Surgically Assisted Maxillary Expansion

Norman J. Betts, DDS, MS a,b,c,*

KEYWORDS
 Transverse maxillomandibular discrepancy  Stability  Surgically assisted maxillary expansion  SAME

KEY POINTS
 The transverse dimension of the maxillomandibular complex must be evaluated, diagnosed, and addressed to achieve
stability after orthognathic correction.
 Orthopedic maxillary expansion (nonsurgical) is effective and stable in the young population before sutural closure and is
not effective or stable in patients after sutural closure in the maxillofacial complex. Treatment with orthopedic expansion
in this group leads to uncontrolled relapse and periodontal and occlusal complications of the teeth after the removal of
orthodontic appliances.
 To achieve the desired expansion and stability, transverse maxillary expansion should be accomplished by sutural ad-
justments in the craniofacial complex, not by alveolar bending and dental tipping. The SAME (surgically assisted maxillary
expansion) procedure is a combination of distraction osteogenesis and controlled soft tissue expansion.
 After the surgical procedure, the maxilla should remain stationary for at least 5 days before initiation of expansion at a rate
of 0.5 mm/d.
 Surgical transverse changes are unstable for a longer period than are most other surgical or orthodontic movements. It
takes approximately 6 months to achieve bony continuity in the midpalatal osteotomy site. Therefore, some form of
skeletal retention is recommended for at least 6 to 12 months after expansion.

Introduction: nature of the problem
Complete and accurate evaluation of a patient with a dentofacial
deformity must include assessment of the transverse dimension.
Few practitioners adequately evaluate the transverse dimension,
often resulting in undiagnosed transverse maxillomandibular
discrepancy. When a transverse maxillomandibular discrepancy
exists, adult patients have traditionally been treated with or-
thodontic expansion or a segmental maxillary osteotomy,
frequently leading to transverse maxillary instability and relapse
after orthodontic appliance removal.
Orthopedic or rapid maxillary expansion (ORME) is also a
technique used to treat transverse maxillomandibular
discrepancy. If used in the correct patient population, this
technique is predicable and stable for the correction of
transverse maxillomandibular discrepancy. It is of limited
benefit in mature teenage and adult patients, because the
maxillary articulations become increasingly resistant to
expansion with aging. Techniques of surgically assisted maxil-
lary expansion (SAME) have been developed to overcome this
a
Private Practice, Chelsea Oral and Facial Surgery, 1303 South Main
Street, Suite B, Chelsea, MI 48118, USA
b
Private Practice, Ann Arbor Oral and Facial Surgery, 3055 Plymouth
Road, Suite 202, Ann Arbor, MI 48105, USA
c quently, the transverse deformity is often not diagnosed when
Department of Oral and Maxillofacial Surgery, University of Michi-
gan School of Dentistry, 3055 Plymouth Road, Suite 202, Ann Arbor, MI
48105, USA
* Chelsea Oral and Facial Surgery, 1303 South Main Street, Suite B,
Chelsea, MI 48118.
E-mail address: njbetts@comcast.net
age limitation. The SAME procedure is a combination of
distraction osteogenesis and controlled soft tissue expansion.
Discussion of SAME is often confusing because various combi-
nations of maxillary, pterygopalatine lateral nasal, septal, and
palatine osteotomies have been used, based on the surgeon’s
theory of where resistance to expansion is located. The pur-
pose of this article is to describe the clinical and radiographic
evaluation of the transverse dimension in patients with den-
tofacial deformity and to present the indications for SAME and
an anatomically based SAME technique.
Surgical technique
Preoperative planning
Accurate diagnosis and treatment of transverse maxillary
deficiency are essential to the long-term stability after
correction of any dentofacial deformity that includes a trans-
verse discrepancy. However, diagnosis of transverse maxillary
deficiency may be difficult, because minimal facial soft tissue
changes are associated with isolated transverse maxillary hy-
poplasia. In contrast, isolated anteroposterior or vertical
skeletal deformities are easier to diagnose, because they often
have obvious associated facial soft tissue findings. Conse-
sagittal and vertical deformities exist concomitantly. There-
fore, it is not surprising that clinical inspection for transverse
maxillary deficiency has been shown to be of poor diagnostic
value. Complete diagnosis of this deformity must include both
clinical and radiographic evaluation.

