Transverse discrepancy, SARPE,SARME,LEFORT 1 Osteotomy, Mandibular midline Osteotomy, seminar September 2019

2. Orthognathic surgical procedures on
non-growing patients with maxillary
transverse deficiency
By: Dr. Muhammad Uzair
FCPS-II Resident Orthodontics
Sharif Medical and Dental College

3. Orthognathic surgical procedures on non-growing
patients with maxillary transverse deficiency
• Dale S. Bloomquist, and Donald R. Joondeph
• Seminars in Orthodontics, Vol 25, Issue 3, September 2019

4. Contents:
• Introduction
• SARPE
• Maxillary LeFort I segmental osteotomy
• Mandibular midline osteotomy
(Considerations, technique, retention and relapse, recommendations
and clinical cases)
• References

5. Introduction
• The treatment of maxillary transverse deficiency in post-pubertal patients
has been an area of disagreement among orthodontists.
• Much of the controversy is over the timing, when to refer to surgery for
adjunctive surgical procedure or traditional orthodontic mechanics should
be attempted.
• Melsen found that there was evidence of midpalatal sutural fusion as early
as 15 years of age in females and 17 years of age in males.

6. Introduction
• Later, Pierson and Thilander showed that the midpalatal suture can
remain patent until the mid-30s.
• Recent systematic review of the literature on this topic could not
come to a definitive conclusion as to the reliability of using skeletal
age as a criterion for the success, or failure, of conventional rapid
maxillary expansion in non-growing individuals.
• The decision, therefore, by an orthodontist of when to refer a
patient for surgery appears to be an individual one.

7. Surgical options
• Surgically assisted rapid palatal expansion (SARPE)
• Maxillary LeFort I segmental osteotomy
• Mandibular midline osteotomy with constriction

8. Surgically assisted rapid palatal
expansion (SARPE or SARME)
• Technique first described by Lines in 1975
• An expander is used concomitant with maxillary osteotomies
• It can be effectively used in the correction of a unilateral
crossbite
• The major limitation to SARPE, is that the skeletal problem needs
to be limited to maxillary deficiency in the transverse plane

9. Considerations
• Used for adult patients who have only maxillary
transverse deficiency and:
1. When arch length is needed
2. Canine width is narrow
3. Negative paranasal and upper lip soft tissue
effects need to be avoided
4. If previous conservative orthopedic palatal
expansion has failed

10. Technique
• A soft tissue incision from canine to the molar region
• A horizontal bone cut is made from piriform rim to the
pterygoid plate, bilaterally
• Midpalatal incision made from behind the nasopalatine
papilla back to just before the end of the hard palate.
• A bone cut is made from the posterior hard palate
forward to just behind the nasopalatine foramen,
angling the bur to either side of the septum.

11. Technique
• Use of a fine osteotome, driving it to a depth of approx.
5-10 mm between the apices of the central incisors.
• Starting the activation immediately after cementing
the appliance in place then expanding at 1.0mm per day
until the desired maxillary width is obtained

12. Variations in technique
1. A vertical cut at the pterygomaxillary suture
 Minimal, if any, benefit.
 Possibility of damaging blood vessels, resulting in excess bleeding
which makes this additional procedure impractical in an office setting
2. Use of a sharp osteotome, driving it posteriorly between the apices of
the central incisors approx. 1.5 cm, instead of direct palatal incision
 May contribute to a common undesired side effect of SARPE that of
unequal expansion

13. Expansion
• With Bone-borne expanders, greater amount of
skeletal movement is possible, but its use is limited
due to the difficulty of placing the expander close to
the horizontal shelf of the palate in a deep, narrow
vault
• Based on the minor differences in the response and
the limitations of application of the bone-borne
expander, it appears that the traditional tooth-borne
expander is most appropriate when significant expansion
of the maxilla is required

14. Expansion
• It is recommended that the expansion should continue until the maxillary
palatal cusps are in contact with the buccal cusps of the mandibular
dentition (Over-Correction)
• Expansion of greater than 5 mm is reported in literature, although it is
possible to expand up to 15mm using additional expansion appliances.

