ORIGINAL ARTICLE

Surgically assisted rapid maxillary expansion:

Cone-beam computed tomography evaluation
of different surgical techniques and their effects
on the maxillary dentoskeletal complex
Antonios Sygouros,a Melih Motro,b Faysal Ugurlu,c and Ahu Acard
Zakynthos, Greece, and Istanbul, Turkey

Introduction: The aims of this study were to evaluate and compare skeletal, dentoalveolar, dental, and peri-
odontal changes in surgically assisted rapid maxillary expansion (SARME) patients with and without pterygo-
maxillary disjunction. Methods: The records of 20 patients who underwent SARME in the clinics of the dental
school at Marmara University in Turkey were collected and divided into 2 groups of 10 patients each, according
to the surgical protocol followed. Cone-beam computed tomography images before the operation and 3 to
6 months after the end of active expansion were analyzed by 20 linear and 7 angular measurements. The
reliability of the 3-dimensional analysis was investigated. Results: All transversal measurements in the dentoal-
veolar and dental levels increased after expansion in both the SARME with pterygomaxillary disjunction and the
SARME without pterygomaxillary disjunction groups with no signicant differences between them. In the
SARME without pterygomaxillary disjunction group, more pronounced buccal alveolar bending and buccal
tipping of the posterior teeth were found, but the difference did not reach statistical signicance. SARME reduces
buccal alveolar width in the premolar region signicantly when pterygoid disjunction is not performed.
Conclusions: SARME with or without pterygomaxillary disjunction is an effective technique to treat maxillary
transverse deciency in adolescent and adult patients. Pterygomaxillary disjunction is advised in periodontally
compromised patients. Cone-beam computed tomography scanning is a reliable method for studying the
dentoskeletal effects of SARME. (Am J Orthod Dentofacial Orthop 2014;146:748-57)

