Journal of Cranio-Maxillo-Facial Surgery (2010) 38, 175e178

Ó 2009 European Association for Cranio-Maxillo-Facial Surgery

doi:10.1016/j.jcms.2009.07.003, available online at http://www.sciencedirect.com

Long term effects of surgically assisted rapid maxillary expansion without

performing osteotomy of the pterygoid plates

Robin SEEBERGER, MD, DDS1, Wolfgang KATER, MD, DDS2, Rolf DAVIDS, MD2, Oliver C. THIELE, MD1
1
Department of Oral and Maxillofacial Surgery, University Hospital Heidelberg, Germany; 2 Department of Oral and
Maxillofacial Surgery, Bad Homburg (Teaching Hospital of Frankfurt University Medical Center), Germany

SUMMARY. Purpose: Surgically assisted rapid maxillary expansions (SARME) are commonly used to widen the
maxilla. This study evaluates long term stability of surgically assisted rapid palatal expansion without perform-
ing osteotomy of the pterygoid plates and its effects on nasal airway volume. Materials and methods: 13 patients
(mean age 31, 23 ^ 6, 11) with a maxillary transverse deficit of at least 5 mm were examined 1 month before and
on average 63 months after a mean palatal distraction of 8.29 ^ 1.68 mm by acoustic rhinometry. Profiles of the
nasal airway volumes were collected. A cast model analysis was performed. The data were evaluated using
Wilcoxon signed rank test. Results: A V-shaped movement of the segments was observed. The gain for total
nasal volume was 23.25%. Findings indicate a significant enhancement of nasal volume in all patients
(P\ 0.01) as result of the maxillary expansion. No relapse occurred in the study group. Conclusion: SARME
provides a long term stable orthodontic bite correction and permanently enhances the nasal airways. A trans-
verse shift of the segments can be achieved over the whole bony palate even when no osteotomy of the
pterygo-maxillary suture is performed. Ó 2009 European Association for Cranio-Maxillo-Facial Surgery

Keywords: distraction osteogenesis, osteotomy, rapid palatal expansion, acoustic rhinometry, cranio-maxillofacial

INTRODUCTION et al., 1997; Shemen and Hamburger, 1997). This study

Surgically assisted rapid maxillary expansion (SARME)
as recommended by Bell and Epker (1976) is a well-
established method for corrective transverse maxillary
deficits in adults (Silverstein and Quinn, 1997). Crossbite
and crowded teeth are a typical characteristic of maxil-
lary compression syndromes. The mid palatal suture
closes from posterior to anterior with a large variation
in closing time from the age 16 to 35 years (Persson,
1973; Melson, 1975; Timms, 1986). Haas reported in
1970 that rapid maxillary expansion without surgical as-
sistance is impossible after the age of 18. Due to the pil-
lars of the upper facial skeleton, namely the apertura
piriformis, crista zygomaticoalveolaris and sutura ptery-
gopalatin (Han et al., 2009; Koudstaal et al., 2009).
They create the resistance responsible for a maxillary
collapse after widening (Haas, 1970; Bell and Epker,
1976; Neubert et al., 1989; Pinto et al., 2001; Wriedt
et al., 2001). Current finite element studies showed that
the crista zygomaticoalveolaris and sutura pterygopala-
tina create the main resistance for the expansion (Jafari
et al., 2003; Holberg, 2005). There is no common con-
sent over the surgical approach due to risk benefit con-
siderations (Zöller and Ullrich, 1991; Crosby et al.,
1992).
With acoustic rhinometry it is possible to examine the
cross-sectional profile of the nasal airways. In combina-
tion with cast model analysis it was possible to describe
the movement of the maxilla (Hilberg et al., 1989; Cory
describes the surgical outcome 5 years after the operation
in relation to the surgical approach described later.
(Fig. 1).
MATERIALS AND METHODS
This study was designed as a retrospective clinical mono-
centre study. Agreement was given by informed consent.
13 patients suffering from cross bite due to maxillary
compression were included to the study. The SARME
was part of a combined orthodontic treatment. No other
surgical actions were needed. 8 female and 5 male pa-
tients with a mean age of 31.23 ^ 6.11 underwent
a SARME. The acoustic rhinometry measurement was
performed 1 month before and on average 63 months af-
ter the operation. The patients were given topical decon-
gestion (xylometazoline 0,1%, 1 ml) 10 min before the
examinations. An additional cast model analysis to in-
clude the dental expansion between the first molars
(Pont’s points) was performed. Patients had no complex
malformation syndromes like clefts or premature cranio-
synostosis and had no operation of the nasal complex
before.
We performed the operation as described by Bell and
Epker (1976). Lateral osteotomy of the maxilla without
the separation of the pterygoid plates was followed by
osteotomy of the anterior portion of the lateral nasal
wall. The palatal suture was then separated by malleting
a thin Lambotts osteotome between the roots of the