Atlas Oral Maxillofacial Surg Clin N Am 24 (2016) 67–77

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68
Clinical evaluation
The existence and extent of a transverse discrepancy must be
determined and the skeletal and dental components of the
deformity must be differentiated before contemplating surgery
(Box 1, Fig. 1).
Radiographic evaluation
A standard posteroanterior (PA) cephalogram is the radiograph
of choice for identification and evaluation of a transverse
discrepancy. Ricketts developed the Rocky Mountain analysis
and established relative norms using specific radiographic
landmarks and measurements to analyze transverse discrep-
ancies between the maxilla and mandible (Box 2, Fig. 2).
Using these landmarks, it is possible to determine the
effective maxillary width, effective mandibular width, and
frontolateral facial lines. The effective maxillary width is the
width of the maxilla between the points JL (jugale left) and JR
(jugale right). The effective mandibular width is the width of
the mandible between AG and GA. The frontolateral facial
lines are the lateral lines constructed from OR (orbitale right)
and OL (orbitale left) to the points AG and GA, respectively.
Using these cephalometric landmarks, it is possible to
determine the maxillomandibular width differential and the
maxillomandibular transverse differential index for quantifi-
cation of the transverse maxillary discrepancy (Fig. 3). The
maxillomandibular width differential is the distance (in milli-
meters) measured from the frontolateral facial line to JL and
JR, respectively, along a line from the frontolateral facial lines
through JR and JL. This measurement is calculated indepen-
dently for each side and compared with a normal value of
10  1.5 mm. If this value is greater than 10 mm, a transverse
discrepancy between the maxilla and mandible exists. The
values greater than 10 mm on each side are summed to
quantify the total transverse deficiency. This technique is
Box 1. Clinical indicators of transverse
maxillary deficiency
1. Facial soft tissue changes including paranasal hollow-
ing, a narrowed alar base, and deepening of the
nasolabial folds
2. Negative space (distance between the corner of the
mouth and the buccal surfaces of the posterior maxil-
lary teeth during full smile)
3. Unilateral or bilateral posterior crossbite (a distinction
must be made between dental and skeletal crossbite)
4. Crowded, rotated, and palatally or buccally displaced
teeth
5. Narrow and tapering maxillary arch form, described as
hourglass shaped
6. High, narrow palatal arch
7. Associated skeletal deformities include maxillary ver-
tical and anteroposterior hypoplasia and zygomatic
hypoplasia (as a result of growth issues)
8. Other associated dentofacial deformities include ver-
tical maxillary excess, mandibular prognathism or
mandibular sagittal deficiency, apertognathia, and
repaired cleft palate
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useful in determining the total discrepancy and showing
whether there is a greater deficiency or excess on 1 side or the
other. However, this differential does not elucidate in which
jaw the discrepancy exists and may be misinterpreted when
mandibular asymmetry is present. The maxillomandibular
transverse differential index is the age-specific expected
maxillomandibular difference minus the actual measured
maxillomandibular difference. The expected max-
illomandibular difference is the age-appropriate expected
AG-GA distance minus the age-appropriate expected JR-JL
distance. The actual maxillomandibular difference is the
actual AG-GA measurement minus the actual JR-JL measure-
ment. In an adult patient, a maxillomandibular transverse
differential index greater than 5 mm suggests a need for sur-
gical expansion. As well as quantifying the total discrepancy,
this method allows for the identification of which jaw is defi-
cient or excessive, because actual values can be compared
with normal values. Normal values have been suggested only
for Caucasian, and these values should not be considered
normal values for other races.
Treatment of transverse maxillomandibular
discrepancy
SAME combines an orthopedic appliance and osteotomies to
achieve maxillary skeletal expansion in 1 to 2 weeks (Box 3).
The technique chosen to correct the transverse discrepancy is
dependent on many factors, but most important is the skeletal
maturity of the patient (Box 4). Additional factors include the
magnitude of the transverse discrepancy and whether gingival
dehiscence or bony fenestration is already present on the
maxillary canine and bicuspid teeth. Generally, patients in the
primary dentition and the mixed dentition stage are treated by
ORME. Transverse maxillary growth ceases and the maxillofa-
cial sutures close at skeletal age 14 to 15 years in females and
15 to 16 years in males. Adults are best treated by SAME or
segmental Le Fort osteotomy.
After sutural closure, ORME is unsuccessful, because the
expansion is composed primarily of alveolar or dental tipping,
with little or no skeletal expansion. This situation can lead to
many problems in adults, including an inability to activate the
appliance, pain on activation, pressure necrosis of the palatal
tissue under the appliance, tipping and extrusion of the
maxillary teeth, bending of the alveolar bone, uncontrolled
relapse after orthodontic appliance removal, and periodontal
complications. These periodontal complications result from
the tipping of the maxillary teeth out through the buccal
cortical bone, resulting in cortical thinning, dehiscence, or
fenestration of the maxillary teeth. If gingival inflammation is
present, the patient is predisposed to gingival recession and
dental instability (Fig. 4). In contrast, if the transverse maxil-
lary deficiency is less than 5 mm of the total maxillomandibular
discrepancy, sufficient buccal bone is generally present to
allow for some dental tipping. In this case, ORME may be
considered if there are no periodontal defects or gingival
recession already present in the posterior maxillary quadrants.
Preparation and patient positioning
Before the procedure, an expansion device must be placed.
The best results are achieved when one of the several varia-
tions of the jackscrew appliance is used. To achieve expansion,
a palatally positioned jackscrew is placed within a framework
Surgically Assisted Maxillary Expansion 69

Fig. 1 (A) Intraoral view of severe transverse maxillary hypoplasia. There is a bilateral palatal crossbite and rotated, crowded, and
displaced teeth. (B) Palatal view of a patient with transverse maxillary hypoplasia. Note the narrow, tapering, hourglass-shaped arch form
in addition to the narrow and high palatal vault. (From Betts NJ, Vanarsdall RL, Barber HD, et al. Diagnosis and treatment of transverse
maxillary deficiency. Int J Adult Orthodon Orthognath Surg 1995;10:77, 91; with permission.)