T
ransverse maxillary deciency is a frequent compo-
nent of malocclusions. Rapid maxillary expansion
(RME) is a well-established method to correct this
problem as well as arch length discrepancies.1-3
Although this is the treatment of choice for growing
adolescents, for skeletally mature patients RME has
proved to have limited orthopedic effects on the
maxillary skeletal structures because of the increased
thickness of the bones, with reduced elasticity and
a
Private practice, Zakynthos, Greece.
b
Research assistant, Department of Orthodontics, Marmara University, Istanbul,
Turkey.
c
Associate professor, Department of Oral and Maxillofacial Surgery, Marmara
University, Istanbul, Turkey.
d
Professor, Department of Orthodontics, Marmara University, Istanbul, Turkey.
All authors have completed and submitted the ICMJE Form for Disclosure of
Potential Conicts of Interest, and none were reported.
Address correspondence to: Antonios Sygouros, Al. Roma 56, Zakynthos, Greece;
e-mail, antonysig@gmail.com.
Submitted, March 2014; revised and accepted, August 2014.
0889-5406/$36.00
Copyright 2014 by the American Association of Orthodontists.
http://dx.doi.org/10.1016/j.ajodo.2014.08.013
748
obliteration of the maxillary sutures that accompany
maturation. Surgically assisted RME (SARME) has been
used in recent years to overcome these obstacles and
offers a true orthopedic result without unwanted effects
such as lateral tipping of the posterior teeth, buccal
fenestrations, failure to open the midpalatal suture,
alveolar bending, extrusion of posterior teeth, pain,
instability, and root resorption.4,5
Although SARME was introduced in 1938 and has
been well established, there is no current consensus for
the surgical technique to be followed.6 Different osteot-
omies and combinations of them have been described in
the literature, and only general guidelines exist. Ideally,
the patient's age, treatment needs, and the stresses
generated in each area of the maxilla during the applica-
tion of orthodontic forces should dictate the osteotomy
lines.4,7,8 Recognized areas of stresses that impede the
unrestricted opening of the maxilla are the piriform
aperture pillars (anteriorly), the zygomatic buttress
(laterally), the pterygoid junction (posteriorly), and the
midpalatal suture (medially).9 More specically, the
Sygouros et al
need for dissecting the pterygoid plates and the effects
of such procedures on the treatment outcome still
need to be elucidated, especially if we consider the
increased risk of an osteotomy in the pterygoid plate
area.
The need for releasing the maxilla from the posterior
stresses of the pterygoid plates has been advocated,5
whereas other authors have shared the more conserva-
tive approach that removing the resistance from the
zygomatic buttress is sufcient for true orthopedic
expansion.10-13 Koudstaal et al14 stated that SARME
without pterygoid separation results in a different
pattern of expansion. They believed that the ratio of
anterior to posterior expansion is higher in patients
with no pterygoid separation than in SARME patients
who underwent pterygoid osteotomy, and this might
be considered as an individualized treatment to achieve
more distraction on either the posterior or the anterior
level.
A review of the literature about SARME shows that
the authors of most studies evaluated the efciency
and efcacy of the technique using plaster models of
the patient's dentition,14 posteroanterior cephalograms,
or computed tomography.15-18 Only recently, cone-
beam computed tomography (CBCT) studies on the
subject of SARME have started appearing, and this is
the rst CBCT study to investigate the effect of pterygoid
disjunction on the treatment outcome.19,20
The aims of this study were to compare and evaluate
the immediate dentoskeletal effects of 2 distinct surgical
techniques used for SARME. The difference between
these techniques consists of whether the release of the
pterygoid junction was performed.
MATERIAL AND METHODS
This was a retrospective study approved by the ethical
committee of the Institute of Health Sciences of Marmara
University in Istanbul, Turkey. Between June 2011 and
July 2012, 26 patients underwent SARME in the Depart-
ment of Orthodontics. Of the 26 patients, 3 with cranio-
facial anomalies, including cleft patients, were excluded
from this study, as were 3 patients with missing diag-
nostic records at the desired time points. CBCT records
of 20 patients (4 male, 16 female; mean age, 18.8 years)
were retrieved from the department's archives. All sub-
jects were white from the same geographic area. CBCT
images were obtained immediately before the surgical
procedure and 3 to 6 months after completion of the
active expansion according to the standardized protocol
for all patients undergoing SARME at Marmara Univer-
sity. In all patients, expansion was performed with the
same intraoral appliance, a bonded acrylic hyrax-type
American Journal of Orthodontics and Dentofacial Orthopedics
749
Table I. Skeletal measurements
Measurement Denition
J distance The distance between jugale points of the left and
right sides. Jugale point for a specic side is
dened on the coronal slice passing through the
molar furcation point of that side, as the
intersection between the arch of the zygomatic
process and the horizontal line passing through
the oor of the nose (Fig 1).
Pir L-R The diameter of the piriform aperture. Distance
between left and right piriform rims (the most
latero-inferior points were traced on the 3D
reconstructed image).
lpp L-R The distance between anterior points of the left and
right lateral pterygoid plates. Pterygoid plates
were traced on the axial slice at the level that the
palatal foramens could be best seen; lateral and
medial plates were traced by 2 points each,
anterior and posteriorposteriorly at the most
posterior aspect of the plate and anteriorly at the
most concave point on the pterygomaxillary
ssure line for the lateral plates and on the
pterygomaxillary ssure line for the medial plates
(Fig 2, A).
lpp angle The angle between the left and right lateral
pterygoid plates (Fig 2, B).
mpp angle The angle between the left and right medial
pterygoid plates.
expander, covering all posterior teeth, without previous
orthodontic treatment.
According to the surgical protocol that was under-
taken, the patients were divided into 2 groups: SARME
with pterygoid disjunction (SARME 1PD) and SARME
without pterygoid disjunction (SARME
PD).
In the SARME
PD group (10 patients; mean age,
19.2 years), the surgical technique involved the bilateral
LeFort I type of osteotomy plus midline osteotomy. In
the SARME 1PD (10 patients; mean age, 18.4 years),
the same protocol was followed with pterygoid disjunc-
tion performed additionally. The lateral LeFort I cuts
extended from the piriform rims anteriorly through the
zygomatic buttress to the tuberosity area posteriorly, 4
to 5 mm above the apices of the maxillary teeth, and
were carried out with a reciprocating saw. The midline
osteotomy was performed with a spatula type of chisel
placed between the anterior nasal spine and the apices
of the central incisors. Separation of the pterygoid plates
was done with an angulated osteotome. Intraoperatively
the hyrax screw was activated 8 times (2 mm) just before
the midline osteotomy. After a latency period of 3 days,
the patients started activating the expander twice daily
(0.5 mm) until adequate expansion was achieved.
All 3-dimensional (3D) scans in DICOM format were
reoriented and resliced based on the Frankfort horizontal
December 2014  Vol 146  Issue 6
750 Sygouros et al

