Original Article

Craniomaxillofacial Trauma &

Reconstruction
2022, Vol. 15(3) 219–228
Current Practice for Transverse ª The Author(s) 2021
Article reuse guidelines:
Mandibular and Maxillary Discrepancies sagepub.com/journals-permissions
DOI: 10.1177/19433875211027694

in the Netherlands: A Web-Based journals.sagepub.com/home/cmt

Survey Among Orthodontists and Oral

and Maxillofacial Surgeons

Atilla Gül, MD, DMD1, Stephen T. H. Tjoa, DDS, MSc, MS1,

Jan P. de Gijt, MD, DMD, PhD2,
Justin T. van der Tas, MD, DMD, MSc, PhD1,
Hadi Sutedja, DMD, DMSc3, Eppo B. Wolvius, DMD, MD, PhD1,
Karel G. H. van der Wal, MD, DMD, PhD1,
and Maarten J. Koudstaal, MD, PhD, DMD1

Abstract
The main objective of this study was to provide an overview of the current practice for transverse mandibular and
maxillary discrepancies in the Netherlands using a web-based survey. Orthodontists (ORTHO) and Oral and Maxillofacial
Surgeons (OMFS) in the Netherlands were invited to the web-based survey via their professional association. Three cases
were presented which could be treated non-surgically and surgically. Participants were asked what treatment they
preferred: no treatment, orthodontic treatment with optional extractions or surgically assisted orthodontic treatment.
The web-based survey ended with questions on various technical aspects and any experienced complication. Invitation
was sent to all 303 members of professional association for ORTHO and to all 379 members of professional association
for OMFS. Overall response number was 276 (response rate of 40.5%), including 127 incomplete responses. Generally,
ORTHO prefer orthodontic treatment with optional extractions and OMFS lean towards surgically assisted orthodontic
treatment. Mandibular Midline Distraction appears to be less preferred, possibly due to lack of clinical experience or
knowledge by both professions despite being proven clinical stable surgical technique with stable long-term outcomes.
There seems to be consensus on technical aspects by both professions, however, there are various thoughts on duration
of consolidation period. Complications are mostly minor and manageable.

Keywords
MMD, SARME, transverse mandibular discrepancy, transverse maxillary discrepancy, current practice, survey

Introduction
Historically, transverse mandibular and maxillary discre-
pancies were managed with orthodontic dental expansion
1
and/or dental extraction therapy. Changes in arch dimen- Department of Oral and Maxillofacial Surgery, Erasmus MC, University
Medical Center Rotterdam, the Netherlands
sions by dental expansion result in unstable post-treatment 2
Department of Oral and Maxillofacial Surgery, Ikazia Hospital,
results. The mandibular symphysis closes at 1 year of age,1,2 Rotterdam, the Netherlands
which makes expansion without surgery impossible. The 3
Private Practice, Rotterdam, the Netherlands
midpalatal suture can be expanded with orthodontic treat-
ment until approximately the age of 15.3 With the introduc- Corresponding Author:
Atilla Gül, MD, DMD, Department of Oral and Maxillofacial Surgery,
tion of distraction osteogenesis for the facial skeleton in Erasmus MC, University Medical Center Rotterdam, Dr. Molewaterplein
1990, new treatment options became possible.4,5 Both osteo- 40, room Nd-324, 3015 GD Rotterdam, the Netherlands.
genesis and histogenesis are induced with this technique. Email: [email protected]
220 Craniomaxillofacial Trauma & Reconstruction 15(3)