attached to the first molars and other teeth as available
(usually the first bicuspid teeth). The most common jackscrew
appliances used today are the Haas and Hyrax. The Haas
appliance (Fig. 5) has acrylic palatal flanges incorporated into
the appliance, which have been shown to decrease buccal
tipping of the dentition and produce greater skeletal expan-
sion. However, because of the acrylic palatal pads, there is a
slightly increased risk of palatal tissue impingement, and food
can become entrapped beneath the flanges. The Hyrax appli-
ance (Fig. 6) is similar in design to the Haas appliance, with the
exception that it does not have the acrylic palatal pads. Its use
theoretically results in more dental tipping and less skeletal
expansion. The occlusal coverage Haas appliance (Fig. 7) is a
hybrid of the Haas appliance with a flat plane occlusal
coverage splint. This appliance must be physically bonded to
the maxillary teeth. Its use is recommended in patients with
periodontally compromised dentition, because the appliance
incorporates more of the teeth in the device (not just the first
bicuspid and first molar teeth). Therefore, the transverse
forces are distributed among more teeth. It may also be useful
in patients with temporomandibular joint (TMJ) symptoms,
because the appliance can be equilibrated like an occlusal
coverage splint during expansion to minimize the premature
dental interferences common during the transverse expansion.
Like the Haas appliance, it use may result in less dental tipping
and more skeletal expansion. However, because of problems
with oral hygiene, it must be removed 3 to 4 months after
placement and an immediate palatal coverage retainer placed
to minimize transverse relapse (Box 4).
The 3 principal areas of vertical and horizontal maxillary
support are the nasomaxillary, zygomaticomaxillary, and
pterygomaxillary buttresses (Fig. 8). The many maxillary
osteotomies that have been empirically proposed to facilitate
lateral maxillary expansion reflect the controversy regarding
the primary area of resistance to expansion in the craniofacial
skeleton. Most recently, investigators have recommended
sectioning of virtually all the maxillary bony articulations, that
is, zygomaticomaxillary buttresses, midpalatal suture, and
pterygomaxillary junction. An investigation by Shetty and co-
workers attempted to give a biomechanical rational for the
choice of osteotomies by analyzing the internal stress response
after SAME in a photoelastic model fabricated from a human
skull. A Hyrax appliance was placed and activated, and
sequential cuts were performed on the model. The alterations
in the internal stresses of the skull were recorded after each
cut. All the bony buttresses of the maxilla contributed resis-
tance to expansion, but the midpalatal suture followed by the
pterygomaxillary articulations were the primary areas of
resistance. These investigators also reported that forces
caused by appliance activation have deep anatomic effects,
with stresses present at sites distant from the force applica-
tion. Even although this study has significant validity and reli-
ability problems, it provides important information concerning

Box 2. Skeletal landmarks used in the evalu-

ation of maxillomandibular transverse
discrepancy
1. JR (jugale right) and JL (jugale left) (the intersection
of the maxillary tuberosity and the zygomatic buttress)
2. AG (antegonion right) and GA (antegonion left) (the
inferior margin of the antegonial protuberance, below Fig. 2 The elements of the PA cephalometric analysis. These
the antegonial trihedral area) landmarks can be used to calculate the effective maxillary width
3. OR (orbitale right) and OL (orbitale left) (representing and effective mandibular width, and the frontolateral lines can be
the intersection of the orbits with the middle cranial constructed. (From Betts NJ, Vanarsdall RL, Barber HD, et al.
fossa) Diagnosis and treatment of transverse maxillary deficiency. Int J
Adult Orthodon Orthognath Surg 1995;10:78; with permission.)

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70
Fig. 3 Worksheet used to determine the radiographic magnitude
and location of the maxillomandibular transverse discrepancy.
(From Betts NJ, Vanarsdall RL, Barber HD, et al. Diagnosis and
treatment of transverse maxillary deficiency. Int J Adult Orthodon
Orthognath Surg 1995;10:79; with permission.)
the areas of resistance to transverse expansion in the adult
human skull.
Typically, this procedure is performed in a hospital setting
as an outpatient or 24-hour stay procedure. Although SAME has
been successfully performed in the outpatient setting, this
Box 3. Benefits of the SAME procedure
1. Improved dental and skeletal stability
2. Nonextraction orthodontic alignment of the dentition
3. Improved aesthetics by the elimination of negative
space (distance between the corner of the mouth and
the buccal surfaces of the posterior maxillary teeth
during full smile) and a decrease in the buccal hol-
lowing of the lateral maxilla
4. Improved long-term periodontal health
5. Improved nasal respiration as a result of widening of
the nasal cavity and internal nasal valve (this widening
results from the lateral repositioning of the lateral
nasal walls during maxillary expansion)
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Betts
practice should be limited to younger patients, because they
require less extensive surgery to accomplish adequate maxil-
lary expansion. Patient positioning in the operating room
should be similar to that described for the Le Fort I osteotomy.
Nasal intubation is preferred. However, because max-
illomandibular fixation is not necessary for this surgical pro-
cedure, oral intubation can be used.
Surgical approach
Based on the knowledge that the areas of resistance to trans-
verse expansion include all the bony buttresses of the maxilla,
the technique advocated is a subtotal Le Fort I maxillary
osteotomy (Box 5, Fig. 9). The mandibular dentition should be
decompensated before surgery to allow assessment of the
amount of transverse expansion necessary and to assist in
preventing postexpansion relapse with dental interdigitation.
In addition, the maxillary expansion appliance must be placed
preoperatively and the appliance key must be present in the
operating suite to allow intraoperative activation.
Surgical caveats
During this procedure, the appliance is widened 3 to 4 mm and
then turned back to a final opening of 1 to 1.5 mm. The
perpendicular plate of the palatine bone is thick and offers
significant resistance posteriorly. During maximal expansion,
the surgeon should check that both maxillae are adequately
mobile. If they are not, the osteotomies should be checked or
more surgery performed.
Sectioning of the posterior portions of the thin lateral nasal
wall is unnecessary because it offers little resistance to
transverse expansion. Release of the pterygoid plates is
necessary because they are part of the sphenoid, which is a
single bone without a midline suture. Therefore, orthopedic
forces cannot widen the pterygoid plates, and they should be
separated from the maxillae. SAME can also be used in cases of
unilateral or asymmetric maxillary deformities. In this situa-
tion, the osteotomies outlined earlier are created on only 1
side, thus allowing a differential anchorage situation with more
expansion on one side. As would be expected, on the non-
operated side, buccal bone bending and dental tipping occur.
After appliance removal, almost complete relapse occurs on
the nonoperated side.
Postoperative care, rehabilitation, and recovery
Routine follow-up care should be similar to that of the Le Fort I
osteotomy, with the exception that liquid diet is followed for
only the first week and the diet is advanced from that time
forward.
After the surgical procedure, the maxilla should remain
stationary for at least 5 days before initiation of expansion at a
rate of 0.5 mm/d (2 activations of the jack screw appliance a
day). This strategy is based on Ilizarov’s work in the extrem-
ities, which showed that a healing period of 5 days allows for
capillary healing across the bony gap. Reestablishment of this
blood supply leads to faster and more complete ossification of
the expanded defect. Ilizarov showed that an expansion rate of
0.5 to 1 mm/d does not outstrip this critical blood supply.
However, in the maxilla, a rate of 0.5 mm/d is recommended.
Expansion rates greater than this may cause gingival recession
Surgically Assisted Maxillary Expansion 71