Fig 1. Lines representing the 3 levels under investigation at the rst molar level sagittally. The upper
line indicates the skeletal effects (J distance), the middle line indicates the dentoalveolar effects
(M1F L-R), and the lower line represents dental expansion (M1 bc L-R). The lines are drawn for explan-
atory reasons and do not necessarily appear on the same coronal slice.

(FH) with a standardized procedure using MIMICS soft-
ware (version 14.0; Materialise, Leuven, Belgium).
Our 3D analysis included measurements on the skel-
etal level (including measurements describing the effects
of the techniques on the pterygoid plate anatomy), on
the dentoalveolar level, on the dental level, and peri-
odontal measurements.
For the skeletal measurements (Table I) at the anterior
part of the maxilla, the diameter of the piriform aper-
turethe distance between the left and right piriform
rimswas measured. Medially, the distance between
jugale points bilaterally (Fig 1); posteriorly, the distance
between the lateral pterygoid plates bilaterally (Fig 2,
A); and the angles between the left and right lateral pter-
ygoid plates (Fig 2, B) and between the medial pterygoid
plates were measured.
For the dentoalveolar measurements (Table II), the
major part of this analysis was based on a plane
dening the dentoalveolar level of the maxilla. This
plane was dened by the trifurcation points of the 2
rst molars separately for each side and is parallel to
the FH plane. After dening the rst molar's root
trifurcation point on the same 2-dimensional axial
slice, the centers of the roots of the rst premolar
and the canine were identied also, and this was
repeated for the contralateral side. Linear distances be-
tween the contralateral points were measured (Fig 3).
Switching to the coronal view, tangents on the alveolar
crests were dened bilaterally on the palatal side at the
molar level sagitally, and the angle between them and
the FH was calculated describing the angulation of the
alveolar crests.
For the dental measurements (Table III), the distances
between the buccal cusps of contralateral teeth were
measured. The angulation of each tooth's axis and the
FH was calculated to evaluate dental tipping. Also, the
vertical effects of the technique were described.
For the periodontal measurements (Table IV), the
periodontal effects of the technique were evaluated by
measuring the width of the buccal alveolar bone
covering the posterior teeth and the canines on the pre-
viously dened dentoalveolar level (Fig 3, A), as well as
the height of the alveolar crest (Fig 3, B).
In addition to the 3D cephalometric analysis, to bet-
ter visualize the dental and skeletal effects of SARME,
the preexpansion and postretention 3D reconstructed
scans were superimposed according to the best t of
the cranial base, and color mapping of the affected areas
was created by the 3-Matic module of the MIMICS
software (Fig 4).
Statistical analysis
Statistical analysis was performed using the Statisti-
cal Package for the Social Sciences (version 15.0.1; SPSS,
Chicago, Ill). The Student t test was used for the inter-
group comparisons of parameters with normal distribu-
tions, and the Mann-Whitney U test was used for the
intergroup comparisons of parameters without normal
distributions. The paired samples t test was used for
the in-group comparisons of parameters with normal
distributions. In the analysis of reliability regarding
parameter measurements, the intraclass correlation
coefcient was calculated. All measurements were

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Sygouros et al 751

Fig 2. A, Tracing of the medial and lateral pterygoid plates on the axial slice; the yellow line depicts the
transverse distance between the lateral pterygoid plates and is used for measuring posterior skeletal
expansion (lpp L-R). B, Angle between the lateral pterygoid plates (lpp angle).

