International Journal of Surgery Case Reports 90 (2022) 106687

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International Journal of Surgery Case Reports

journal homepage: www.elsevier.com/locate/ijscr

Case report

Surgically assisted rapid palatal expansion for transverse maxillary

discrepancy in adults - Case report
Kanistika Jha a, Manoj Adhikari b, *
a
Department of Orthodontics, College of Medical Sciences, Chitwan, Bharatpur, Nepal
b
Department of Oral and Maxillofacial Surgery, Nepalese Army Institute of Health Sciences, College of Medicine, Sanobharyang, Kathmandu, Nepal

A R T I C L E I N F O A B S T R A C T

Keywords: Introduction and importance: Transverse maxillary deficiency is one of the most detrimental problems to midfacial
Case report growth and the integrated dentoalveolar structures. Early diagnosis and proper treatment of such cases is most
SARPE important to maintain the balance between the basal bones and stable occlusion.
SARME
Case presentation: In our case, a 17-year-old male had irregular upper front teeth with an unpleasant smile. Detail
Distraction of maxilla
examination revealed a symmetrical face with an orthognathic profile, mild malar deficiency, competent lips,
Constricted maxilla
Midpalatal split asymmetrical arches, Class I molar and canine relationships bilaterally. Crowding was present in the upper
anterior arch with 2 mm of anterior open bite and posterior cross bite present in the premolar region and molar
region bilaterally. Lefort-1 osteotomy, midpalatal split, pterygomandibular disjunction without down fracture
was done. The HYRAX appliance was cemented. Distraction started after four days of surgery. One mm
distraction per day was done for 10 days. The patient was transferred to fixed orthodontic treatment to relive the
anterior crowding. Records were taken after 1 year of follow up and analyzed. Skeletal relationships were in
harmony. Dental crowding, anterior open bite and posterior crossbite were corrected.
Clinical discussion: The zygomatic buttress and the pterygomaxillary junction are considered as the critical areas
of resistance for maxillary expansion. Literature claims lefort-1 osteotomy in combination with palatal distrac­
tion results in more displacement and less stress in the maxilla.
Conclusion: SARPE has proved to be clinically effective and stable for the correction of transversely deficient
maxilla after cessation of growth in adult patients.

1. Introduction transverse maxillary deficiency. In mild to moderate adult cases,

(discrepancy less than 5 mm) this can be treated by slow maxillary
Transverse maxillary deficiency is one of the most detrimental expansion. However, maxillary transverse dysplasia of greater than 5
problems to mid facial growth and the integrated dentoalveolar struc­ mm needs to be treated using various osteotomies protocols for true
tures [1]. Early diagnosis and proper treatment of such cases is most skeletal expansion [3]. Lefort-1 osteotomy to free the maxilla from all
important to maintain the balance between the basal bones and stable the cranial bones to gain a true increase in maxillary width or partial
occlusion. The management of maxillary transverse deficiency depends osteotomy with attachment of expanders (SARPE) to reduce resistance
upon the severity and age/sex factors. According to literature, opening for rapid expanders can be treatment options in adult cases.
of the mid palatal suture during growth spurt can be achieved with rapid Most of the cases of skeletal Class III malocclusion require three-
palatal expansion [2], while in adult cases, palatal resistance to piece maxilla for correction of all anteroposterior, vertical and trans­
expansion increases, leading to dentoalveolar expansion, buccal tipping verse discrepancy. But this case is specific as being skeletal Class III due
of dentition, posterior extrusion, lateral compression of the periodontal to retrognathic maxilla with transverse discrepancy, the profile is
membrane, buccal root resorption, palatal tissue necrosis, and fenes­ orthognathic, soft tissue is in harmony with skeletal bases. From
tration in the buccal cortex instead of an increase in basal width of the investigation and diagnosis, we concluded that space is required to align
maxilla. the crowding along with correction of transverse discrepancy with no
Slow and rapid maxillary expansion is modalities for correction of change in facial profile. Therefore, only SARPE was considered in this

* Corresponding author.
E-mail address: adhikarimanoj2007@gmail.com (M. Adhikari).

https://doi.org/10.1016/j.ijscr.2021.106687
Received 1 November 2021; Received in revised form 6 December 2021; Accepted 14 December 2021
Available online 21 December 2021
2210-2612/© 2021 The Author(s). Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd. This is an open access article under the CC BY license
(http://creativecommons.org/licenses/by/4.0/).
K. Jha and M. Adhikari International Journal of Surgery Case Reports 90 (2022) 106687

case instead of three-piece maxilla. This case was managed at Nepalese

Army Institute of Health Sciences, college of Medicine, tertiary center,
Kathmandu, Nepal. This case of SARPE is presented here according to
SCARE 2020 guidelines [4].