Mandibular midline distraction (MMD) is a proven sur- Three cases were presented clinical and radiographic
gical technique to widen the mandible in order to solve with transverse mandibular and maxillary discrepancies
transverse mandibular discrepancies with stable long-term that can be treated both non-surgically and surgically
outcomes.6,7 In conjunction with an osteotomy in the mid- (Online Supplemental Appendices I, II, and III).
line of the mandible a distractor is attached on both sides of Case 1 was a 16-years old woman, case 2 a 44-years old
the osteotomy, after which the skeletal dental base can be man and case 3 a 43-years old man. The patients’ chief
expanded by distraction osteogenesis. General indications complaint was explicitly not mentioned in order to disclose
for MMD are V-shape of the mandible, anterior or posterior an unbiased treatment planning decision.
crowding, uni- and bilateral crossbite and impacted anterior All 3 presented patients had given prior written consent
teeth with inadequate space and tipped teeth.5,8-10 For max- for the use of their visual material for this web-based sur-
illary transverse discrepancies, surgically assisted rapid vey and publication in a scientific journal.
maxillary expansion (SARME) is a widely applied stable Participants were asked what treatment they prefer with
technique.11,12 Clinically, indications for SARME include the following answer options:
anterior or posterior crowding, uni- and bilateral crossbite,
black buccal corridors, buccal tipping of the maxillary – No treatment.
molars and lingual tipping of the mandibular molars.11-13 – Orthodontic treatment with optional extractions:
There are various types of distractors available such as Without premolar extractions in the lower and upper
tooth-borne, bone-borne or a combination of both (hybrid). jaw, only orthodontic alignment of both dental
Following surgery, generally a latency period is respected arches.
to create soft callus formation before starting with distrac-  With premolar extractions only in the lower jaw, fol-
tion. In contrast to distraction technique for the long lowed by orthodontic alignment of both dental
bones,14 there is no standardized protocol for MMD and arches.
SARME. In the literature, there are many variable factors  With premolar extractions only in the upper jaw, fol-
like the clinical indication, anesthesia technique, osteotomy lowed by orthodontic alignment of both dental
technique (MMD: vertical or step, SARME: surgical trans- arches.
ections), latency period, distractor type, distraction rate,  With premolar extractions in both the lower and upper
overcorrection and consolidation period. jaw, followed by orthodontic alignment of both den-
The main objective of this study was to provide an over- tal arches.
view of the current practice for transverse mandibular and – Surgically assisted orthodontic treatment:
maxillary discrepancies in the Netherlands using a web-
based survey. Orthodontists and Oral and Maxillofacial  Surgically assisted expansion of the lower jaw only
Surgeons can use this information to align and improve the with distraction osteogenesis, followed by orthodon-
treatment modalities for transverse mandibular and maxil- tic alignment of both dental arches.
lary discrepancies and inform their patients better about the  Surgically assisted expansion of the maxilla only with
possible treatment options. distraction osteogenesis, followed by orthodontic
alignment of both dental arches.
 Surgically assisted expansion of both the lower and
Materials and Methods upper jaw with distraction osteogenesis followed by
Orthodontists and Oral and Maxillofacial surgeons in the orthodontic alignment of both dental arches.
Netherlands were invited per mail to participate anon- After giving the preference of treatment, our applied treat-
ymously in this web-based survey after approval had been ment(s) were shown for each case separately. Case 1 was
obtained from the Medical Ethics Committee of Erasmus treated with surgically assisted orthodontic treatment: with
MC, University Medical Center Rotterdam, the Netherlands MMD using a bone-borne (Rotterdam Mandibular) distractor
(approval number: MEC-2020-0459). This was provided by and with SARME using a Hyrax distractor. Case 2 was
using the professional associations for Orthodontists treated with surgically assisted orthodontic treatment: with
(“Nederlandse Vereniging van Orthodontisten,” MMD using a tooth-borne distractor and with SARME using
NVvO) and for Oral and Maxillofacial Surgeons a Haas distractor. Case 3 was treated with orthodontic treat-
(“Nederlandse Vereniging voor Mondziekten, Kaak- en ment with premolar extractions in both the lower and upper
Aangezichtschirurgie,” NVMKA). To maximize the jaw followed by orthodontic alignment of both dental arches.
response rate, the invitation to participate was sent twice In addition, participants were asked if they were satis-
to the same mail list by both professional associations and fied with our applied treatment by using a score scale
the web-based survey was built with tick box answers. (1 ¼ very dissatisfied and 5 ¼ very satisfied) and whether
In this web-based survey participants were asked what they will recommend (again) the applied treatment in the
specialism they practice, what their place of training was, future for the same indication.
how many years of experience they have and if they are The web-based survey ended with questions on various
practicing in a training clinic. technical aspects concerning the number of surgically
Gül et al. 221