calculated twice by the same investigator (A.S.) in a
2-week interval (P \0.05).
RESULTS
On the skeletal level (Table V), true anterior skeletal
expansion was evident in both groups with no statisti-
cally signicant differences between them. No expan-
sion can be reported for the posterior aspect of the
maxilla on the skeletal level (lpp L-R difference,
0.93 6 1.68/0.75 6 1.19 mm). In the middle area of
the maxilla, however, in the SARME
PD group,
constriction was seen between the jugale points. The
skeletal measurements between the 2 groups did not
differ signicantly.
On the dentoalveolar level (Table VI), signicant
expansion was achieved between the contralateral teeth
(P \0.01) in both groups. No signicant differences can
be reported between the 2 groups. The decrease seen in
the or-alv L,R angle postoperatively compared with the
preoperative values indicated buccal tipping of the alve-
olar crest. More pronounced tipping was reported in the
SARME
PD group (
5.45 6 4.25 ) than in the
SARME 1PD group (
7.34 6 5.81 ); however, the dif-
ference did not reach statistical signicance.
On the dental level (Table VII), all distances between
cusps of the contralateral teeth increased signicantly in
both groups with no difference between the groups.
SARME resulted in buccal tipping of all posterior teeth
but not of the canines. Moreover, the distance between
the molar furcation point and the FH decreased signi-
cantly in both groups.
On the periodontal level (Table VIII), the width of
buccal alveolar bone decreased for all posterior teeth
in both groups. This decrease was not statistically signif-
icant for the canines in the SARME
PD group. There

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752 Sygouros et al

Table II. Dentoalveolar measurements

Measurement Denition
CF L-R Distance between the canine furcation points bilaterally (Fig 3, A).
P1F L-R Distance between the rst premolar furcation points bilaterally (Fig 3, A).
P2F L-R Distance between the second premolar furcation points bilaterally (Fig 3, A).
M1F L-R Distance between the rst molar furcation points bilaterally (Fig 3, A).
Or-alv L,R Angulation of the alveolar crests. On each side and at the coronal slice of the molar furcation point, a line tangent to the
alveolar crest is dened. This measurement represents the angle between this line and the line passing through the
Or points (the outer angle).

Fig 3. A, Axial slice at the dentoalveolar level. Distances between the red dots indicate transverse den-
toalveolar widths (CF L-R, P1F L-R, P2F L-R, M1F L-R); green lines indicate buccal alveolar widths
(BAC to CF, P1F, P2F, M1F). B, Distance between buccal alveolar edge and buccal cusps (cusp to
BAE M1) used to evaluate the height of the alveolar crest.

was more loss of buccal alveolar bone in the premolar
area of the SARME
PD group than in the
SARME 1PD group. The results show that the height
of the alveolar crest was reduced more in the SARME

PD group in the premolar area, but the intergroup dif-
ference did not reach statistical signicance (P .0.05).
The results of the analysis of the intraclass correlation
coefcient regarding the reliability of the measurements
showed that skeletal, dentoalveolar, dental, and peri-
odontal measurements could be repeated with an insignif-
icant error not affecting the results, indicating CBCT as a
reliable way to evaluate maxillary dentoskeletal changes.

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Sygouros et al 753

Table III. Dental measurements

Measurement Denition
C c L-R Intercanine width. Distance between the left and right canine cusps.
P1 bc L-R Interpremolar width for rst premolars. Distance between the buccal cusps of the left and right rst premolars.
P2 bc L-R Interpremolar width for second premolars. Distance between the buccal cusps of the left and right second premolars.
M1 bc L-R Intermolar width. Distance between the mesiobuccal cusps of the left and right rst molars.
Or-C Canine angulation. Angle between the Or line and the canine axis as dened by the cusp and root apex.
Or-P1 First premolar angulation. Angle between the Or line and the rst premolar axis as dened by the buccal cusp and the buccal
root apex.
Or-P2 Second premolar angulation. Angle between the Or line and the second premolar axis as dened by the buccal cusp and
the buccal root apex.
Or-M1 Molar angulation. Angle between the Or line and the rst molar axis as dened by the mesiobuccal cusp and the palatal root apex.
FH to M1 Vertical molar movement. Distance between the molar furcation point and the Frankfort horizontal.