2. Presentation of case

A 17-year-old male reported to the dental department with com­

plaints of irregularly placed upper front teeth and an unpleasant smile
without any significant medical or dental history. There was no any
relevant drug history, family history, psychosocial history or any rele­
vant genetic information. Pretreatment records were taken and
analyzed. Extra-oral examinations revealed a symmetrical face with an
orthognathic profile, mild malar deficiency with competent lips.
Intraoral examination revealed asymmetrical arches with Class I molar
and canine relationships bilaterally. Crowding is present in the upper
anterior arch with 2 mm of anterior open bite and posterior cross bite
present in the premolar and molar region bilaterally (Figs. 1 and 2). Fig. 2. Pre-treatment intraoral maxillary occlusal photographs.
Lateral cephalogram analysis confirmed Class III skeletal base rela­
tionship (ANB: − 3.0◦ , Wits appraisal: − 3.2 mm, SNA: 76.7◦ , SNB: 79.3◦ ) 5. Surgery
with a vertical growth pattern (SN-MP: 38.2◦ FMA-30◦ , Jarabak ratio -
61.26%). The inclination of the maxillary and mandibular incisors were The patient was operated under general anesthesia. Orthognathic
within normal range (U1-SN: 112.3◦ , U1-NA: 30◦ , IMPA: 96◦ ). The pa­ surgery was done by consultant Oral and Maxillofacial surgeon, Dr.
tient had an average nasolabial angle (96.3◦ ), and his lower lip was Manoj Adhikari. The incision site was marked in the maxillary vestibule,
protrusive relative to the E line (+1 mm). 6 mm above the mucogingival junction, extending from maxillary left
Posteroanterior cephalogram (PA) analysis revealed symmetrical 1st molar tooth to right 1st molar. 2% lignocaine with adrenaline (1:2
facial skeleton with constricted maxillary arch (J-J′ : 58 mm, it should be lakh dilution) was injected at incision site. The incision was given,
68 mm at 16 years of age). The maxilla-mandibular differential index mucoperiosteal flap was raised. An osteotomy cut was given using pie­
was 72.5% (Normal 80%) suggestive of maxillary constriction. zotome extending from inferolateral margin of anterior nasal aperture to
The dental cast analysis showed discrepancy of 12 mm with an inter- posterolateral area of maxilla bilaterally. Lateral nasal osteotomy was
canine width of 33 mm, an inter-premolar width of 36 mm and an inter- done using lateral nasal osteotome. Septal osteotomy was done using
molar width of 47 mm in the maxillary arch. nasal septal osteotome. Pterygomaxillary disjunction was done with a
curved chisel and mallet bilaterally. Down fracture was not done. Palatal
3. Treatment objectives osteotomy was done with piezotome, starting anteriorly between two
central incisors (Fig. 3). Prefabricated Hyrax was cemented and few
Based on chief complain and diagnostic records the following turns were given to confirm completeness of palatal osteotomy. After
treatment objectives were derived. 1. To expand the maxillary base. 2. confirmation turn was reversed. Flap closure was done using standard
To achieve alignment and leveling 3. To achieve normal inclination and technique. Surgery was completed without any complications. All the
placement of upper and lower anterior. 4. To maintain normal overjet post-surgical instructions were given and analgesics along with antibi­
and overbite. 5. To maintain the facial profile. otics were prescribed to the patient.

4. Treatment planning 6. Treatment progress

Ideal treatment planning was orthognathic surgery involving Phase I After 4 days of surgery, expansion was started with 2 turns/day (1
(surgery)-Patient treated with SARPE (Surgically Assisted Rapid Palatal mm opening per day). Expansion continued for 10 days and a total of 8
Expansion). Phase II –alignment and leveling. mm of expansion was achieved. A midline diastema of 8 mm appeared
The patient was scheduled for SARPE. The bonded HYRAX appliance and expansion was stopped. Records were taken to evaluate the mid­
was constructed. A day before surgery, an appliance trial was conducted. palatal opening and required expansion achieved. The expansion
The appliance was checked for proper fitness and any discomfort. appliance with a rigid framework was maintained in its place for one

Fig. 3. Intraoperative photograph showing surgical cuts at lefort-1 level and

Fig. 1. Pre-treatment intraoral frontal view of occlusion. mid-palatal split.