assisted orthodontic treatment performed, preference of Case 2

distractor type, latency period, distraction rate, overcorrec-
Case 2 was filled out completely by 119 ORTHO members
tion, consolidation period, orofacial soft tissue effects and
(response rate of 39.3%), of which 73 members had
any experienced complication.
chosen for orthodontic treatment with optional extractions,
All the obtained data were stored automatically and
35 members for surgically assisted orthodontic treatment
anonymously in LimeSurvey GmbH, version 2.06lts Build
(MMD, 3; SARME, 22; MMD and SARME, 8) and
160524, which is provided by the local Erasmus MC server.
11 members for no treatment. The mean score scale of
satisfaction for our applied treatment was 3.67 + 1.00
(n ¼ 97), of which 32 members (33%) would choose our
Statistical Analysis applied treatment again.
Seventy-nine OMFS members (response rate of 20.8%)
Descriptive statistics are used to characterize the study
filled out completely the same case. Out of this 32 members
population. Means are presented for data that followed a
had chosen for orthodontic treatment with optional extrac-
normal distribution and medians if the data followed a non-
tions, 35 members for surgically assisted orthodontic treat-
normal distribution. The presented proportions are based on
ment (MMD, 4; SARME, 23; MMD and SARME, 8) and
the number of valid cases.
12 members for no treatment. The mean score scale of
For data handling and analyses, the Statistical Package
satisfaction for our applied treatment was 3.98 + 0.83
of Social Sciences version 25.0 for Windows (IBM Corp,
(n ¼ 66), of which 37 members (56.1%) would choose our
Armonk, NY, USA) was used. The graphical figures were
applied treatment again.
made by exporting the data to Microsoft Excel 2016 for
Windows version 16.0 (Microsoft, Redmond, WA, USA).
In reporting of this study the STROBE guidelines were Case 3
followed.15
Case 3 was filled out completely by 107 ORTHO members
(response rate of 35.3%), of which 66 members had
chosen for orthodontic treatment with optional extractions,
Results 35 members for surgically assisted orthodontic treatment
This web-based survey was sent per mail twice to all 303 (MMD, 2; SARME, 14; MMD and SARME, 19) and
members of the NVvO (Orthodontists, ORTHO) and to all 6 members for no treatment. The mean score scale of satis-
379 members of the NVMKA (Oral and Maxillofacial faction for our applied treatment was 2.92 + 1.17 (n ¼ 97),
Surgeons, OMFS). There was an overall response number of which 29 members (29.9%) would choose our applied
of 276 (response rate of 40.5%), including 127 incomplete treatment again.
responses. See Table 1 and Figures 1, 2, and 3 for a com- Finally, 72 OMFS members (response rate of 19%)
plete overview of the responses and results per case. filled out the same case completely, of which 18 members
had chosen for orthodontic treatment with optional extrac-
tions, 49 members for surgically assisted orthodontic treat-
ment (MMD, 0; SARME, 18; MMD and SARME, 31) and
Case 1 5 members for no treatment. The mean score scale of satis-
Case 1 was filled out completely by 135 ORTHO members faction for our applied treatment was 2.97 + 1.14 (n ¼ 66),
(response rate of 44.6%), of which 118 members had cho- of which 21 members (31.8%) would choose our applied
sen for orthodontic treatment with optional extractions, treatment again.
10 members for surgically assisted orthodontic treatment
(MMD, 0; SARME, 5; MMD and SARME, 5) and 7 mem-
bers for no treatment. The mean score scale of satisfaction Technical Aspects
for our applied treatment was 3.5 + 1.01 (n ¼ 100), of See Table 1 for a complete overview of the results per
which only 15 members (15.0%) would choose our applied technical aspect. Ninety-three ORTHO members (response
treatment again. rate of 30.7%) have performed at least 1 MMD and/or
On the other hand, 90 OMFS members (response rate of SARME annually. The general preference of distractor
23.7%) filled out completely, of which 45 members had type was the tooth-borne distractor combined with a
chosen for orthodontic treatment with optional extractions, latency period of 0-5 days where after a distraction rate
39 members for surgically assisted orthodontic treatment of 0.5 mm/day was applied generally for both MMD and
(MMD, 2; SARME, 22; MMD and SARME, 15) and SARME. In contrast to SARME, generally no overcorrec-
6 members for no treatment. The mean score scale of satis- tion of distraction is preferred for the MMD. Generally,
faction for our applied treatment was 3.67 + 1.00 (n ¼ 67), after active distraction, a consolidation period of 4 months
of which 27 members (40.3%) would choose our applied for MMD and 6 months for SARME is preferred. In gen-
treatment again. eral, before start of MMD and/or SARME possible
222 Craniomaxillofacial Trauma & Reconstruction 15(3)