Table IV. Periodontal measurements

Measurement Denition
BAC to CF Width of the buccal alveolar bone in the canine region. The shortest distance between the canine furcation point and the edge
of the alveolar bone at the same axial slice (Fig 3, A).
BAC to P1F Width of the buccal alveolar bone in the rst premolar region. The shortest distance between the rst premolar furcation point
and the edge of the alveolar bone at the same axial slice (Fig 3, A).
BAC to P2F Width of the buccal alveolar bone in the second premolar region. The shortest distance between the second premolar furcation
point and the edge of the alveolar bone at the same axial slice (Fig 3, A).
BAC to M1F Width of the buccal alveolar bone in the rst molar region. The shortest distance between the rst molar furcation point and the
edge of the alveolar bone at the same axial slice (Fig 3, A).
Cusp to BAE C Alveolar bone height in the canine region. Distance between canine cusp and the marginal ridge of the alveolar bone. Buccal
alveolar edge (BAE) points are given on the 3D reconstruction of the scan at the middle of the anatomic crown of the tooth
(Fig 3, B).
Cusp to BAE P1 Alveolar bone height in the rst premolar region. Distance between the rst premolar buccal cusp and the marginal ridge of the
alveolar bone (Fig 3, B).
Cusp to BAE P2 Alveolar bone height in the second premolar region. Distance between the second premolar buccal cusp and the marginal ridge
of the alveolar bone (Fig 3, B).
Cusp to BAE M1 Alveolar bone height in the rst molar region. Distance between the rst molar mesiobuccal cusp and the marginal ridge of the
alveolar bone (Fig 3, B).

DISCUSSION separation should be part of SARME in patients who

In all areas of medicine and dentistry, the trend of
minimally invasive procedures and treatments is
evident. Also in the treatment of transverse maxillary
deciency, efforts are being made to reduce the
extent21,22 or the number of surgical procedures for a
specic patient,23 or even not to use surgical assis-
tance.24,25 In this context, disjunction of the
pterygoid plates must be justied. Disjunction of the
pterygoid plates increases the duration of the
operation, general anesthesia is usually required, and
trauma of the palatine artery or the cranial nerve are
known complications.26-28 Until now, only 1
computed tomography study has evaluated the effect
of pterygoid separation on RME.17 In 2009, Laudemann
et al17 examined the conventional computed tomogra-
phy scans of 65 patients and reported similar ndings
to ours concerning the pattern of expansion and the
periodontal effects of pterygoid disjunction on the pos-
terior teeth, reaching the conclusion that pterygoid
are more than 20 years of age.
Although this was a retrospective study, the same
appliance was used as well as the same operative and
postoperative protocols in all patients. On the skeletal
level, the palatine foramina was used as an anatomic
landmark for measuring posterior maxillary width
changes because it is a reproducible16,29,30 and stable
structure unaffected by the surgical procedure.16 The
piriform aperture was used as an anatomic feature
from which true anterior skeletal expansion is seen as
in most similar studies.4,12 In the middle of the maxilla
sagittally, the jugale points (Table I) were used bilater-
ally. Surprisingly, the middle of the maxilla seemed to
be constricting (J distance,
0.58 6 1.48 and

1.39 6 1.57). This can be attributed to our denition
of J point following the oor of the nose; we know from
several studies that the oor of the nose moves occlu-
sally after maxillary expansion, thus carrying the J point
to a more constricted area of the maxilla.31-33 Another

