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Journal of Cranio-Maxillo-Facial Surgery (2010) 38, 166e174
Ó 2009 European Association for Cranio-Maxillo-Facial Surgery
doi:10.1016/j.jcms.2009.06.006, available online at http://www.sciencedirect.com
A systematic review of the effects of bone-borne surgical assisted rapid
maxillary expansion*
Jeroen VERSTRAATEN, DDS1, Anne M. KUIJPERS-JAGTMAN, DDS, PhD, FDSRCS (Eng)1,
Maurice Y. MOMMAERTS, MD, DDS, PhD2, Stefaan J. BERGÉ, MD, DDS, PhD3, Rania M. NADA, DDS1,
Jan G. J. H. SCHOLS, DDS, PhD1, In collaboration with the Eurocran Distraction Osteogenesis Group
1
Department of Orthodontics and Oral Biology (Head of the department: Prof. A.M. Kuijpers-Jagtman, DDS, PhD,
FDSRCS (Eng)), Radboud University Nijmegen Medical Centre, The Netherlands; 2 Division of Maxillo-Facial Surgery,
Department of Surgery, General Hospital St. Jan, Bruges, Belgium; 3 Department of Oral and Maxillofacial Surgery,
Radboud University Nijmegen Medical Centre, The Netherlands
SUMMARY. Introduction: A systematic literature review was conducted to find out if bone-borne maxillary
expansion with corticotomies is an effective and secure orthodontic/orthopaedic treatment modality, eliminating
orthodontic and periodontal side effects of tooth-borne maxillary expansion with corticotomies. Material and
methods: Randomized controlled trials (RCT), controlled clinical trials (CCT) and case series with a sample
size ‡ 5 were electronically searched in PubMED, MEDLINE, EMBASE Excerpta Medica, CINAHL, Biological
Abstracts and CENTRAL till June 2008. Data were extracted by 2 observers. Results: Ten studies fulfilled the
inclusion criteria, of which 9 were prospective and 1 was a retrospective case series. Conclusion: No RCT’s or
CCT’s were published on bone-borne surgically assisted rapid maxillary expansion (SARME). For expected
advantages compared to tooth-borne SARME, only weak evidence was found for less buccal tipping of the teeth
used as anchor teeth in tooth-borne expansion. The heterogeneity of the retrieved publications and the wide
variety of outcome variables posed serious restrictions on the review of the literature in a quantitative systematic
manner. There is a need for well designed clinical trials research on the effects of tooth-borne and bone-borne
SARME. Ó 2009 European Association for Cranio-Maxillo-Facial Surgery
Keywords: review, systematic, palatal expansion technique, osteogenesis, distraction, maxilla, bone-borne,
assessment, outcomes
(SARME) with tooth-borne banded or bonded orthodontic appliances and corticotomies of the areas of skeletal
resistance (piriform aperture, zygomatic buttress, pterygoid junction and midpalatal suture), is nowadays an
accepted treatment option for transverse maxillary
hypoplasia.
Although the results of SARME are largely positive,
side effects as well as relapse are not eliminated (Phillips
et al., 1992; Pogrel et al., 1992; Northway and Meade,
1997; Chung and Goldman, 2003; Byloff and Mossaz,
2004). The negative effects are presumably due to the
tooth-borne anchorage of conventional appliances.
Tooth-borne appliances deliver stresses to the roots and
periodontal ligament as well as the alveolar bone during
expansion. Also the bony movement is not retained during the consolidation period.
This led to the introduction of the first bone-borne appliance (distractor) in 1999, which delivers the expansion
force directly to the maxillary bone and would avoid the
negative orthodontic and periodontal effects (Mommaerts,
1999). The objective of this systematic review is to investigate whether bone-borne SARME
INTRODUCTION
Transverse maxillary hypoplasia is frequently seen in
non-syndromic adolescents and adults (Proffit et al.,
1998). Non-surgical treatment options to correct transverse maxillary hypoplasia in children and young adolescents are slow maxillary expansion (SME) for mild
discrepancies or rapid maxillary expansion (RME) for
more severe cases. Although RME with a bonded or
banded orthodontic appliance is an accepted treatment
modality, the long-term dental and skeletal stability of
the expansion remain uncertain (Lagravère et al.,
2005a,b).
Due to the increased skeletal resistance, RME in adults
is associated with alveolar bending, periodontal ligament
compression, buccal root resorption of the anchor teeth,
fenestration of the buccal cortical plate, and tipping and
extrusion of the anchor teeth (Barber and Sims, 1981;
Carmen et al., 2000). Therefore in adults the alternative
of surgically assisted rapid maxillary expansion
*
This study is part of Eurocran (European Collaboration on Craniofacial Anomalies) and was funded by the EU-Framework-V Program,
grant number QLG1-CT-2000-01019.
(1) Is an effective orthodontic and orthopaedic treatment
modality.
