Conservative surgical orthodontic adult

rapid palatal expansion: Sixteen eases

Andrew S. Glassman, D.D.S.,* Stephen J. Nahigian, D.D.S.,**
Jerald M. Medway, D.D.S.,*** and Harry I. Aronowitz, D.M.D.****
Los Angeles, Calif.

A conservative surgical orthodontic technique that facilitates the widening of the adult maxilla at the midpalatal
suture is presented. This procedure uses only lateral maxillary corticotomies and a maxillary Hyrax split-palate
appliance. In all sixteen cases attempted, separation of the midpalatal suture was confirmed by occlusal
radiographs and a diastema between the maxillary central incisors.

Key words: Adult, rapid palatal expansion, surgical, orthodontic appliance, malocclusion

Surgical facilitation of rapid palatal ex-

pansion (RPE) in adults has been reported previ-
ously. Although the techniques have varied in the
reported procedures, surgical treatment of the mid-
palatal suture and pterygomaxillary junction was de-
scribed.‘, x 3-8, “-‘L ‘O* 21 Initially, the midpalatal
suture was identified as a significant area of osseous
resistance to palatal expansion in patients beyond their
late teens. *, ‘*, I43 15, i9, *I More recently, important
contributions to the problem of palatal expansion have
indicated that the zygomaticomaxillary buttress and the
pterygomaxillary junction are critical areas of resis-
tance to palatal expansion.2%3, I13 l4
It is evident that controversy still exists in that re-
cent contributions to the literature continue to con-
template palatal surgery in many cases.a* *ix I9321 Fig. 1. Diagram of osteotomy. Made from lateral aspect of
We would like to present a series of cases in which piriform rim to pterygoid plates.
successful RPE was achieved without midpalatal or
pterygomaxillary surgery. This simplified technique
can be used safely in an office setting, with minimal of possible hemorrhage in the area of the pterygomaxil-
morbidity and postoperative complications. The con- lary fissure.
tents of the incisive canal are preserved, and there is no Maxillary arch-width discrepancies in children have
risk of surgical dehiscence of nasal or palatal tissue or been corrected with relatively straightforward ortho-
dontic techniques. Various rapid and slow palatal
appliances have been advocated with good, predictable
*In private practice of oral and maxillofacial surgery, Beverly Hills, Calif.;
success,“-7’ 10. 22 Expansion was confirmed radio-
Chief, Section of Oral and Maxillofacial Surgery, Cedars-Sinai Medical Cen-
ter, Los Angeles, Calif. graphically in both deciduous and mixed dentitions by
**In private practice of oral and maxillofacial surgery, Beverly Hills, Calif.;
opening of the median palatal suture.gs lo With the in-
Attending Staff, Cedars-Sinai Medical Center, Los Angeles, Calif.
***In private practice of orthodontics, West Los Angeles, Calif.; Clinical creased interest in adult orthodontics, maxillary width
Instructor, Department of Orthodontics, University of California, Los Angeles problems in the nongrowing patient have been encoun-
School of Dentistry.
tered with greater frequency. Successful RPE has
****In private practice of orthodontics, Beverly Hills, Calif.; Assistant Clini-
cal Rofessor, Department of Orthodontics, University of Southern California proved to be less predictable in the adult than in a child.
School of Dentistry. Resistance, relapse, and pain associated with palatal

207
20% Classman et al

Fig. 2. Patient L.H. prior to rapid palatal expansion with bilateral Fig. 4. Initial dissection with exposure of lateral maxillary wall.
posterior crossbite.

Fig. 3. Hyrax appliance in place prior to surgery Fig. 5. Osteotomy made through lateral maxillary wall.

expansion have been attributed to several factors, in- and pterygomaxillary osteotomy, while the second
cluding increased rigidity of the facial bones, especially group was either an unoperated control or had palatal
the zygomatic buttress and other circummaxillary osteotomy alone. Their conclusion was that “true
sutures. 3, 6. 7, 9-12, 22 movement of basal bone of the maxilla by RPE could
Fusion at the midpalatal suture was also cited as a be accomplished by reduced resistance to lateral
contributing factor to the poor prognosis for adult movement via osteotomy through the zygomatic but-
RpE 12. 15, 19. ?I
tress, nasomaxillary, and pterygomaxillary areas. “I2
In 1975 LinesI and in 1976 Bell and Epke?
REVIEW OF THE LITERATURE
brought clinical relevance to the question of adult RPE
In 1959 Kale’” advocated selective dentoalveolar when they advocated these same selected osteotomies
osteotomies to section cortical bone and eliminate resis- in their skeletally mature patients. However, the latter
tance to orthodontic movement. Converse and Horo- still recommended placement of a chisel in the mid-
witz suggested both labial and palatal cortical os- palatal suture from the nasal side, while the former
teotomies for their expansion technique in 1969. made a palatal incision and with a bur cut through the
In 1976 Kennedy and associates’” studied the ef- midpalatal suture.
fects of selected maxillary osteotomies as an adjunct to Jacobs and his colleagues” reported in an article in
RPE in mature rhesus monkeys. Their results revealed March, 1980, that “once a diagnosis of absolute trans-
a strong statistical difference between two groups; one verse maxillary deficiency has been made, and it is
group was treated with lateral maxillary, pterygomaxil- ascertained that the need for expansion of the maxillary
lary, and palatal osteotomy or simply lateral maxillary arch does exist, other factors must be considered to
Volume 86 Conservative surgical adult rapid palatal expansion 209
Number 3