Fig. 4 Palatal (A) and lateral (B, C) views of an adult patient who had previously undergone unsuccessful orthopedic rapid maxillary
expansion. The expansion has relapsed and has also resulted in significant buccal gingival recession bilaterally in the canine and premolar
regions. (From Betts NJ, Vanarsdall RL, Barber HD, et al. Diagnosis and treatment of transverse maxillary deficiency. Int J Adult Orthodon
Orthognath Surg 1995;10:84; with permission.)

on the mesial side of the central incisors, especially if bone and
attachment loss is already present.
During expansion, the patient should feel little discomfort.
If pain is experienced, there is bony interference or inadequate
mobilization or the appliance is not functioning properly.
However, symptoms of tightness and minor discomfort in the
nasal root/glabellar area and posterior orbit can and do occur,
with anatomic basis. Pain in the nasal root area can be
attributed to an outward rotation of the maxillary halves
around an axis of rotation located near the frontonasal suture
(because the lateral nasal walls are not osteotomized
completely during the surgical procedure) (Fig. 10). The pres-
sure felt in the posterior orbit is caused by the small articu-
lation of the palatine bone, which is not sectioned during the
surgical procedure.
Palatal expansion must occur within 4 weeks of surgery or
the osteotomies may heal before the required transverse
dimension has been achieved. During the period of expansion,
immature attached gingival tissue should be seen medial to
each central incisor tooth. This immature attached gingival
tissue arises when skeletal or dental expansion exceeds the
ability of the attached gingiva to remodel. It is a sign of suc-
cessful expansion and should appear bilaterally and be
symmetric. If gingival recession or gapping occurs between the
gingiva and the root surface, the expansion rate should be
decreased. In contrast to ORME, overcorrection is not recom-
mended for SAME.
Surgical transverse changes are unstable for a longer period
than are most other surgical or orthodontic movements. It
takes approximately 6 months to achieve bony continuity in the
midpalatal osteotomy site. Therefore, some form of skeletal
retention is recommended for at least 6 to 12 months after
expansion. The expansion device can be retained for this
purpose or a palatal coverage retainer can be placed (Fig. 11).
Potential complications
Intraoperative complications of SAME are similar to those that
occur with Le Fort I maxillary osteotomy. Intraoperative
hemorrhage can be limited by respecting the relevant anat-
omy, carefully elevating nasal mucosa, limiting the lateral
nasal wall osteotomies to the first 1.5 mm, and appropriately
placing and orienting the pterygoid osteotome. By maintaining
the horizontal osteotomy 5 mm above the dental apices, risk of
devitalizing the teeth is diminished. The vertical osteotomy

Fig. 5 Clinical example of a Haas palatal expansion device. Fig. 6 Hyrax expansion device. (From Betts NJ, Vanarsdall RL,
(From Betts NJ, Vanarsdall RL, Barber HD, et al. Diagnosis and Barber HD, et al. Diagnosis and treatment of transverse maxillary
treatment of transverse maxillary deficiency. Int J Adult Orthodon deficiency. Int J Adult Orthodon Orthognath Surg 1995;10:83; with
Orthognath Surg 1995;10:83; with permission.) permission.)