166
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Effects of bone-borne surgical assisted rapid maxillary expansion 167
(2) Is effective in eliminating orthodontic (buccal tilting,
extrusion) and periodontal (root resorption, tooth mobility) side effects.
(3) Is a safe and secure treatment modality.
METHODS
not present enough relevant information were obtained in
full. Secondly, full-text articles were reviewed according
to all the inclusion criteria. In the event of a discrepancy
between the observers, a consensus decision was taken.
The results were compared and the data were analyzed
using the index of inter-rater reliability (Cohen’s Kappa).
Types of studies, participants and intervention
RESULTS
Randomized controlled trials (RCT), controlled clinical
trials (CCT) and case series with a sample size of
N $ 5 were included in this review. We included adolescents and adults who had undergone a SARME with
a bone-borne palatal distractor. There was no restriction
on the persisting malocclusion and/or the origin of malocclusion.
Search results
Search strategy
We performed an electronic search in the following databases:
PubMED (from 1966 to week 4 of June 2008).
MEDLINE (from 1966 to week 4 of June 2008).
EMBASE Excerpta Medica (from 1980 to week 4 of
June 2008).
CINAHL (from 1982 to week 4 of June 2008).
Biological Abstracts (from 1991 to 2001).
CENTRAL (to the first quarter of 2008).
The search strategy was developed and databases were
selected with the help of a senior librarian who specialized in health sciences. The search strategy focused on
two aspects:
(1) terms to search for the surgical procedure of interest
(i.e., osteotomies with expansion of the maxilla and
palate);
(2) terms to search for the appliance (i.e., bone-borne).
Free text words and MeSH terms were used. The
heading sequence (‘‘rapid palatal expansion’’ OR ‘‘rapid
maxill* expan*’’ OR ‘‘palatal expansion technique
[MeSH]’’) AND (‘‘bone-borne’’ OR ‘‘bone-anchored’’
OR ‘‘transpalatal distractor’’ OR ‘‘palatal distractor’’
OR ‘‘transpalatal’’ OR ‘‘skeletally-anchored’’ OR ‘‘distraction’’) was selected. No exclusion of articles based
on language was performed. To complete the search, references of each selected publication about bone-borne
SARME were hand-searched. Where there were multiple
publications from the same research group, one of the
authors was contacted to obtain additional information.
When a study was published both in English and another
language, the former was selected.
The search results and the number of abstracts selected
are depicted in Table 1. The search revealed 96 publications in PubMed, 91 publications in MEDLINE, 10 publications in EMBASE, 4 publications in CINAHL, 2
publications in Biological Abstracts and 1 in CENTRAL.
PubMed had the greatest number (45) of abstracts
selected among the databases that were used. One of
the selected abstracts was not retrieved from PubMed
and was also found in Biological Abstracts. The QUORUM-flow diagram gives an overview of the selection
process (Fig. 1).
Of the 46 selected abstracts (inter-rater K ¼ 0.979), 23
reported a SARME technique with a bone-borne distractor. From the hand search of the references of these 23
studies, we selected 27 further titles for abstract retrieval
and further selection. After application of the inclusion
criteria by both observers all publications from the
hand search were excluded.
Thirteen publications fulfilled all inclusion criteria
(Matteini and Mommaerts, 2001; Pinto et al., 2001;
Neyt et al., 2002; Gerlach and Zahl, 2003; Ramieri
et al., 2005; Koudstaal et al., 2006a,b; Hansen et al.,
2007; Scolozzi et al., 2007; Seitz et al., 2007, 2008; Tausche et al., 2007, 2008).
After contact with the authors 3 publications were excluded (Hansen et al., 2007; Seitz et al., 2007; Tausche
et al., 2008) because the studies were published in another, more extensive or English written, publication
(Tausche et al., 2007; Seitz et al., 2008).
Table 2 shows the characteristics of the ten studies
finally included. We included three studies from the
research group from Bruges, Belgium (Matteini and
Mommaerts, 2001; Pinto et al., 2001; Neyt et al.,
2002). After contact with the authors it appeared that potentially the same subjects were used in their study on
morbidity associated with bone-borne SARME (Neyt
et al., 2002) and in their studies measuring post-expansion changes on dental casts (Matteini and Mommaerts,
Table 1 e Search results from databases
Database
Data extraction
Data were extracted and methodological quality assessed
independently by two observers (JV, AK). Data were recorded on special extraction forms. First, the abstracts
were reviewed without considering the number of patients reported. Articles that apparently fulfilled the inclusion criteria and articles of which the title or abstract did
Abstracts Abstracts Abstracts not found
found
selected in pubmed
PubMed
96
MEDLINE
91
EMBASE excerpta medica 10
CINAHL
4
Biological Abstracts
2
CENTRAL
1
Abbreviations: NA, not applicable.