15. Retention and Relapse
• Fixed retention should be maintained for at least twelve weeks
following surgery and preferably longer
• Clinician should anticipate a loss of approx. one third (33%) of the
transverse dental expansion obtained with SARPE while the skeletal
expansion achieved is quite stable

16. Recommendations
Orthodontist:
1. Start early in treatment, before any orthodontic tooth movement attempted in the
maxillary arch
2. Monitor expansion with the oral and maxillofacial surgeon and decide when
expansion is sufficient
3. Overcorrect similar to orthopedic expansion in adolescents
4. Maintain with TPA or equivalent for at least twelve weeks
5. Maintain expansion during active treatment with expanded Mx archform
Surgeon:
6. Avoid pterygo-maxillary osteotomies

17. Clinical Case
• Patient Name: RJ
• Initial records at age 28-7
Problem list
• Class III malocclusion
• Bilateral maxillary constriction
• Maxillary crowding and open bite

18. Before SARPE After SARPE

19. Pre-surgical records prior to mandibular
osteotomies to rotate the mandible
counterclockwise to correct the AP and
vertical discrepancies
Final photos and occlusion at age 31-8.
Note maintenance of midface esthetics and
nasal tip angle.

20. Final cephalometric radiograph and
composite tracing showing mandibular
counterclockwise rotation to close
open bite
Two years postoperative at age 32-6 showing
excellent stability of SARPE procedure and
counterclockwise mandibular rotation for
open bite correction

21. Maxillary LeFort I segmental osteotomy
• Old and traditional surgical procedure
• The primary benefit of this surgery over SARPE is the ability to control
the maxillary segments in all three planes of space
• The immediate post-operative occlusion is predictable
• Instability of the transverse correction is the primary disadvantage

22. Considerations
1. Use when expansion is needed along with correction of the maxilla
in at least one other plane of space or if wish to alter occlusal plane
2. Limited usage in situations where there is insufficient intercanine width
3. Use with care in situations where the patient has soft tissue drape that
may be worsened with a LeFort I osteotomy

23. Technique
• Parasagittal soft tissue incisions have been
recommended for those who use a mid-palatal cut
• In situations requiring larger than 5.0mm of expansion,
a horseshoe osteotomy should be the preferred treatment. In that
osteotomy, parallel cuts are made just mesial to the medial nasal
wall then they are connected across the palate behind the
nasopalatine foramen
• The expansion occurs with the elevation of palatal tissue from
alveolus bilaterally. When the maxillary arch is expanded, the mid-
portion of the palate drops down resulting in a decreased depth of
the vault.

24. Technique
• Many surgeons believing that greater than 6.0mm expansion should
Not be attempted although up to 15mm has been reported
• In patients with a thin upper lip, the surgeon should
Not making a mucosal incision across the midline,
Instead, use small incisions and tunneling as is done
With SARPE, in order to have minimal effect on volume
of the upper lip
Tunnel technique

25. Retention and Relapse
• In addition to over correction;
• The use of a transpalatal arch, palatal splint, Placement of an
edgewise stabilizing archwire as soon as possible postoperatively and
even placing an expanded headgear inner bow into buccal tubes for
10 weeks.
• In the most recent study, they found that relapse occurred in almost
all of the cases, and that 30% of the patients had more than 3.0mm
of postoperative constriction

26. Complications
• Infection
• Persistent oral fistula
• Damage to periodontium and dental roots adjacent to the vertical
osteotomies
• Potential negative aesthetic affects in the paranasal and labial regions

27. Recommendations
Orthodontist:
1. Do not attempt to correct the transverse discrepancy with
orthodontic mechanics.
2. Attempt to normalize posterior dental axial inclination - eliminate
curve of Wilson as much as possible prior to surgery
3. Ensure that roots are parallel, if not divergent, with open contacts
of at least 1.0mm if a segmental osteotomy is to be made off the
midline

28. Recommendations
Surgeon:
1. Overcorrect transverse expansion anticipating significant relapse
2. Provide a rigid dental fixation of posterior segments with a system
that allows the patient to maintain hygiene
3. Minimize the number of maxillary segments