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754 Sygouros et al

Table V. Skeletal effects of SARME and differences

between the 2 groups
SARME +PD SARME
PD

Skeletal measurement Mean 6 SD Mean 6 SD Pz

J distance
Preop 63.23 6 6.54 63.49 6 6.50 0.930
Postop 62.64 6 6.05 62.09 6 6.90 0.853
P 0.242 0.021*
Pir L-R
Preop 20.38 6 1.94 20.08 6 1.99 0.737
Postop 22.55 6 1.49 22.84 6 1.84 0.705
P 0.001y 0.001y
Fig 4. Cranial superimposition and color mapping indi- lpp L-R
cating mostly dentoalveolar-dental effects of SARME Preop 45.27 6 3.93 45.34 6 2.69 0.964
(red areas). Notice the loss of bone between the central Postop 46.20 6 3.21 46.09 6 3.24 0.940
incisors (blue areas). P 0.113 0.077
lpp angle
Preop 67.35 6 14.02 76.43 6 11.55 0.132
reason for this nding, as Chamberland and Proft32 re- Postop 61.20 6 13.80 77.20 6 9.90 0.008y
ported in 2011, is that the rotation of the hemimaxillae P 0.119 0.827
during expansion causes buccal alveolar bending; thus, mpp angle
Preop 18.67 6 8.75 19.46 6 11.86 0.866
the alveolar edges below the buccal osteotomy move in- Postop 14.23 6 9.86 23.49 6 7.50 0.030*
ward, affecting the coronal position of J point. The pos- P 0.228 0.272
terior expansion did not reach the level of statistical SARME +PD SARME
PD
signicance. Although the opinion that a more parallel
pattern of expansion can be achieved in the 1PD group Difference Mean 6 SD (median) Mean 6 SD (median) P
because of the released posterior stresses has been ex- J distance
0.58 6 1.48 (
0.77)
1.39 6 1.57 (
0.92) 0.257
Pir L-R 2.16 6 1.41 (2.66) 2.75 6 1.41 (2.24) 0.545
pressed, this cannot be assumed in our study, since no lpp L-R 0.93 6 1.68 (0.73) 0.75 6 1.19 (0.57) 0.650
signicant differences could be seen between the lpp angle
6.15 6 11.30 (
3.62) 0.77 6 10.83 (4.92) 0.112
groups.10 mpp angle
4.44 6 10.85 (
2.09) 4.02 6 10.86 (5.25) 0.096
No clear conclusion can be made concerning the ef-
Preop, Before surgery; Postop, after active expansion.
fect of the surgical technique on the pterygoid plate *P \0.05; yP \0.01; zStudent t test; paired samples t test.
anatomy. Although the measurements' level of differ-
ence did not reach statistical signicance (P .0.05)
for both angles (mpp and lpp) in the 1PD group, and right sides to prevent mistakes caused by roll rota-
both angles decreased after the operation, whereas tion of the maxilla. As expected, SARME proved effective
they increased in the
PD group. This may indicate for increasing the transverse dimension in both groups
outward bending of the pterygoid plates in the 1PD with no differences between them; however, a signicant
group, but the small sample size and the large standard part of this increase was due to buccal alveolar bending
deviation prevent clear conclusions and limit this (7.34 6 4.64 for the SARME
PD group, and
study. 5.45 6 4.25 for the SARME 1PD group).
On the dentoalveolar level, different points of refer- On the dental level, all distances between contralat-
ence have been used in other studies, such as tooth eral teeth increased, and buccal tipping occurred for all
apices,33 ectomolare points bilaterally (our BAE M1 posterior teeth. Although the canines did not seem to
point),34 or maxillary width parallel to the lower border tip, this might have been because some of them were in-
of the computed tomography image and tangent to the frapositioned and uprighted after space became avail-
hard palate.15 In our study, to better visualize the den- able. Vertically, the molars' furcation point moved
toalveolar effect of SARME in each group, a reference closer to the FH, but if buccal tipping is considered,
plane passing through the alveolar crest and also passing occlusal movement of the molars' palatal cusps negates
through the center of resistance of each posterior tooth in this nding, proving no signicant vertical differences
the maxilla was sought. Based on the approach of Garrett clinically.
et al,3 we dened a dentoalveolar reference plane pass- Another important conclusion is reached if we
ing through the molars' furcation point and parallel to compare alveolar tipping with dental tipping. When
the FH. This plane was dened separately for the left expansion forces are exerted, the maxilla splits in a

