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 of when it is appropriate for these patients to be referred to an oral and maxillofacial surgeon for an adjunctive surgical procedure or whether traditional orthodontic mechanics should be attempted. The decision, therefore, by an orthodontist of when to refer a patient for surgery appears to be an individual one. The question then becomes which of the three basic surgical procedures would be most appropriate for the patient. Specifically, consideration must be given to surgically assisted rapid palatal expansion, segmental LeFort I osteotomy, or mandibular midline osteotomy with constriction.

1. Orthognathic surgical procedures on
non-growing patients with maxillary
transverse deficiency: An update
DR MAMOON MARWAT
PGR MDS ORTHODONTICS (PGY-III)
SARDAR BEGUM DENTAL HOSPITAL, GANDHARA UNIVERSITY

2. • Treatment of maxillary transverse deficiency in post-pubertal
patients has long been an area of disagreement among
orthodontists.
• Traditionally, orthodontists have relied on Melsen’s work on
autopsy specimen
• She 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

3. • Pierson and Thilander showed that the midpalatal suture can
remain patent until the mid-30 s.
• A recent systematic review of the literature on this topic could
not come to a definitive conclusion that skeletal age as a
criterion for the success, or failure, of conventional rapid
maxillary expansion in nongrowing- growing individuals
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.
Thilander B, Persson M. Palatal suture closure in man
from 15 to 35 years of age. Am J Orthod. 1977;72(1):42–

4. • Clearly, there are patients in whom most would agree that
surgery should be considered
Previous unsuccessful attempts at conventional orthopedic
expansion
Adult patients with significant bilateral or asymmetric
unilateral crossbites
and patients with other accompanying facial skeletal
discrepancies.
• The decision then becomes which of the three basic
surgical procedures would be best for the patient.

5.  Surgically assisted rapid palatal expansion
(SARPE or SARME)
• The use of an expander concomitant with maxillary osteotomies
is a technique first described by Lines in 1975.
• He described a surgical approach similar to one that is
commonly utilized at the present time

6. • Following a soft tissue incision from canine to the molar region.
• Horizontal bone cut is made from piriform rim to the pterygoid
plate.
• Accomplished bilaterally followed by a midpalatal incision made
from behind the nasopalatine papilla back to just before the end
of the hard palate.
• After elevating palatal tissue on either side of the suture a bone
cut is made angling the bur to either side of the septum.

7. • This cut is made from the posterior hard palate forward to just
behind the nasopalatine foramen.
• The primary difference between Lines’ technique and the
procedure that is commonly used is the
• Lines did not separate the maxillary tuberosity form Pterygoid plate
• He waited two or three weeks following surgery before intiating
expansion

8. • There are several variations of this basic technique with the
most controversial being the use of a vertical cut at the
pterygomaxillary suture.
• There is also the possibility of damaging blood vessels in that
region during vertical at the pterygomaxillary suture.

9. • A final major technique variation is the use of bone-borne
instead of tooth-borne expanders.
• Interestingly, the benefit of applying pressure directly to the
bone is not as clearly supported by literature as would be
expected

10. • The following have been reported in the literature as
indications for SARPE
 To increase maxillary arch perimeter, to correctposterior
crossbite, and when no additional surgical jaw movements are
planned.
 To widen the maxillary arch as a preliminary procedure, even
if further orthognathic surgery is planned.
 To provide space for a crowded maxillary dentition when
extractions are not indicated.
 To widen maxillary hypoplasia associated with clefts of the
palate.
 To reduce wide black buccal corridors when smiling.

11. • Complications usually associated with
• Root resorption,
• Injury to the branches of the maxillary nerve
• Infection, pain, devitalization of teeth and altered Pulpal blood flow
• Periodontal breakdown
• Alar base flaring
• Relapse and unilateral expansion.

12. • Postoperative relapse does occur, but it has been shown to be
similar in
amount when compared to conventional orthopedic expansion
in adolescents
• The evidence indicates that the clinician should anticipate a loss
of approximately one third (33%) of the transverse dental
expansion obtained with SARPE while the skeletal expansion
achieved is quite stable
Chamberland S, Proffit WR. Closer look at the stability
of surgically assisted rapid palatal expansion. J Oral
Maxillofac Surg. 2008;66(9):1895–1900. https://doi.
org/10.1016/j.joms.2008.04.020.