Table 1. Complete Overview of the Responses and Results Per Case.

OMFS (n ¼ 379) ORTHO (n ¼ 303)

Responses (overall n ¼ 276) (40.5%) 113 (29.8%) 150 (49.5%)

Work experience as a specialist:
Less than 5 years 38 25
Between 5-10 years 25 21
Between 10-15 years 14 27
More than 15 years 32 59
Resident in training 11 16
No longer working 3 2
Place of education:
“Vrije Universiteit” Amsterdam 14 36
“Academisch Medisch Centrum” Amsterdam 10 —
“Universitair Medisch Centrum” Utrecht 14 —
“Universitair Medisch Centrum” Leiden 5 —
“Universitair Medisch Centrum” Maastricht 4 —
“Universitair Medisch Centrum” Groningen 23 27
“Radboud Universiteit” Nijmegen 19 47
“Erasmus Medisch Centrum” Rotterdam 15 —
Other 5 29
Total 109 139
Practicing in a training clinic:
No 52 113
Yes/partially 46 19
Not anymore 1 —
Total 99 132
Case 1 (n) 90 135
Treatment
Orthodontic treatment 45 (50%) 118 (87.4%)
Without PM extractions 17 (37.8%) 47 (39.8%)
With PM extractions LJþUJ 16 (35.6%) 69 (58.5%)
With PM extractions LJ 10 (22.2%) 2 (1.7%)
With PM extractions UJ 2 (4.4%) 0 (0.0)
Surgically assisted orthodontic treatment 39 (43.3) 10 (7.4%)
MMD 2 (5.1%) 0
SARME 22 (56.4%) 5 (50%)
Both 15 (38.5%) 5 (50%)
No treatment 6 (6.7%) 7 (5.2%)
Satisfaction
Mean + SD 3.67 + 1.00 (n ¼ 67) 3.50 + 1.01 (n ¼ 100)
Recommend (again) the applied treatment
Yes 27 (40.3%) 15 (15.0%)
No 40 (59.7%) 85 (85%)
67 100
Case 2 (n) 79 119
Treatment
Orthodontic treatment 32 (40.5%) 73 (61.3%)
Without PM extractions 9 (28.1%) 35 (47.9%)
With PM extractions LJþUJ 21 (65.6%) 13 (17.8%)
With PM extractions LJ 2 (6.3%) 6 (8.2%)
With PM extractions UJ 0 19 (26.0%)
Surgically assisted orthodontic treatment 35 (44.3%) 35 (29.4%)
MMD 4 (11.4%) 3 (9.1%)
SARME 23 (65.7%) 22 (66.7%)
Both 8 (22.9%) 8 (24.2%)
No treatment 12 (10.6%) 11 (9.2%)
Satisfaction
Mean + SD 3.98 + 0.83 (n ¼ 66) 3.67 + 1.00 (n ¼ 97)