Fig. 6. Primary closure of incision. Fig. 8. Frontal view with diastema

Fig. 7. Patient on sixteenth postoperative day showing Hyrax Fig. 9. Patient with posterior crossbite and diastema closed 5
appliance expanded. months after beginning orthodontic treatment.

determine whether such expansion should be achieved the minimal amount of surgery. Timms advocated a
through lateral maxillary osteotomies and rapid maxil- surgical palatal split in his technique.
lary expansion, as an integral part of the presurgical We have found that uniform palatal expansion can
orthodontic therapy, or by segmentalizing the maxilla be achieved in either extraction or nonextraction cases
at the time of the surgery to achieve transverse correc- without sectioning of either the palate or the pterygo-
tion, concomitantly with ultimate vertical and/or sagit- maxillary fissure. A technique of lateral corticotomy
tal treatment objectives.” They also stated that “if from the piriform rim anteriorly and posteriorly, to and
nonextraction orthodontic therapy is desired, then, lat- through the zygomaticomaxillary buttress, was used
eral maxillary osteotomies and rapid maxillary expan- exclusively in the cases reported in this study, which
sion is the treatment of choice.” In that article, they included nonextraction, simultaneous extraction, uni-
also refer to reports of maxillary expansion via lateral lateral, and bilateral cases in patients from 14 to 44
maxillary, pterygomaxillary, and palatal osteotomies to years of age.
achieve their expansion.
DESCRIPTION
Most recently (in 1981) Timms,21 basing his ap-
proach on the findings of Persson and ThilanderlY who Upon perceiving unilateral or bilateral buccal
had reported various degrees of midpalatal ossifications crossbite in the adult patient, the orthodontist can con-
in different age groups, sought to establish a conserva- sider RPE in his treatment plan. A Hyrax* appliance is
tive and definitive staging sequence to provide a cemented to the first premolar and to the first molar. If
“modus operandi” for the oral surgeon and orthodon-
tist to employ the maximal amount of expansion with *Registered trademark of O.I.S., Wilmington, Del
210 Glasman et al. Am. J. Orthod.
Srptember 1984

Fig. 10. Patient R.M. with bilateral posterior crossbite.

Fig. 12. Maxillary occlusal radiograph showing separation at

midpalatal suture.

simultaneous first-premolar extraction is indicated, the

appliance may be cemented to the second premolar and
second molar without compromising treatment objec-
Fig. 11. Patient R.M. after rapid palatal expansion therapy.
tives. The orthodontist may elect to attempt expansion
without surgery, as placement of the appliance will not
Table I. interfere with any proposed surgery. If the RPE is un-
Unilateral
successful, or is deemed inappropriate by virtue of the
Case Patient’s Compli- patient’s advanced age or skeletal maturity, the patient
No. initials Sex Age bilayeral cations* is referred to the oral surgeon.
1 D.R. M 35 B
After adequate consultation, the patient is prepared
2 R.G. M 22 B 4 for surgery and given light anesthetic sedation which is
3 K.M. F 25 B 4 supplemented by local anesthetic nerve block. An inci-
4 L.H. F 22 B sion is then made in the height of the buccal vestibule
5 C.F. F 29 B 2 from the mesial aspect of the first molar to the distal
6 D.K. M 18 B
7 B.G. M 19 B 4
aspect of the canine. The lateral maxillary wall is ex-
8 A.B. M 34 B I posed by mucoperiosteal elevation from the piriform
9 M.H. M 26 B anteriorly across the zygomatic maxillary buttress, then
10 M.V. F 14 B posterior to the pterygomaxillary fissure via a sub-
II R.M. F 21 B
periosteal tunneling technique. A fissure bur is used to
12 M.T. M 18 U 4
13 R.P. F 15 U 3 effect an osteotomy approximately 5 mm above the
14 K.D. F 22 B apices of the teeth from the piriform rim to the zygo-
15 K.A. F 44 B matic maxillary buttress, ending just anterior to the
16 P.B. M 20 U pterygoid fissure (Fig. 1). Care is taken at the anterior
*Key to symbols: 1 = Sinus infection. 2 = Transient extrusion of
aspect of the osteotomy to avoid tearing the nasal mu-
abutment tooth. 3 = F’re-existing cleft palate with unilateral pos- coperiosteum by using a freer elevator as a tissue
terior collapse. 4 = Transient epistaxis. guard. The wound is then closed with a Vicryl3-0 dyed
Volume 86 Conservative surgical adult rapid palutal expansion 211
Number 3