13. • The length of retention after expansion also varies but it is
recommended that fixed retention be maintained for at least
twelve weeks following surgery and preferably longer.
• Recently two variations of SARPE are have been suggested in
the treatment of obstructive sleep apnea:
• EASE
• DOME

14.  EASE
• SARPE may not achieve the surgical goal of expanding the
airway, especially in the posterior nasal aspect

17.  Distraction Osteogenesis Maxillary Expansion (DOME)
protocol

20. • Additional benefits of surgically assisted rapid palatal expansion
over maxillary segmental osteotomy need to be emphasized:
• Equal expansion can be achieved from the molar to canine regions
• Buccal incisions can be limited to about 1.5 cm thus minimizing the
potential negative labial and paranasal soft tissue aesthetic changes
that have been associated with maxillary LeFort I osteotomies.

24.  Maxillary lefort 1 segmental osteotomy
• The use of a segmental LeFort I osteotomy in treatment of
maxillary constriction is an old and traditional surgical procedure
• Ability to control the maxillary segments in all three planes of
space.
• The long-term maintenance of that transverse correction is of
concern with instability being the primary disadvantage of this
surgical procedure.

25. • There are two dilemmas facing the clinician when planning to
use a maxillary segmental osteotomy for the transverse
deficiency
• First is to determine the appropriate amount of overcorrection
and second is how to best hold the correction following surgery.

27. • The probability of both skeletal and dental relapse occurring is
increased if dental tipping occurs during the presurgical
orthodontic phase.
• Various methods of holding the transverse change, in addition
to over correction, have been recommended including
• Transpalatal arch
• Palatal splint
• Placementof an edgewise stabilizing archwire
• Placing an expanded headgear inner bow into buccal tubes.

28. • Complications are unusual with segmental maxillary
osteotomies, although, if they do occur can be more significant
than those associated with surgically assisted expansion.
• Infection
• Persistent oral fistula and damage to teeth

29.  Mandibular midline osteotomy
• Not routenly considered
• This osteotomy has been found to be a safe, very stable,
minimally invasive
• This procedure is considered insituations where transverse
correction is required and there is no additional maxillary
skeletal problem as well n cases with obvious mandibular
transverse excess.

30. • It can be used to narrow second molar width up to 10 mm.
• The only major difference in orthodontic preparation for the
surgery is that the mandibular archwire needs to be constricted
just prior to the surgery to maintain the anticipated constriction.
• Long-term dental relapse has been shown to be less than
comparable width changes using either surgically assisted rapid
palatal expansion or segmental LeFort I maxillary osteotomies.

31. Considerations and recommendations
for correcting
transverse maxillary deficiencies

32. Surgically assisted rapid palatal expansion:
Considerations
Used for adult patients who have
only maxillary transverse deficiency
and:
A. When arch length is needed
B. Canine width is narrow
C. Negative paranasal and upper
lip soft tissue effects need to be
avoided
D. If previous conservative
orthopedic palatal expansion
has failed
Recomendations
Start early in treatment, before any
orthodontictooth movement
attempted in the maxillary arch
A. Monitor expansion with the oral
and maxillofacial surgeon and
decide when expansion is
sufficient
B. Overcorrect similar to orthopedic
expansion in adolescents
C. Maintain with TPA or equivalent
for at least twelve weeks
D. Maintain expansion during active
treatment with expanded Mx
archform

33. LeFort I segmental osteotomy
Considerations
• Use when expansion is needed
along with correction of the
maxilla
• Limited usage in situations where
there is insufficient intercanine
width
• Use with care in situations where
the patient has soft tissue drape
Recomendations
• Do not attempt to correct the
transverse discrepancy with
orthodontic mechanics.
• Attempt to normalize posterior
dental axial inclination as
possible prior to surgery
• Overcorrect transverse
expansion anticipating
significant relapse.
• Provide a rigid dental fixation
• Minimize the number of
maxillary segments.

34.  Mandibular midline osteotomy in
conjunction with bilateral sagittal
osteotomy
Considerations
• Consider procedure when
there is no other reason for a
maxillary osteotomy to be
performedother than to
increase transverse
dimension
• Consider when constriction is
needed primarily at the molar
region with no significant
width change required
between the mandibular
canines
Recommendations:
• Plan to constrict mandibular
archwire immediately prior to
surgery the amount of the
anticipated surgical
constriction