2
K. Jha and M. Adhikari International Journal of Surgery Case Reports 90 (2022) 106687

year. After six months, the patient was transferred to fixed orthodontic
treatment to relive the anterior crowding. Upper full arch bonding was
done and sequential wire was progressed to align the upper/lower
arches. Slowly, the midline diastema started to close. Occlusion settling
was achieved. Orthodontic treatment was done by consultant Ortho­
dontics, Dr. Kanistika Jha. Records were taken again after one year of
follow up and analyzed.

7. Treatment results

The treatment outcome was satisfactory. Skeletal relationships were

in harmony. Dental crowding, anterior open bite and posterior crossbite
were corrected (Figs. 4 and 5). Preoperative and Postoperative frontal Fig. 5. Post-treatment intraoral frontal view of occlusion.
view of face is shown in Figure Supplementary Figure 6 and
Figure Supplementary Figure 7 respectively. No periodontal complica­ control as compared to banded HYRAX [9]. The distraction started 4
tions like gingival recession or bony dehiscence were observed after days after surgery once the callus bone was formed and the rate of
treatment. Post expansion study model analysis and posteroanterior expansion was 2 turns per day (1 mm per day). The literature is unclear
cephalometry evaluation were done. Model analysis reveals net expan­ about the activation schedule, so the rate of distraction osteogenesis has
sion of 4 mm in canine region, 5 mm in first premolar region and 6 mm been recommended in this study.
in first molar region (Table 1). Cephalogram reveals maxillary skeletal The total amount of expansion in first molar region was 6 mm one
base width increases by 5 mm (Table 2). year after retention, which corresponds with previous findings (Berger
et al [10]). A total relapse of about 4% was measured one year post
8. Discussion retention period. Inter-canine and inter-premolar expansion were 4 mm
and 5 mm in one year post retention. Less relapse in this study was
The aim of this study was to manage adult cases of transverse because the same HYRAX with a rigid framework was used till one year
maxillary dysplasia surgically with maxillary osteotomies procedures. post retention. On PA cephalometric evaluation, skeletal maxillary
Though we have different approaches to manage transverse dysplasia, expansion was 5 mm (J′ -J′ ), which is coincident with Berger et al. [10]
ossified maxillary sutures and periodontal complications are the great
hindrance. To avoid the complications SARPE was considered as treat­ 9. Conclusion
ment plan [5]. The case was started with orthognathic surgery followed
by orthodontic treatment, i.e., two-step procedures rather than the Over recent years, SARPE has proved to be clinically effective and
conventional three-step surgical orthodontic approach, including pre­ stable for the correction of transversely deficient maxilla. Surgery first
surgical orthodontic, orthognathic surgery, and postoperative ortho­ approach with only two stage treatment, instead of traditional three
dontic was done. The long duration of treatment and negative stage treatment, can be done for SARPE. While making the treatment
compliance of the patient in the three-step technique were taken into plan, soft tissue must be taken into consideration along with underlying
consideration. bone.
The zygomatic buttress and the pterygo-maxillary junction are
considered as the critical areas of resistance for maxillary expansion. Patient perspective
Therefore, subtotal lefort-1 osteotomy, paramedian split, along with
palatal distraction, is a widely used surgical technique [6]. Literature The patient was very happy and grateful to the operating team. His
claims lefort-1 osteotomy in combination with palatal distraction results appearance was completely changed, treatment duration was also short
in more displacement and less stress in the maxilla [7]. During surgery, and did not have any complications.
an osteotomy cut is given along all the lateral support of the maxilla
followed by a mid-palatal split. For palatal distraction, the tooth-borne
Source of funding
appliance HYRAX was used. Recent randomized controlled trial (RCT)
has shown comparable effects of both tooth-borne and bone borne dis­
This research did not receive any specific grant from funding
tractors [8]. Bonded HYRAX has shown beneficiary effects over vertical
agencies in the public, commercial, or not-for-profit sectors.

Ethical approval

It is our routine standard surgical procedure so ethical clearance was

not required.

