchorage teeth and tipping of the skeletal segments, was detected. Soft tissue findings reflected the underlying dentoalveolar changes. A decrease in the buccal alveolar bone thickness and alveolar crest level occurred. Results confirm that CBCT is an accurate and reliable method to assess anatomical changes after SARPE. Although this systematic review provides valuable preliminary information about the effects of SARPE, results should be interpreted with caution due to the low level of evidence of the publications, great heterogeneity among study groups regarding outcome variables and surgical-orthodontic protocols, and lack of long-term data.

Surgically assisted rapid maxillary expansion (SARME) with or without intraoperative releasing of the nasal septum

OBJECTIVE

To assess nasal septum deviation after surgically assisted rapid maxillary expansion (SARME) with or without intraoperative releasing of the nasal septum.

STUDY DESIGN

A total of 20 consecutive adult patients with transverse maxillary deficiency underwent SARME with intraoperative releasing (n = 10) or nonreleasing (n = 10) of the nasal septum. Cone beam computed tomography scans were obtained immediately after surgery (T1), after the end of distraction (T2), and 6 months after SARME (T3). Deviation of the nasal septum was evaluated by angular measurements on superimposed cone beam computed tomography images from T1 to T3. Moreover, visible nasal septum deviation was assessed by using superimposed clinical photos obtained preoperatively (CP1) and before second-stage surgery (CP2).

RESULTS

No significant differences were found between releasing and nonreleasing of the nasal septum in angular radiographic measurements from T1 to T3 (0 degrees; 95% confidence interval -0.62 to 0.62; P = .5) or visible nasal deviation from CP1 to CP2 (-0.14 degrees; 95% confidence interval -0.64 to 0.36; P = .28).

CONCLUSIONS

The results of the present study indicate that there is no need for intraoperative releasing of the nasal septum during SARME. However, further randomized studies based on large patient groups are needed before final conclusions on this topic can be reached.

Effect of Surgically Assisted Rapid Maxillary Expansion on Upper Airway Volume: A Systematic Review

PURPOSE

Surgically assisted rapid maxillary expansion (SARME) is required in non-growing patients when maturity or resistance precludes desired sutural separation by noninvasive techniques. The aim of this review was to determine what volumetric changes occur in the upper airway spaces after SARME in adults.

MATERIALS AND METHODS

A systematic review was performed with data assessed for suitability of meta-analysis. The primary outcome measurement of volumetric changes in an upper airway space was sought in non-growing patients undergoing SARME. Electronic database searches were performed for published literature in Medline (by Ovid), Pre-Medline, Old Medline, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) spanning all available years to August 1, 2015. Unpublished literature was searched electronically through ClinicalTrials.gov and the National Research Register. Additional hand searching of reference lists of relevant articles, grey searching, and expert correspondence was conducted for any additional studies. Two authors independently screened search results, extracted data, and assessed the risk of bias of included studies.

RESULTS

Twenty-one studies were located by initial screening; 10 were excluded after full-text review, leaving 11 studies eligible that met all inclusion criteria for this systematic review. In total, 204 treated patients (mean age, 18 to 31 yr) were included in the qualitative synthesis. Ten studies evaluated nasal cavity volume, 2 evaluated palatal volume, and 1 evaluated oropharyngeal volume. Appliances used included tooth-borne hyrax and transpalatal distractor devices.

CONCLUSIONS

SARME was found to produce substantial short-term volume increases in the nasal cavity in non-growing patients that were maintained for at least 63 months. Evidence weakly suggested no effect on oropharyngeal volume. However, most studies were evaluated as having a high risk of bias. The effect of such volume changes on respiratory function still needs to be determined; thus, SARME cannot be recommended for respiratory purposes.