175
176 Journal of Cranio-Maxillo-Facial Surgery
Fig. 1 e Skull model schema illustrating the main structural pillars for
the maxillary complex.
Fig. 2 e Example of initial finding of maxillary width compression.
Fig. 3 e Finding after distraction with tooth born Hyrax-jackscrew
distractor in situ.
central incisors without any palatal incision. Distraction
was then performed by a tooth born Hyrax-jackscrew
fixed on to the first molars and the first premolars.
(Figs. 2e4).
Fig. 4 e Finding at the end of orthodontic treatment.
The device was activated by 1 mm during surgery. The
patients then started distraction 1 week after the opera-
tion by 2 turns a day (0.5 mm/d). The acoustic rhinome-
try measurement was performed with a Rhinoklack RK
1000 (IfM Leiche, Wettenberg-Launsbach, Germany).
Acoustic rhinometry has been developed using the
principles of impedance differences inside hollow spaces,
when an acoustic pulse is applied (Hilberg et al., 1989).
A 55 db acoustic pulse is given and the reflected acoustic
pulse is then recorded within 10 ms. A cross-sectional
and volumetric profile is now traceable by measuring
the amplitude and velocity differences of output and re-
flected acoustic pulse (Cory et al., 1997). The total vol-
ume for each patient was divided into areas, the
anterior, medium posterior segment of the nasal cavity
and the nasal isthmus. The ranges were set in a distance
from the nasal isthmus for the anterior segment
0e2.3 cm, the medium segment 2.3e4.6 cm and for
the posterior segment 4.6e7 cm as described elsewhere
(Kunkel et al., 1999; Wriedt et al., 2001). For pre and
post therapeutic evaluation, a Wilcoxon signed rank
was performed for all volumetric data with the level of
significance set at P \ 0.01.
RESULTS
All patients showed a significant enlargement of the nasal
volume as result of the palatal transverse distraction. The
increase in volume was highly significant in the Wil-
coxon signed rank test (P \0.01) for all the measured
nasal segments. 5 years after the surgical approach the to-
tal nasal volume is increased in mean 23.25% Table 1
and Fig. 5). The volumes of the different segments indi-
cate a V-shaped movement of the segments. The gain
was greater in the anterior than in the medium and pos-
terior segments. Enhanced nasal respiration was reported
by all patients as a result of the widening. The nasal isth-
mus increased by a mean of 30.36%. No relapse of the
maxillary expansion was observed. The cast model anal-
ysis showed a mean distraction width of 8.29 ^ 1.68 mm
measured on Pont’s points of the first upper molar. Stable
orthognathic occlusions were observed 63 months after
treatment. All patients reported substantial improvement
of nasal respiration (Table 2).
 Effects of surgically assisted rapid maxillary expansion without performing osteotomy of the pterygoid plates 177

Fig. 5 e Irregular distributions of the volume gain in the different segments.