Fig. 13. Patient R.G. with severe crowding and posterior Fig. 14. Patient R.G. after rapid palatal expansion therapy.
crossbite.

suture. Prophylactic antibiotics, nasal decongestants,

and analgesics are prescribed.
The appliance is activated four turns (1 mm) at the
time of surgery to absorb some of the elastic properties
of the appliance. On the third postoperative day, the
patient is instructed to activate one turn in the morning
and then one turn in the evening, until adequate expan-
sion has been achieved. The appliance is left in place
for 12 weeks in a passive position, after which time
routine orthodontic procedures can be initiated or con-
tinued.
CASE REPORT
Patient L.H., a 24-year-old woman, sought orthodontic
treatment in May. 1982. Oral examination revealed sig-
nificant bilateral posterior maxillary crossbite(Fig. 2). There
was a Class I molar relationship with an open-bite tendency.
Anterior maxillary crowding was evident, as was anterior
mandibular crowding to a Iesser extent. To correct the cross-
bite and create additional arch width, RPE was considered.
An oral surgical consultation was obtained in July, 1982.
History and physical examination revealed a healthy woman
with no contraindication for surgery. Radiographic evaluation
revealed normal dental and osseous structures, no gross decay
or periapical pathoses, and normal sinus configuration. The
third molars were partial bony, mesial angular. Surgical re- Fig. 15. Maxillary occlusal radiograph showing separation of
moval of the third molars and a lateral maxillary corticotomy midpalatal suture.
were scheduled for August, 1982. The patient returned to her
orthodontist for placement of the Hyrax RPE device (Fig. 3).
When seen in February, 1983, the patient had maintained
In August, 1982, the patient underwent the previously
the Class I molar relationship, but the crossbite was elimi-
described surgical procedure. Initial incision and maxillary
nated and the diastema was closed (Fig. 9). Orthodontic
exposure (Fig. 4) were followed by lateral maxillary cor-
treatment continues.
ticotomy (Fig. 5). The wound was closed (Fig. 6), the proce-
dure was repeated on the opposite site, and the third molars iXCUSSlON
were then removed. The Hyrax appliance was activated 1 mm
(four turns) at the time of surgery, then one turn in the morn- Rapid palatal expansion with lateral corticotomy
ing and evening after the third postoperative day. Expansion only has been successful in all sixteen cases in which it
of 5.5 mm was seen on the sixteenth postoperative day (Figs. has been attempted (Table I). The technique has several
7 and 8). apparent advantages over the previously described
 212 Glassrnan et ul Am. J. Orthod.
Sr@vnber 1984

Fig. 16. Patient E.G. with posterior crossbite and recent extrac-
tion of maxillary first premolar.

Fig. 16. Maxillary occlusal radiograph showing separation of

midpalatal suture.

In all cases thus far completed, there was only one

incident of postoperative sinus infection. This patient
was found to have, at a later date, a calcified nasal
antral ostium. In the one case of extrusion of the teeth
Fig. 17. Patient E.G. after rapid palatal expansion treatment. cemented to the Hyrax appliance, removal of the buccal
aspect of the cemented Hyrax band allowed intrusion
techniques. As no palatal approach is contemplated, the without loss of palatal expansion.
Hyrax appliance can be placed prior to surgery, and In our series of cases extending over a period of 5
nonsurgical RPE can be attempted by the orthodontist. years, there has been no visual relapse, either immedi-
Should nonsurgical RPE fail or be associated with sig- ately following removal of the expansion device or
nificant pain, then surgery can be performed without after case completion. The postorthodontic series of
removing the appliance. Moreover, the pain associated cases have been followed 2 years after band removal
with palatal osteotomy, whether by bur or chisel, is without any observable relapse.
avoided.
SUMMARY
Operative bleeding and trauma to the incisive canal
are minimized by avoiding the surgical split of the pal- A conservative approach for surgical facilitation of
ate. As the maxillary expansion proceeds, a diastema is rapid palatal expansion has been presented. It provides
produced between the central incisors, similar to RPE greater flexibility on the part of the orthodontist and
in children (Figs. 10 to 18). The procedure may be decreases time and morbidity from a surgical approach.
performed safely in an office environment and postex- The elimination of the palatal osteotomy in this tech-
pansion relapse has not been observed. nique has proved successful in all sixteen cases thus
Possible postoperative complications include sinus treated.
infection, devitalization of the teeth (if osteotomy is
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Nurnbrr 3

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