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Sygouros et al 755

Table VI. Dentoalveolar effects of SARME and differ- Table VII. Dental effects of SARME and differences
ences between the 2 groups between the 2 groups
SARME +PD SARME
PD SARME +PD SARME
PD
Dentoalveolar
y
measurement Mean 6 SD Mean 6 SD P Dental measurement Mean 6 SD Mean 6 SD Pz
CF L-R C c L-R
Preop 26.74 6 2.17 26.20 6 1.65 0.572 Preop 33.91 6 2.25 33.82 6 2.85 0.937
Postop 29.61 6 3.05 29.03 6 2.43 0.669 Postop 37.60 6 2.77 37.77 6 2.85 0.898
Pz 0.001* 0.001* P 0.001y 0.016*
P1F L-R P1 bc L-R
Preop 32.20 6 2.81 31.26 6 1.95 0.417 Preop 38.48 6 2.32 37.68 6 2.44 0.476
Postop 36.43 6 3.27 34.96 6 2.96 0.319 Postop 44.93 6 2.96 44.37 6 3.57 0.715
Pz 0.001* 0.001* P 0.001y 0.001y
P2F L-R P2 bc L-R
Preop 36.92 6 3.43 36.50 6 2.20 0.748 Preop 43.79 6 2.83 43.88 6 1.80 0.936
Postop 40.75 6 3.54 40.08 6 2.99 0.653 Postop 50.79 6 2.94 50.42 6 3.01 0.783
Pz 0.001* 0.001* P 0.001y 0.001y
M1F L-R M1 bc L-R
Preop 42.25 6 4.05 42.28 6 1.42 0.979 Preop 50.09 6 4.02 50.40 6 2.25 0.833
Postop 46.20 6 3.89 45.79 6 2.35 0.777 Postop 56.03 6 4.05 56.49 6 3.62 0.796
Pz 0.001* 0.001* P 0.001y 0.001y
Or-alv L,R Or-C L-R
Preop 80.05 6 3.16 78.39 6 4.51 0.356 Preop 76.03 6 6.64 77.45 6 4.83 0.588
Postop 74.59 6 4.23 71.05 6 3.94 0.069 Postop 75.58 6 7.29 76.11 6 3.70 0.841
Pz 0.003* 0.001* P 0.554 0.401
SARME +PD SARME
PD Or-P1 L-R
Preop 80.53 6 4.75 79.67 6 4.43 0.690
Difference Mean 6 SD (median) Mean 6 SD (median) P Postop 75.94 6 5.50 74.42 6 4.59 0.525
CF L-R 2.86 6 1.78 (2.86) 2.82 6 1.35 (2.73) 0.965 P 0.001y 0.003y
P1F L-R 4.23 6 1.35 (3.89) 3.69 6 1.77 (4.00) 0.775 Or-P2 L-R
P2F L-R 3.83 6 1.29 (3.63) 3.57 6 1.91 (3.78) 0.880 Preop 80.53 6 3.57 78.45 6 3.79 0.224
M1F L-R 3.95 6 1.47 (3.64) 3.50 6 1.70 (2.98) 0.496 Postop 74.69 6 6.08 72.71 6 4.81 0.432
Or-alv L,R
5.45 6 4.25 (
4.67)
7.34 6 4.64 (
5.81) 0.257 P 0.002y 0.001y
Or-M1 L-R
Preop, Before surgery; Postop, after active expansion. Preop 66.62 6 3.80 65.23 6 2.99 0.373
*P \0.01; yStudent t test; zpaired samples t test. Postop 61.95 6 6.03 59.50 6 4.20 0.307
P 0.006y 0.001y
FH to M1 L-R
nonparallel manner. A pyramid-like separation of the Preop 34.24 6 3.17 35.40 6 2.24 0.359
Postop 33.63 6 3.19 34.37 6 2.76 0.584
maxillary halves is seen with the fulcrum of the maxillary
P 0.001y 0.018*
rotation at the frontomaxillary suture.35 Kartalian et al1
SARME +PD SARME
PD
in a sample of patients undergoing RME showed that
buccal alveolar bending was followed by compensating Difference Mean 6 SD (median) Mean 6 SD (median) P
lingual dental uprighting. In our study, absolute dental C c L-R 3.68 6 1.39 (3.28) 3.95 6 3.56 (3.91) 0.722
tipping, however minimal, was lingual in all groups, P1 bc L-R 6.44 6 1.99 (5.89) 6.68 6 2.61 (7.75) 0.935
since the alveolar bending was more pronounced than P2 bc L-R 7.00 6 2.03 (7.29) 6.54 6 2.09 (7.49) 0.705
M1 bc L-R 5.94 6 2.30 (6.13) 6.09 6 2.39 (6.99) 0.821
the molars' relative buccal tipping (
4.67 of molar Or-C L-R
0.44 6 2.28 (
0.19)
1.34 6 4.84 (
1.48) 0.326
tipping compared with
5.45 of alveolar tipping for Or-P1 L-R
4.58 6 3.03 (
4.02)
5.24 6 3.79 (
4.85) 0.369
the SARME 1PD group, and
5.72 compared with Or-P2 L-R
5.83 6 4.23 (
6.90)
5.74 6 2.40 (
5.54) 0.705