medium and posterior segment indicate a transverse shift

Table 1 e Changes in the different segments pre- and postoperatively in in these segments is taking place. In this region, the tooth
cm3 (percentages)
born distractor is utilized. The mean distraction width of
Variable Mean SD Percent Segment 8.29 ^ 1.68 mm combined with orthognathic occlusion
after the treatment emphasizes the results. Tooth tilting
Volume difference total 5.95 1.17 23.25 0e7 cm
Volume difference anterior 1.00 0.24 25.31 0e2.3 cm
of the anchor teeth is a likely side effect of tooth born dis-
Volume difference 1.95 0.44 22.11 2.3e4.6 cm tractors. The wide range of distraction is only achievable
mid point if there is bony movement at the palatal suture. Our
Volume difference posterior 3.06 0.78 23.87 4.6e7 cm results indicate a V-shaped transverse movement of the
Volume difference isthmus 0.17 0.04 30.36 segments. The result is underlined by the gain of
30.36% for the nasal isthmus and of 25.31% for the
anterior Segment. The results of Kunkel and
Hochban (1994) describing the maximum effects of mu-
Table 2 e The pre- and postoperative results in cm3
cosal decongestion found only a slight movement in the
Variable Pre (mean ^ SD) Post (mean ^ SD) medium and posterior segments. Not separating the pter-
ygoid plates as a resistance to the maxillary expansion
Volume difference total 25.55 ^ 0.96 31.49 ^ 0.94
Volume difference anterior 3.95 ^ 0.29 4.95 ^ 0.44 (Jafari et al., 2003; Holberg et al., 2005) did not result
Volume difference 8.82 ^ 0.43 10.77 ^ 0.64 in any relapse. Studies from Zöller (1991) emphasize
mid point our results. Marchetti et al. (2009) reported a relapse of
Volume difference posterior 12.82 ^ 0.92 15.88 ^ 0.38 28% in the intercanine and 36% in the intermolar dis-
Volume difference isthmus 0.56 ^ 0.05 0.73 ^ 0.03
tance after SARME even though they performed separa-
tion of the pterygoid plates. Analysing a cast models
DISCUSSION briefly post expansion, and 2 years later, with orthodontic
treatment in between, the effects of the orthodontic treat-
SARME clearly has an influence on the nasal airflow ment like teeth shift and tilt were not considered as
conditions as described elsewhere (Haas, 1970; Lines, explaining the results.
1975; Neubert et al., 1989; Mommaerts, 1999). Examin- Patients in our study experienced an increase in nasal
ing flow conditions, nasal volumes and cross-sectional airflow was also shown by Siddik et al. (2007). Our study
profiles with acoustic rhinometry is a well-established, showed a persistent increase in the total nasal volume of
non-invasive method (D’Urzo et al., 1987; Hilberg 23.25% combined with stable orthognathic occlusion
et al., 1989; Kunkel and Hochban, 1994). It is well suited five years after the surgical approach. Risk benefit con-
for follow-up controls (Hilberg et al., 1989; Kunkel and siderations indicate that omitting separation of the ptery-
Hochban, 1994; Shemen and Hamburger, 1997). Han goid plates is possible (Koudstaal et al., 2005).
et al. (2009) concluded in their finite element study,
that a pterygo-maxillary separation is an effective proce- CONCLUSION
dure for increasing the expansion of the maxilla with
lower side effects for the anchor teeth. Our results Long term stable bite corrections are achievable by sur-
show that a transverse shift of the segments can be gically assisted rapid maxillary expansion even without
achieved over the whole bony palate even though no separating the pterygoid plates. The results show a slight
osteotomy of the pterygo-maxillary suture was performed. anterior-posterior V-shaped transverse shift of the seg-
In our study, widening of 22.11% and 23.87% for the ments. No maxillary relapse or malocclusion occurred.
178 Journal of Cranio-Maxillo-Facial Surgery
The total nasal volume increased by 23.25% and patients
experienced a better nasal airflow as well as faster anasta-
sis after the operation. Due to anatomical circumstances
in the pterygo-maxillary fossa, our surgical approach pro-
vides a better risk benefit consideration.
CONFLICT OF INTEREST
No authors wish to disclose any financial or personal rela-
tionships with other people or the organizations involved.
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Robin SEEBERGER, MD, DDS
Department of Oral and Maxillofacial Surgery
University Hospital Heidelberg
INF 400
69120 Heidelberg
Germany
Tel.: +49 6221 56 39716
Fax: +49 6221 56 4222
E-mail: robin.seeberger@med.uni-heidelberg.de
Paper received 13 March 2009
Accepted 3 July 2009