29. Clinical Case
• Patient Name: OM
• Initial records at age 14-0
Problem list:
• Class III malocclusion
• Bilateral maxillary constriction
• Anterior vertical facial excess
• Open bite

30. Initial records (Cont’d)

31. Pre-Surgical
Records
at age 16-6
Note maintenance of the
vertical step maxillary occlusal
plane in preparation for
orthognathics

32. Pre-Surgical records (Cont’d)

33. Final records
at age 17-2
Surgery consisted of a three
piece maxillary LeFort
osteotomy with mandibular
osteotomy and genioplasty

34. Final records
at age 17-2

35. Mandibular midline osteotomy
• The use of a mandibular midline osteotomy in conjunction with
bilateral sagittal osteotomy, although a good option, is unfortunately
not routinely considered, the reason for this is unclear and probably
based on misperceptions
• It has been found to be a safe, very stable, minimally invasive surgical
option with virtually no adverse aesthetic impact
• Since it can be used to narrow second molar width up to 10 mm, it
easily fits into the treatment objectives of the many patients with
transverse discrepancies of 6.0mm or less

36. Mandibular midline osteotomy
• Long-term dental relapse has been shown to be less than
comparable width changes using either SARPE or segmental LeFort I
maxillary osteotomies.
• There are no periodontal or temporomandibular joint
contraindications to this procedure

37. Considerations:
1. Consider procedure when there is no other reason for a maxillary
osteotomy to be performed other than to increase transverse
dimension
2. Consider when constriction is needed primarily at the molar
region with no significant width change required between the
mandibular canines

38. Technique
• Always done in conjunction with BSSO
• A midline cut is made after the sagittal splits are
completed, and the mandible is placed into
intermaxillary fixation using an occlusal splint
• A sagittal saw is used to make a bicortical cut from the inferior
border of the mandible to a point midway between the apices of
the central incisors.

39. Technique
• The cut is then continued only through the buccal cortex up to the
attached gingiva
• A fine osteotome is twisted in the cut to achieve final splitting of the
mandible
• The two mandibular body segments are then fully seated into the
surgical splint, and the intermaxillary fixation is tightened.

40. Recommendations:
Orthodontist:
1. Plan to constrict mandibular archwire immediately prior to
surgery the amount of the anticipated surgical constriction
2. Ensure the roots are parallel between the mandibular central
incisors
3. Do not section the mandibular archwire

41. Recommendations:
Surgeon:
1. Over constrict the mandible by at least 2.0 mm.
2. Do not section the mandibular archwire.

42. Clinical Case
• Patient Name: MB
• Initial records at age 37-0
Problem List:
• Class II malocclusion
• Open bite
• Centric mandibular shift

43. Innitial Records (37-0) Presurgical (38-2)

44. Final records at age 38-9
After mandibular
osteotomies for advancement
and rotation with mandibular
constriction, and avoiding
any alteration of midface
esthetics

45. Initial (37-0) Final (38-9)
These photographs are reflecting maintenance of paranasal soft tissue
characteristics by avoiding the potential detrimental impact
associated with a LeFort I procedure

46. References:
1. Melsen B. Palatal growth studied on human autopsy material. A histologic micro radiographic study.
Am J Orthod. 1975;68(1):42–54
2. Thilander B, Persson M. Palatal suture closure in man from 15 to 35 years of age. Am J Orthod.
1977;72(1):42–52.
3. Seif-Eldin NF, Elkordy SA, Fayed MS, Elbeialy AR, Eid FH. Transverse skeletal effects of rapid
maxillary expansion in pre and post pubertal subjects: a systematic review. Open Access Maced J
Med Sci. 2019;7(3):467–477.
4. Bailey LJ, White RP, Proffit WR, Turvey TA. Segmental LeFort I osteotomy for management of
transverse maxillary deficiency. J Oral Maxillofac Surg. 1997;55(7):728– 731
5. Lines PA. Adult rapid maxillary expansion with corticotomy. Am J Orthod. 1975;67(1):44–56.
6. Suri L, Taneja P. Surgically assisted rapid palatal expansion: a literature review. Am J Orthod
Dentofac Orthop. 2008;133 (2):290–302.
7. Zandi M, Miresmaeili A, Heidari A, Lamei A. The necessity of pterygomaxillary disjunction in
surgically assisted rapid maxillary expansion: a short-term, double-blind, historical controlled
clinical trial. J Cranio-Maxillofacial Surg. 2016;44(9):1181–1186.