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72
Fig. 7 Occlusal coverage Haas-type appliance. (From Betts NJ,
Vanarsdall RL, Barber HD, et al. Diagnosis and treatment of
transverse maxillary deficiency. Int J Adult Orthodon Orthognath
Surg 1995;10:83; with permission.)
between the central incisors should be performed with a
spatula osteotome to preserve bony coverage of the medial
surface of the central incisor roots. Preoperative orthodontics
may be useful in splaying the roots in preparation for surgery.
Postoperative complications can be divided into those
caused by inadequate release of the maxillae (Box 6) and those
caused by problems with the expansion device (Box 7, Figs. 12
and 13).
Other caveats (modification of the surgically assisted
maxillary expansion procedure)
There is increased resistance to expansion with increasing
skeletal maturity and age. To achieve stable and adequate
Box 4. Indications for SAME
1. Skeletal maxillomandibular transverse discrepancy
greater than 5 mm (Caucasian patients)
2. Significant transverse maxillary deficiency associated
with a narrow maxilla and wide mandible
3. Failed orthodontic or orthopedic expansion
4. Necessity for a large amount (>7 mm) of expansion, or
preference to avoid the potential increased risk of
segmental osteotomies
5. Extremely thin, delicate gingival tissue or presence of
significant buccal gingival recession in the canine-
bicuspid region of the maxilla
6. Significant nasal stenosis
7. Need for widening of the maxillary arch when no other
skeletal deformity is present
8. Widening of the arch to provide space for dental
alignment without requiring maxillary extractions to
create space
9. Widening of the arch after collapse associated with the
cleft palate deformity
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Betts
Fig. 8 The maxillary buttresses: nasomaxillary, zygomatico-
maxillary, and pterygomaxillary. Resistance to palatal expansion
also arises from the midpalatal suture. (From Betts NJ, Vanarsdall
RL, Barber HD, et al. Diagnosis and treatment of transverse
maxillary deficiency. Int J Adult Orthodon Orthognath Surg
1995;10:85; with permission.)
expansion, the surgeon must perform more extensive surgery
in older patients. Older patients often require rechecking of
the osteotomies and scoring of the posterior wall of the sinus to
achieve adequate mobilization.
Palatal tori can be a significant barrier to palatal expansion,
because they are composed of dense cortical bone. The pres-
ence of a palatal torus in this situation can be approached in 2
different ways. The ideal treatment is to surgically remove the
torus 4 to 6 months before the SAME procedure. However,
concomitant removal of the torus can be performed if the
surgeon is willing to place the expansion appliance intra-
operatively. The appliance must be fabricated on a model from
Box 5. Summary of the surgical procedure
(see Fig. 9)
1. Vestibular incision 5 mm above the mucogingival
junction bilaterally from the first molar area to the
midline
2. Bilateral maxillary osteotomy from the pyriform rim to
the pterygomaxillary fissure; this osteotomy is created
parallel to the maxillary occlusal plane with a step at
the buttress and ostectomy performed the buttress to
allow expansion
3. Release of the nasal septum (to prevent septal devia-
tion during expansion)
4. Midline palatal osteotomy extended interdentally be-
tween the maxillary incisors and from the anterior
nasal spine through the posterior nasal spine
5. Osteotomy of the anterior 1.5 mm of the lateral nasal
wall
6. Bilateral release of the pterygoid plates
7. Activation of the appliance with a total widening of 1
to 1.5 mm, with evaluation for symmetric expansion
8. Soft tissue closure, including alar base cinch with
nonresorbable suture and V-Y closure to control the
soft tissues of the nasal base and upper lip
Surgically Assisted Maxillary Expansion 73

Fig. 9 Individual steps in the technique of SAME (A) Preoperative state. (B) The Haas palatal expansion device in place before surgery. The
appliance has not been activated. (C) Clinical photograph of the surgical incision identical to the one used for the LeFort I osteotomy,
above the mucogingival junction. (D) The maxillary osteotomy extending from the pyriform rim to the pterygomaxillary fissure. This
osteotomy is parallel to the occlusal plane, with a step and bone removed at the buttress to allow for expansion. (E) Clinical photograph
showing the maxillary osteotomies. (F) Release of the nasal septum from anterior nasal spine to the posterior nasal spine. (G) The nasal
septal release. (H) The midline palatal osteotomy. The osteotome is first directed inferiorly to split the alveolar bone between the
maxillary central incisors and then posteriorly to split the hard palate. (I) Osteotome placement being used to split the alveolar bone
between the maxillary central incisors. (J) Separation of the hard palate, with the osteotome directed posteriorly along the palate. (K) The
lateral nasal wall osteotomy, which is carried posteriorly for 1.5 mm. (L) Release of the pterygoid plates from the tuberosity of the
posterior maxilla. Note that a curved osteotome of less than 10 mm is being positioned in an inferior, anterior, and medial direction. (M)
Clinical view of the placement of the curved osteotome to separate the pterygoid plates. (N) Expansion device key used for appliance
activation. The key should be attached to floss or string to prevent accidental swallowing or aspiration. (O) Clinical view showing activation
of the appliance with the key. (P) Frontal diagram of the completed SAME.

which the torus has been removed. Because a midpalatal
incision is necessary to remove the torus, thus compromising
palatal blood supply, the lateral, nasal, horizontal maxillary,
pterygomaxillary, and anterior midpalatal osteotomies should
be performed through vertical incisions in the buccal mucosa
combined with subperiosteal tunneling. The torus is then
removed by the conventional technique, and parasagittal
palatal osteotomies are completed directly through this inci-
sion. The expansion appliance is then tested to ensure that it
has no direct contact with the palatal tissues.
When performing SAME on patients with a skeletal open bite
or open-bite tendency, care must be taken to prevent worsening
of the open bite with this procedure. If a ramped or angled cut is
made from the pyriform rims to the maxillary buttress, the
maxilla preferentially moves inferiorly at the first molar during
expansion (Fig. 14A). This movement can cause worsening of an
open bite or conversion of an open-bite tendency to a skeletal
open bite, therefore mandating a secondary maxillary osteot-
omy. Prevention of this problem requires modification of the
SAME technique to ensure that all osteotomies of the anterior
and lateral maxillary walls are parallel to the maxillary occlusal
plane. A vertical step is created at the maxillary buttress so that
transverse expansion can occur without bony interference in the
buttress region. Bone removal of just less than half the desired
amount of transverse expansion is completed at each buttress
(see Fig. 14B). If a secondary Le Fort I maxillary osteotomy is
planned because of the existence of other dentofacial de-
formities, the osteotomies for SAME should be placed in the