(continued)
Gül et al. 223

Table 1. (continued)
OMFS (n ¼ 379) ORTHO (n ¼ 303)

Recommend (again) the applied treatment

Yes 37 (56.1%) 32 (33%)
No 29 (43.9%) 65 (67%)
66 97
Case 3 (n) 72 107
Treatment
Orthodontic treatment 18 (25%) 66 (61.7%)
Without PM extractions 11 (61.1%) 45 (68.2)
With PM extractions LJþUJ 2 (11.1%) 1 (1.5%)
With PM extractions LJ 1 (5.6%) 7 (10.6%)
With PM extractions UJ 4 (22.2%) 13 (19.7%)
Surgically assisted orthodontic treatment 49 (68.1%) 35 (32.7%)
MMD 0 2 (5.7%)
SARME 18 (36.7%) 14 (40%)
Both 31 (63.3%) 19 (54.3%)
No treatment 5 (6.9%) 6 (5.6%)
Satisfaction
Mean + SD 2.97 + 1.14 (n ¼ 66) 2.92 + 1.17 (n ¼ 97)
Recommend (again) the applied treatment
Yes 21 (31.8%) 29 (29.9%)
No 45 (68.2%) 68 (70.1%)
66 97
Technical aspects:
Type of distractor MMD
Tooth-borne 13 (59.1%) 5 (38.5%)
Bone-borne 7 (31.8%) 4 (30.8%)
Hybrid 2 (9.1%) 4 (30.8%)
Type of distractor SARME
Tooth-borne 34 (68%) 50 (61.7%)
Bone-borne 10 (20%) 14 (17.3%)
Hybrid 6 (12%) 17 (21%)
Latency period MMD
Direct 1 (4.5%) 0
0-5 days 5 (22.7%) 6 (46.2%)
5-7 days 13 (59.1%) 4 (30.8%)
7-10 days 3 (13.6%) 3 (23.1%)
Latency period SARME
Direct 4 (8%) 14 (17.3%)
0-5 days 8 (16%) 31 (38.3%)
5-7 days 35 (70%) 27 (33.3%)
7-10 days 3 (6%) 9 (11.1%)
Distraction rate MMD
0.25 mm/day 4 (18.2%) 5 (38.5%)
0.5 mm/day 14 (63.6%) 7 (53.8%)
1.0 mm/day 4 (18.2%) 1 (7.7%)
2.0 mm/day — —
Distraction rate SARME
0.25 mm/day 7 (14.3%) 18 (22.2%)
0.5 mm/day 28 (57.1%) 56 (69.1%)
1.0 mm/day 14 (28.6%) 7 (8.6%)
2.0 mm/dag — —
Overcorrection MMD
Yes 9 (42.9%) 3 (23.1%)
No 12 (57.1%) 10 (76.9%)
Overcorrection SARME
Yes 34 (69.4%) 71 (87.7%)
No 15 (30.6%) 10 (12.3%)

(continued)
224 Craniomaxillofacial Trauma & Reconstruction 15(3)

Table 1. (continued)
OMFS (n ¼ 379) ORTHO (n ¼ 303)