Consent

Written informed consent was obtained from the patient for publi­
cation of this case report and accompanying images. A copy of the
written consent is available for review by the Editor-in-Chief of this
journal on request.

Author contribution

Dr. Kanistika Jha: First Author.

Fig. 4. Post-treatment intraoral maxillary occlusal photograph with brackets Contributions: study concept or design, data collection, data analysis
and retainer in situ. or interpretation, writing the paper, orthodontic treatment etc.

3
K. Jha and M. Adhikari International Journal of Surgery Case Reports 90 (2022) 106687

Table 1
Mean interdental distance measured on models (mm).
variables Pre expansion (T1 in mm) Post expansion (T2 in mm) One year post expansion (T3 in mm) T3-T1 (difference from start of treatment in mm)

Canines (mm) 33 38 37 4
First premolars (mm) 36 42 41 5
First molars (mm) 47 55 53 6

publication of this paper.

Table 2
Posteroanterior cephalogram analysis.
Appendix A. Supplementary data
Variables Pre Post T2- One year T3-T1
expansion expansion T1 post (difference
Supplementary data to this article can be found online at https://doi.
(T1) (T2) expansion from start of
(T3) treatment org/10.1016/j.ijscr.2021.106687.
Maxillary 58 mm 64 mm 6 63 mm 5 mm
Width mm
References
-J′ -J′
(mm) [1] J.A. McNamaraa, Maxillary transverse deficiency, Am. J. Orthod. Dentofac.
Orthop. 117 (5) (2000) 567–570.
[2] R.A. Bell, A review of maxillary expansion in relation to rate of expansion and
patient's age, Am. J. Orthod. 81 (1) (1982) 32–37.
Dr. Manoj Adhikari: Corresponding Author and Co-Author. [3] L. Suri, P. Taneja, Surgically assisted rapid palatal expansion: a literature review,
Contributions: study concept or design, data collection, data analysis Am. J. Orthod. Dentofac. Orthop. 133 (2) (2008) 290–302.
or interpretation, writing the paper, surgical treatment etc. [4] R.A. Agha, T. Franchi, C. Sohrabi, G. Mathew, A. Kerwan, A. Thoma, A.J. Beamish,
A. Noureldin, A. Rao, B. Vasudevan, B. Challacombe, The SCARE 2020 guideline:
updating consensus surgical CAse REport (SCARE) guidelines, Int. J. Surg. 84
Research registration (2020) 226–230.
[5] Dena Sawchuk, et al., Diagnostic methods for assessing maxillary skeletal and
dental transverse deficiencies: a systematic review, Korean J. Orthod. 46 (5) (2016)
This case report does not include any ‘first in man’ studies, so, 331–342.
registration was not required. [6] A. Anttila, K. Finne, K. Keski-Nisula, M. Somppi, K. Panula, T. Peltomäki,
Feasibility and long-term stability of surgically assisted rapid maxillary expansion
with lateral osteotomy, Eur. J. Orthod. 26 (4) (2004) 391–395.
Guarantor [7] D.S. de Assis, T.A. Xavier, P.Y. Noritomi, E.S. Gonçales, Finite element analysis of
bone stress after SARPE, J. Oral Maxillofac. Surg. 72 (1) (2014) 167, 1-7.
Dr. Manoj Adhikari, Consultant Oral and Maxillofacial Surgeon, [8] M. Zandi, A. Miresmaeili, A. Heidari, Short-term skeletal and dental changes
following bone-borne versus tooth-borne surgically assisted rapid maxillary
Nepalese Army Institute of Health Sciences, College of Medicine, Kath­
expansion: a randomized clinical trial study, J. Craniomaxillofac. Surg. 42 (7)
mandu, Nepal. (2014) 1190–1195.
[9] S. Asanza, G.J. Cisneros, L.G. Nieberg, Comparison of hyrax and bonded expansion
Provenance and peer review appliances, Angle Orthod. 67 (1) (1997) 15–22.
[10] J.L. Berger, V. Pangrazio-Kulbersh, T. Borgula, R. Kaczynski, Stability of
orthopedic and surgically assisted rapid palatal expansion over time, Am. J.
Not commissioned, externally peer-reviewed. Orthod. Dentofac. Orthop. 114 (6) (1998) 638–645.

Declaration of competing interest

The authors declare that there is no conflict of interests regarding the