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74 Betts

Fig. 9 (continued) (Q) Palatal view of a Haas expansion device in place, with the vectors of expansion shown (R) An alar cinch suture and V-Y
closure are used to close the incision to control the soft tissues of the upper lip and nasal base. Clinical photograph of a Boley gauge checking
the width of the alar base of the nose after an alar cinch suture has been placed to reposition the tissues to the preoperative value. (S) Clinical
photograph showing the use of a Boley gauge set at 10 mm to correctly close the vertical leg of the V-Y closure. (T) Completed V-Y closure. (U)
Palatal view of the maxilla with the Haas appliance in place after 2 weeks of expansion. (V) Maxillary occlusal film showing the palatal
expansion after 2 weeks. (W) Clinical palatal view of same patient 3 months after expansion with Haas appliance used as a retention device.
(X) Haas appliance removed. (Y) Occlusal coverage transpalatal retainer which will be used for the next 3 months to prevent transverse
relapse. This patient had preexisting TMJ problems, hence the occlusal coverage. (From Betts NJ, Vanarsdall RL, Barber HD, et al. Diagnosis
and treatment of transverse maxillary deficiency. Int J Adult Orthodon Orthognath Surg 1995;10:86e9; with permission.)

location of the planned osteotomy cut of the future Le Fort
procedure. This strategy is because the osteotomies in the
anterior and lateral maxillary walls seldom completely heal
after SAME, and this may compromise future osteotomies or the
ability to apply rigid fixation.
Surgically assisted maxillary expansion versus
segmental maxillary osteotomy and clinical results in
the literature
When a patient requires surgical correction of a transverse
discrepancy, a decision must be made regarding which surgical
technique (SAME or segmental maxillary osteotomy) will be
used. Certainly, for a patient who requires a maxillary osteot-
omy to correct vertical or anteroposterior deformities, consid-
eration should be given to the segmental maxillary osteotomy.
There are some difference (other than SAME requiring a second
surgical procedure) that merit discussion. The first is post-
operative stability. Pogrel and associates studied 12 patients
1 year after SAME (still in orthodontic appliances) and found an
11.8% relapse at the maxillary first molar. Bays and Greco
studied 19 patients who had undergone SAME who had
completed orthodontic therapy more than 6 months previously
and found an 8.8% relapse at the canines, 1% at the first bicuspid,
and 7.7% at the first maxillary molar. The reported relapse in the
transverse component of segmental maxillary osteotomies has
been considerably higher. Stephens found a 30% and 23% relapse
at the canine and molar regions, respectively, in 15 patients who
had undergone segmental maxillary osteotomies with an
average follow-up of 47.5 months after debanding. Phillips and
colleagues compared the transverse stability in 39 patients who
underwent either a 2-piece Le Fort osteotomy (n Z 26) or a 3-
piece Le Fort osteotomy (n Z 13). The postorthodontic follow-
up was 14 to 47 months (mean Z 24.4 months). Significant
transverse relapse in both groups was observed, ranging from
11% at the canines to 47% at the second molar in the 2-piece
group and from 30% at the first premolar to 51% at the first molar
in the 3-piece group.

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Surgically Assisted Maxillary Expansion
Fig. 10 The outward rotation of the maxillary halves around the
axis of rotation located near the frontonasal suture. This situation
results from incomplete lateral nasal wall osteotomies, which are
not sectioned during surgery and articulate with the skull high in
the nasal cavity. (From Betts NJ, Vanarsdall RL, Barber HD, et al.
Diagnosis and treatment of transverse maxillary deficiency. Int J
Adult Orthodon Orthognath Surg 1995;10:90; with permission.)
The pattern of transverse expansion is different for SAME
than for maxillary segmental osteotomies. More expansion
occurs at the canines and less at the molars after SAME. In
contrast, during segmental Le Fort maxillary osteotomy, more
expansion is achieved at the maxillary molars than at the ca-
nines. In the SAME procedure, all the maxillary articulations
are not osteotomized superiorly and posteriorly (lateral nasal
wall and palatine bone); therefore, the greater resistance to
expansion in the posterior maxilla accounts for less posterior
expansion. The inelasticity of the palatal mucosa is a major
limiting factor for segmental Le Fort osteotomy. Widening of
more than 6 mm is not stable or feasible. Therefore, transverse
expansion greater than 7 mm would be an indication for SAME.
SAME is generally performed early in the treatment
sequence. Early expansion of the maxilla allows orthodontic
alignment in the severely crowded maxillary arch without the
need to extract teeth. Treatment plans that include a
Fig. 11 (A) Haas expansion device maintained as a retention device after expansion. Note the immature red granulation tissue present
bilaterally on the medial surfaces of the maxillary central incisors. (B) Palatal coverage retainer used as a retention device. The acrylic
base plate should not touch the anterior teeth and allows for orthodontic movement and closure of the midline diastema. (From Betts NJ,
Vanarsdall RL, Barber HD, et al. Diagnosis and treatment of transverse maxillary deficiency. Int J Adult Orthodon Orthognath Surg
1995;10:91; with permission.)
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75
segmental maxillary osteotomy often include extraction of
teeth with partial orthodontic space closure to allow for safe
performance of interdental osteotomies. In nonextraction
segmental osteotomies, the dentition requires buccal expan-
sion before surgery, which is unstable and prone to post-
operative relapse.
The major disadvantage of a treatment plan that includes
SAME followed by a 1-piece Le Fort maxillary osteotomy is
that 2 surgical procedures are required. If a patient who has
had a SAME procedure requires a Le Fort osteotomy for
correction of concomitant dentofacial deformity, a second
procedure must occur after orthodontic decompensation of
the maxillary and mandibular dentition. In contrast, a
segmental maxillary osteotomy attempts to correct the de-
formities in all planes of space during 1 surgical procedure.
The segmental maxillary osteotomy is a more difficult, more
technically sensitive, and potentially more morbid procedure
than a 1-piece maxillary osteotomy. Complications such as
tooth root injuries, periodontal defects, and vascular
compromise are more common in segmental than in 1-piece
maxillary osteotomies. The total cumulative time under
general anesthesia is approximately the same for SAME fol-
lowed by a 1-piece Le Fort I as for a segmental Le Fort
osteotomy. The potential postoperative morbidity is reduced
when SAME followed by a 1-piece Le Fort maxillary osteotomy
is performed. Surgical and operating costs are less for the
segmental maxillary osteotomy when performed in the hos-
pital, but costs could be less if the SAME were performed in an
ambulatory or office setting.
Summary and suggestions regarding the
correction of transverse discrepancies in adult
patients
 For patients who require less than 5 mm of transverse
expansion with adequate buccal bone present and no
gingival recession on the posterior maxillary dentition,
orthodontic/orthopedic expansion should be attempted.
 If the transverse discrepancy is greater than 5 mm, SAME
should be performed early in the treatment sequence,
after dental decompensation of the mandibular dentition.
 In a patient requiring a maxillary osteotomy for correction
of concomitant dentofacial deformities with a transverse
 Box 6. Complications associated with inade- Box 7. Complication caused by the expansion
quate surgery (activation of an appliance device
against mature, intact sutures)
1. Lack of appliance expansion
1. Pain and pressure 2. Deformation of the appliance caused by processing
2. Dental tipping errors (see Fig. 12)
3. Periodontal breakdown (as teeth are pushed through 3. Stripping or loosening of the midpalatal screw (see
the buccal plate) Fig. 13)
4. Palatal tissue impingement by the expansion device
(possibly with tissue necrosis)
5. Postorthodontic relapse