Consolidation period MMD

1 month 1 (4.8%) 1 (7.7%)
2 months 1 (4.8%) 2 (15.4%)
3 months 14 (61.9%) 3 (23.1%)
4 months 4 (19%) 5 (38.5%)
5 months 0 1 (7.7%)
6 months 2 (9.5%) 1 (7.7%)
Consolidation period SARME
1 month 3 (6.1%) 0
2 months 2 (4.1%) 3 (3.8%)
3 months 28 (57.1%) 23 (28.8%)
4 months 7 (14.3%) 18 (22.5%)
5 months 0 4 (5.0%)
6 months 9 (18.4%) 32 (40%)
Discussion of orofacial soft tissue effects
Yes 42 (70%) 58 (62.4%)
No 8 (13.3%) 22 (23.7%)
N/A 10 (16.7%) 13 (14%)
Total 60 93
Widening of the nose 36 48
Flattening of the upper lip 29 28
Downward displacement of the chin 4 7
Reduction of black buccal corridors 30 39

Abbreviations: LJ, premolar extractions in lower jaw; MMD, mandibular midline distraction; OMFS, oral and maxillofacial surgeons; N/A, not applicable;
ORTHO, orthodontists; PM, premolar; SARME, surgically assisted rapid maxillary expansion; UJ, premolar extractions in upper jaw.

orofacial soft tissue effects (widening of the nose, flatten- asymmetric expansion, 33; loss of tooth, 1; deviation of
ing of the upper lip, downward displacement of the chin nasal septum, 1; gingival and periodontal recession and/or
and reduction of black buccal corridors) are discussed with pockets, 6; necrosis of gingiva, 1; undesired expansion, 4;
the patients by 62.4% of the same 93 ORTHO members. broken distractor, 2; floating maxilla, 1; bad split through
On the other hand, 60 OMFS members (response rate of periodontal ligament of central incisor, 1; severe relapse, 1;
15.8%) have performed at least 1 MMD and/or SARME damage of central incisor apex, 1; too much resistance dur-
annually. The general preference of distractor type was the ing distraction, 1; temporary change of incisor color, 1; tem-
tooth-borne distractor combined with a latency period of porary loose incisor, 1; sinusitis, 1; discomfort, 1; ankyloses
5-7 days where after a distraction rate of 0.5 mm/day was of incisor, 1 and sensibility disturbance of the upper lip, 1).
applied generally for both MMD and SARME. During dis-
traction generally no overcorrection is preferred for the
MMD, but for SARME it is. After distraction generally a Discussion
consolidation period of 3 months for both MMD and In the orthodontic and oral and maxillofacial surgery liter-
SARME is preferred. In general, before start of MMD ature, there are still a lot of controversies and a lack of
and/or SARME possible orofacial soft tissue effects consensus regarding indication for MMD and SARME,
(widening of the nose, flattening of the upper lip, down- distractor type, latency period, distraction rate, overcorrec-
ward displacement of the chin and reduction of black buc- tion, and consolidation period for MMD and SARME. The
cal corridors) are discussed with the patients by 70.0% of main objective of this study was to provide an overview of
the same 60 OMFS members. the current practice for transverse mandibular and maxil-
lary discrepancies in the Netherlands using a web-based
survey about 3 specific cases. The results show that gener-
Complications ally ORTHO prefer orthodontic treatment with optional
Regarding complications, by the same 93 ORTHO and extractions and OMFS lean towards surgically assisted
60 OMFS members, 13 complications were reported for orthodontic treatment. The choice for no treatment was for
MMD (loose distractor, 2; discomfort, 3; non-union, 2; loss both specialisms broadly the same. Although the average
of tooth, 2; loss of vitality, 2; infection, 1 and severe lacera- satisfaction score per case for our applied treatments ran-
tion of soft tissue, 1) and 74 complications for SARME ged between neutral and satisfied, our applied treatments
(bleeding, 5; loss of vitality, 5; loose distractor, 5; seemed generally not to be preferred in the future by both
Gül et al. 225

Figure 1. Choice of treatment case 1. LJ indicates premolar extractions in lower jaw; MMD, mandibular midline distraction; OMFS, oral
and maxillofacial surgeons; ORTHO, orthodontists; SARME, surgically assisted rapid maxillary expansion; Tx, treatment; UJ, premolar
extractions in upper jaw.