47. References:
8. Racey G. Surgically assisted rapid palatal expansion: an outpatient technique with long-term
stability. J Oral Maxillofac Surg. 1992;50(2):114–115
9. Bays RA, Greco JM. Surgically assisted rapid palatal expansion: an outpatient technique with long-
term stability. J Oral Maxillofac Surg. 1992;50(2):110–113
10. Koudstaal MJ, Wolvius EB, Schulten AJM, Hop WCJ, van der Wal KGH. Stability, tipping and relapse
of boneborne versus tooth-borne surgically assisted rapid maxillary expansion; a prospective
randomized patient trial. Int J Oral Maxillofac Surg. 2009;38(4):308–315
11. Verstraaten J, Kuijpers-Jagtman AM, Mommaerts MY, Berge SJ, Nada RM, Schols JGJH. A systematic
review of the effects of bone-borne surgical assisted rapid maxillary expansion. J Cranio-Maxillo-
Facial Surg. 2010;38(3):166–174
12. Blæhr TL, Mommaerts MY, Kjellerup AD, Starch-Jensen T. Surgically assisted rapid maxillary
expansion with boneborne versus tooth-borne distraction appliances—a systematic review. Int J Oral
Maxillofac Surg. 2019;48(4):492–501
13. Kr€usi M, Eliades T, Papageorgiou SN. Are there benefits from using bone-borne maxillary expansion
instead of tooth-borne maxillary expansion? a systematic review with meta-analysis. Prog Orthod.
2019;20(1).

48. Thank you

49. SARPE
(Extent of surgery) (AJO-DO, 2008;133:290-302)
• Timms and Vero (1981) suggested that there are 3 stages of surgical
assistance for maxillary expansion based on the patient’s age.
• Stage 1 (median osteotomy) is performed for patients aged 25 years or
older, or younger if rapid maxillary expansion was tried and failed
• Stage 2 (median and lateral osteotomies) is reserved for those aged 30
years and older
• Stage 3 (median, lateral maxillary and anterior maxillary osteotomies)
is for patients aged 40 years and older.

50. SARPE
(Extent of surgery) (AJO-DO, 2008;133:290-302)
• From the review of the literature, it is apparent that there is no
consensus about either the extent or the procedure for SARPE
• The extent of surgery ideally should depend on the areas of
resistance with some individualization

51. Expansion Rate (AJO-DO, 2008;133:290-302)
• Cureton and Cuenin(1999) suggested that the expansion schedule
Should be tailored for every patient, depending on the symmetry
of the bony fracture and the health of the gingival
attachment(maxillary midline interdental papilla and the
adjoining gingiva)
• Expansion performed too rapidly can lead to mal-union or
nonunion of the segmentalized maxilla; if the activation is too
slow, premature consolidation will occur before achievement of
the desired expansion.
• Fixed appliances like the Haas, the hyrax, and the bonded palatal
expander are recommended for use with SARPE

52. Complications with
SARPE
(AJO-DO, 2008;133:290-302)
• Significant hemorrhage
• gingival recession
• Root resorption
• injury to the branches of the
maxillary nerve
• Infection
• Pain
• devitalization of teeth and altered
pulpal blood flow
• Palatal tissue irritation
• periodontal breakdown
• Sinus infection,
• alar base flaring
• extrusion of teeth attached to the
appliance
• Unilateral expansion
• loosening (more common with bone-
borne expanders and breakage and
stripping or locking of the appliance
screw

53. Complications With SARPE (AJO-DO, 2008;133:290-302)
• Occasionally, aberrant fractures of the maxillary articulation are
Seen. These are especially common when areas of resistance
remain.
• Some unusual complications that have been reported include
orbital compartment syndrome resulting in permanent blindness,
bilateral lingual anesthesia, and a nasopalatine canal cyst