Fig. 12 (A) Example of an appliance that was overheated during fabrication, leading to deformation of the metal frame rather than
expansion. The patient experienced pain from the palate with each activation of the expansion key. Note the absence of a midline
diastema, indicating lack of maxillary expansion. (B) Palatal view after removal of the expansion appliance, showing a large ulcer on the
plate extending to the alveolar ridge. (From Betts NJ, Vanarsdall RL, Barber HD, et al. Diagnosis and treatment of transverse maxillary
deficiency. Int J Adult Orthodon Orthognath Surg 1995;10:91; with permission.)

Fig. 13 Occlusal view showing unequal expansion of a Haas appliance that had a malfunctioning jackscrew, although adequate expansion
was achieved. (From Betts NJ, Vanarsdall RL, Barber HD, et al. Diagnosis and treatment of transverse maxillary deficiency. Int J Adult
Orthodon Orthognath Surg 1995;10:92; with permission.)

Fig. 14 (A) The result of performing SAME using a ramped cut. As the expansion is performed, the maxilla moves inferiorly at the first
molar, worsening an open bite or converting an open-bite tendency into a true open bite. (B) This problem of inferior movement of the
maxilla during expansion can be overcome by performing the osteotomies parallel to the maxillary plane and creating a vertical cut at the
buttress, with excision of bone in the amount of the planned movement. This allows the maxillary expansion to occur without any bony
interference. (From Betts NJ, Vanarsdall RL, Barber HD, et al. Diagnosis and treatment of transverse maxillary deficiency. Int J Adult
Orthodon Orthognath Surg 1995;10:92; with permission.)