specialisms. This might be related to the clinic where by ORTHO, where OMFS prefer 3 months for both MMD
the clinicians were trained, but in the current survey the and SARME.
numbers were too low to draw any conclusions. Regarding complications for MMD discomfort was
To our knowledge, in the literature this is the first survey mentioned most often. This could be related to the design
regarding transverse mandibular and maxillary discrepan- of the distractor. Bone-borne distractors are positioned in
cies with comparison from the view of ORTHO and OMFS. the lower mucobuccal fold close to the mucosa of the lower
MacLaine et al has previously conducted a nationwide lip, which could lead to pressure ulcers and discomfort.
survey in the United Kingdom for OMFS, however this was Due to the position of the bone-borne distractor and saliva
only focused on SARME.16 MacLaine et al showed a gen- with food accumulation, wound healing issues could occur.
eral preference for a tooth-borne distractor (78%) and a A second procedure, under local anesthesia or general
general preference of 5-7 days for latency period anesthesia, is needed to remove the distractor. Moreover,
(roughly 50%).16 These preferences are in line with our tooth-borne distractors are positioned sublingual which
results. However, the preference of distraction rate was 1 could interfere with the tongue position and lead to dis-
mm/day with a preference of overcorrection by only 23%. comfort. In this web-based survey, the mentioned compli-
These preferences are not in line with our general prefer- cations are generally in line with our previous study on
ence of distraction rate of 0.5 mm/day and a strong prefer- complications in MMD.17 However, the reported 2 non-
ence for overcorrection. union cases are remarkable in this web-based survey.
In this study, there seems to be consensus on the tech- Regarding complications for SARME, the most fre-
nical aspects by both professions. The general preference quently mentioned complication was asymmetric expan-
of distractor type is the tooth-borne distractor with a dis- sion. A possible explanation for this could be the
traction rate of 0.5 mm/day for both MMD and SARME minimal invasive trend of surgery with transection of only
by both professions. ORTHO prefer a latency period of the piriform aperture, the zygomatic buttress and the mid-
0-5 days where OMFS prefer 5-7 days for both MMD and palatinal suture without transection of the pterygomaxillary
SARME. Finally, the consolidation period seems to be junction. This theory is also supported with the outcomes of
preferred 4 months for MMD and 6 months for SARME Carvalho et al in the systematic review of complications for
226 Craniomaxillofacial Trauma & Reconstruction 15(3)

Figure 2. Choice of treatment case 2. LJ indicates premolar extractions in lower jaw; MMD, mandibular midline distraction; OMFS, oral
and maxillofacial surgeons; ORTHO, orthodontists; SARME, surgically assisted rapid maxillary expansion; Tx, treatment; UJ, premolar
extractions in upper jaw.

Figure 3. Choice of treatment case 3. LJ indicates premolar extractions in lower jaw; MMD, mandibular midline distraction; OMFS, oral
and maxillofacial surgeons; ORTHO, orthodontists; SARME, surgically assisted rapid maxillary expansion; Tx, treatment; UJ, premolar
extractions in upper jaw.
Gül et al. 227

SARME. When transection of the pterygomaxillary junc- Funding

tion was not performed there was an increased rate of The author(s) received no financial support for the research,
asymmetric or incorrect and undesired expansion.18 Due authorship, and/or publication of this article.
to the anatomic relation, the transection between the piri-
form aperture and the zygomatic buttress is never com- Patient Consent
pletely horizontal on both sides of the median osteotomy.
All 3 presented patients had given prior written consent for the use
Due to this, expanding the maxilla may result in an asym- of their visual material for this web-based survey and publication
metric position in vertical direction. Other factors that in a scientific journal.
could lead to an asymmetric expansion are broken or mal-
functioning distractors.
Supplemental Material
The most cited comment on the survey itself by the
Supplemental material for this article is available online.
participants was the lack of patients’ chief complaint per
presented case. Only general information was given in
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