7.34 for the SARME
PD group). Longer retention Or-M1 L-R
4.67 6 4.16 (
4.49)
5.72 6 3.15 (
4.92) 0.406
times would probably result in more dental uprighting. FH to
0.61 6 0.27 (
0.58)
1.02 6 1.13 (
1.28) 0.174
M1 L-R
In 2011, Gauthier et al19 reported similar results to
our study concerning the periodontal measurements. Preop, Before surgery; Postop, after active expansion.
Buccal alveolar width was decreased after the postre- *P \0.05; yP \0.01; zStudent t test; paired samples t test.
tention period in all groups and areas (Table IV). This
decrease was found to be statistically signicant for for the SARME 1PD group. For the rst and second
the rst molars, second premolars in all groups, rst premolars, signicant differences were noted between
premolars for the SARME
PD group, and the canines the 2 groups (P \0.05). When pterygoid disjunction

American Journal of Orthodontics and Dentofacial Orthopedics December 2014  Vol 146  Issue 6
756 Sygouros et al

of the teeth. It is evident from this study that although

Table VIII. Periodontal effects of SARME and differ-
SARME without separation of the pterygoid plates
ences between the 2 groups
achieves its goals to correct the transverse dimension,
SARME +PD SARME
PD it puts an additional signicant strain on the peri-
Periodontal
measurement Mean 6 SD Mean 6 SD Pz
odontal apparatus of the patients, especially in the pre-
BAC to CF molar area, by reducing both the buccal alveolar width
Preop 4.24 6 0.55 4.30 6 0.36 0.795 and the height of the alveolar crest, when compared
Postop 3.93 6 0.62 3.88 6 0.68 0.857 with SARME with pterygoid disjunction. Although
P 0.025* 0.059
BAC to P1F studies with larger sample sizes and longer observation
Preop 3.99 6 0.36 4.43 6 0.49 0.042* periods are needed to further elucidate the long-term
Postop 3.74 6 0.38 3.71 6 0.52 0.898 effects of pterygoid disjunction, we recommend initial
P 0.081 0.001y
BAC to P2F periodontal screening as a mandatory procedure for
Preop 4.61 6 0.54 5.09 6 0.49 0.050* candidates for SARME and consultation with an oral
Postop 4.16 6 0.39 3.94 6 0.37 0.206 and maxillofacial surgeon for the surgical plan of
P 0.024* 0.001y
BAC to M1F choice during treatment planning.
Preop 6.29 6 1.00 6.31 6 0.46 0.946
Postop 5.45 6 0.64 5.60 6 0.59 0.607
P 0.002y 0.006y
CONCLUSIONS
Cusp to BAE C SARME is an effective technique to correct transverse
Preop 12.85 6 4.38 12.32 6 1.19 0.716
Postop 11.25 6 1.18 12.51 6 1.30 0.036* discrepancies and treat maxillary transverse deciencies.
P 0.362 0.549 CBCT is a reliable means to assess maxillary dentoskele-
Cusp to BAE P1 tal changes after expansion. With SARME, we can
Preop 9.21 6 1.25 9.17 6 0.53 0.923
Postop 9.35 6 0.77 9.94 6 0.91 0.149 achieve dental, dentoalveolar, and anterior skeletal
P 0.573 0.019* expansion, but buccal tipping of all posterior teeth and
Cusp to BAE P2 buccal alveolar bending should be expected. If no
Preop 8.50 6 0.74 8.70 6 0.58 0.508
Postop 8.61 6 0.85 9.12 6 0.88 0.200 disjunction of the pterygoid plates is performed, peri-
P 0.525 0.094 odontal support is compromised. The reduction of the
Cusp to BAE M1 buccal alveolar width was signicantly more at the pre-
Preop 8.22 6 0.73 8.81 6 0.69 0.078
Postop 8.90 6 1.02 9.05 6 0.74 0.715 molar area in patients who did not undergo separation
P 0.106 0.267 of their pterygoid plates during SARME compared with
SARME +PD SARME
PD patients who did.
Difference Mean 6 SD (median) Mean 6 SD (median) P
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