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Surgically Assisted Maxillary Expansion
discrepancy of less than 7 mm, consideration should be
given to segmental maxillary osteotomy.
 When a segmental maxillary osteotomy is used in a pa-
tient with a transverse discrepancy of greater than 6 mm,
complete expansion at the molars is difficult to achieve at
the time of surgery, because of palatal tissue inelasticity,
and is difficult to retain in the posttreatment period.
Therefore, SAME should be performed early in the treat-
ment sequence, followed by a 1-piece Le Fort osteotomy.
 If 2 separate maxillary surgical procedures are planned,
the SAME osteotomies should be performed where the 1-
piece maxillary osteotomies are projected to be.
 The diagnosis of maxillomandibular transverse discrep-
ancy may be difficult in adult patients when sagittal and
vertical deformities mask the transverse maxillary
discrepancy. When appropriate clinical and radiographic
assessments are performed, the correct diagnosis and
treatment sequences can be applied, resulting in an
acceptable and stable outcome.
Further readings
Angell EH. Treatment of irregularities of the permanent or adult teeth.
Dental Cosmos 1860;1:540e4. 599-601.
Bailey L, White RP, Proffitt WR, Turvey TA. Segmental LeFort I
osteotomy for management of transverse maxillary deficiency. J
Oral Maxillofac Surg 1997;55:728e31.
Banning LM, Gerard N, Steinberg BJ, Bogdanoff E. Treatment of
transverse maxillary deficiency with emphasis on surgically assisted
rapid maxillary expansion. Compend Cont Educ Dent 1996;17:
170e8.
Basdra EK, Zoller JE, Komposch G. Surgically assisted rapid palatal
expansion. J Clin Orthod 1995;29:762e6.
Bays RA, Greco JM. Surgically assisted rapid palatal expansion: an
outpatient technique with long-term stability. J Oral Maxillofac Surg
1992;50:110e3.
Bays RA, Greco JM, Hale RG. Stability of surgically assisted rapid
palatal expansion. A long term study. J Dent Res 1990;69:296.
Bell WH, Epker BN. Surgical-orthodontic expansion of the maxilla. Am J
Orthod 1976;70:517e28.
Bell WH, Jacobs JD. Surgical-orthodontic correction of horizontal
maxillary deficiency. J Oral Surg 1979;37:897e902.
Bell RA. A review of maxillary expansion in relation to rate of expansion
and patient’s age. Am J Orthod 1982;81:32e7.
Betts NJ, Lisenby CW. Normal adult transverse jaw values obtained
using standardized posteroanterior cephalometrics. J Dent Res
1994;73:298.
Betts NJ, Rosenberg M. Two different alar cinch suturing techniques
following surgical maxillary expansion. J Dent Res 1995;74:96.
Betts NJ, Scully JR. Transverse maxillary distraction osteogenesis.
In: Fonseca RJ, Marciani R, Turvey TA, editors. Oral and
maxillofacial surgery. 2nd editionvol. III. St Louis (MO): Saun-
ders; 2009. p. 219e37.
Betts NJ, Fonseca RJ, Vig P, et al. Changes in the nasal and labial soft
tissues after surgical repositioning of the maxilla. Int J Adult
Orthodon Orthognath Surg 1993;8:7e23.
Betts NJ, Vanarsdall RI, Barber HD, et al. Diagnosis and treatment of
transverse maxillary deficiency. Int J Adult Orthodon Orthognath
Surg 1995;10:75e96.
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For personal use only. No other uses without permission. Copyright ©2016. Elsevier Inc. All rights reserved.
77
Betts NJ, Thanasas AG, Lisenby CW, Mosier KM. Evaluation of racial
(African-American, Caucasian) and gender differences in skeletal
transverse dimension. J Oral Maxillofac Surg 1997;55(Suppl 3):86e7.
Buamrind S, Korn EL. Transverse development of human jaws between
the ages of 8.5 and 15.5 years, studied longitudinally with the use of
implants. J Dent Res 1990;69:1298e306.
Crosby DR, Jacobs JD, Bell WH. Special adjunctive considerations:
transverse (horizontal) maxillary deficiency. In: Bell WH, editor.
Modern practice in orthognathic and reconstructive surgery, vol. 3.
Philadelphia: WB Saunders; 1992. p. 2403e30.
da Silva Filho OG, Boas MC, Capelozza Gilho L. Rapid maxillary
expansion in the primary and mixed dentitions: a cephalometric
evaluation. Am J Orthod 1991;100:171e81.
Enlow DH. The facial growth process: part 1. In: Enlow DH, edi-
tor. Facial growth. 3rd edition. Philadelphia: WB Saunders;
1990. p. 58e76.
Haas AJ. Rapid expansion of the maxillary dental arch and nasal cavity
by opening the midpalatal suture. Angle Orthod 1961;31:73e90.
Haas AJ. The treatment of maxillary deficiency by opening the mid-
palatal suture. Angle Orthod 1965;35:200e17.
Ilizarov GA. Clinical applications of tension-stress effects for limb
lengthening. Clin Orthop Relat Res 1990;(250):8e26.
Kraut RA. Surgically assisted rapid maxillary expansion by opening the
midpalatal suture. J Oral Surg 1984;42:651e5.
Krebs A. Midpalatal suture expansion studied by the implant method
over a seven year period. Trans Eur Orthod Soc 1964;40:131e42.
Lanigan DT, Hey JH, West RA. Aseptic necrosis following maxillary
osteotomies: report of 36 cases. J Oral Maxillofac Surg 1990;48:
142e56.
Melson B. A histological study of the influence of sutural morphology
and skeletal maturation on rapid palatal expansion in children.
Trans Eur Orthod Soc 1972;48:499e507.
Mossaz CF, Byloff FK, Richter M. Unilateral and bilateral corticotomies
for correction of maxillary transverse discrepancies. Eur J Orthod
1992;14:110e6.
Persson M, Thilander B. Palatal suture closure in man from 15-35 years
of age. Am J Orthod 1977;72:42e52.
Phillips C, Medland WH, Fields HW Jr, et al. Stability of surgical
maxillary expansion. Int J Adult Orthodon Orthognath Surg 1992;7:
139e46.
Pogrel MA, Kaban LB, Vargervik K, Baumrind S. Surgically assisted rapid
maxillary expansion in adults. Int J Adult Orthodon Orthognath Surg
1992;7:37e41.
Ricketts RM, Roth RH, Chaconas SJ, et al. Orthodontic diagnosis and
planning.their roles in preventative and rehabilitative dentistry.
Denver (CO): Rocky Mountain Data Systems; 1982. p. 20e5. 42,
50e59, 138, 233e235.
Ricketts RM. Perspectives in the clinical application of cephalometrics,
the first fifty years. Angle Orthod 1981;51:115e50.
Shetty V, Cardid JM, Caputo AA, et al. Biomechanical rationale for
surgical-orthodontic expansion of the adult maxilla. J Oral Max-
illofac Surg 1994;52:742e9.
Silverstein K, Quinn PD. Surgically-assisted rapid palatal expansion for
management of transverse maxillary deficiency. J Oral Maxillofac
Surg 1997;55:725e7.
Stephens CR. An examination of the long-term stability of surgical-or-
thodontic maxillary expansion [Master’s thesis]. Columbus (OH):
Ohio State University; 1986.
Turvey TA. Maxillary expansion: a surgical technique based on surgical-
orthodontic treatment objectives and anatomic considerations. J
Maxillofac Surg 1985;13:51e8.