45
42
7
0
1
0
NA
0
0
0
1
0
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168 Journal of Cranio-Maxillo-Facial Surgery
Electronic search identified abstracts and screened for retrieval
N = 97
Manual search identified relevant abstracts in references
N = 27
Excluded abstracts
N = 51
Reason: not topic related
Excluded abstracts
N = 13
Reason: not topic related
Articles retrieved for more information
N = 46
Bone-borne SARME (N = 23)
Abstracts not enough information (N = 23)
Articles retrieved for more information
N = 14
Excluded articles
N = 33
Reason: did not meet the inclusion criteria
Excluded articles
N = 14
Reason: did not meet the inclusion criteria
Potentially appropriate to be included
N = 13
Potentially appropriate to be included
N=0
13 articles
Excluded 3 articles
(multiple publications of same study)
Final selection
10 articles
Fig. 1 e QUORUM-flow diagram.
2001; Pinto et al., 2001). This overlap was not considered a problem because the topic of research was different. For counting the total number of patients included in
the review, it was decided to use the study with the biggest sample (Neyt et al., 2002). There was complete
agreement between the two observers for inclusion of
the studies.
Types of included studies
All studies were case series from Europe, 9 prospective
and 1 retrospective. No RCT’s or CCT’s were found.
Outcomes of included studies
The following outcomes were reported:
Assessment of expansion in terms of changes in dental
and skeletal structures (Matteini and Mommaerts, 2001;
Pinto et al., 2001; Gerlach and Zahl, 2003; Ramieri
et al., 2005; Tausche et al., 2007).
Assessment of orthodontic side effects in terms of tipping of teeth (Pinto et al., 2001; Tausche et al., 2007).
Report of treatment related difficulties i.e., appliance
failure, surgical complications (Neyt et al., 2002;
Gerlach and Zahl, 2003; Ramieri et al., 2005; Koudstaal
et al., 2006a,b; Scolozzi et al., 2007; Seitz et al., 2008).
Dental and periodontal side effects (Ramieri et al.,
2005).
Assessment of pain (Gerlach and Zahl, 2003).
Methodological quality of the included studies
All studies had a minimal follow-up until the removal of
the distractor. No studies were found that aimed to follow
the study subjects until the completion of the orthodontic-surgical intervention.
The planned anterioreposterior location of the distractor was not reported in 2 studies (Koudstaal et al.,
2006a,b).
In one study two different surgical approaches were
used but the number of patients in each group was not
reported (Gerlach and Zahl, 2003).
The procedure for retaining the achieved expansion
after removal of the distractor was not reported in nine
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studies (Matteini and Mommaerts, 2001; Pinto et al.,
2001; Neyt et al., 2002; Gerlach and Zahl, 2003; Ramieri
et al., 2005; Koudstaal et al., 2006a,b; Scolozzi et al.,
2007; Seitz et al., 2008).
Positional changes measured on dental cast
Belgium
Patients in the included studies
Abbreviations: MWD, maxillary widening device; DD, Dresden Distractor; TPD, transpalatal distractor; RPD, Rotterdam Palatal Distractor; ?, unknown.
TPD
0
Prospective case series
Belgium
Belgium
Neyt et al. (2002)
Matteini and
Mommaerts (2001)
Pinto et al. (2001)
20
14e30 (21.5)
20
0
0
TPD
TPD
0
0
Retrospective case series
Prospective case series
Germany
Gerlach and Zahl (2003)
57
20
11e43 (18)
12e42 (20)
57
20
0
0
0
0
Magdeburg
Netherlands
Italy
Koudstaal et al. (2006b)
Ramieri et al. (2005)
Prospective case series
Germany
Switzerland
Germany
Netherlands
Tausche et al. (2007)
Scolozzi et al. (2007)
Hansen et al. (2007)
Koudstaal et al. (2006a)
10
12e37 (25.8)
0
0
0
10
Complication
Positional changes measured on dental cast,
radiographic and clinical evaluation of
dental and periodontal condition
Positional changes measured on dental cast
Pain perception on VAS scale
Problems, obstacles, complications
Positional changes measured on dental cast
TPD
TPD
0
0
10
29
13e20 (16.5)
? (26.4)
0
27
4
2
6
0
0
Positional changes measured on CT data
Clinical experience
3D cephalometrics
Clinical experience
DD
TPD
DD
RPD
10
8
12
13
18e6 (25.3)
13e15 (13.9)
17e36 (23,3)
?
10
0
12
5
0
8
0
2
0
0
0
6
0
0
Clinical experience
MWD
0
Germany
Seitz et al. (2008)
Technical note,
prospective case series
Prospective case series
Prospective case series
Prospective case series
Technical note,
prospective case series
Retrospective case series
Prospective case series
22
14e34 (19.5)
22
0
0
Distractor
Study design
Origin
Author, year of
publication
Table 2 e Overview of the included studies
N
Age range
(median) years
N, developmental
deformity
N, cleft lip
palate
N, other
congenital
deformity
N, unknown
diagnosis
Main outcome variable
Effects of bone-borne surgical assisted rapid maxillary expansion 169
The total number of patients included in the systematic
review was 159. From the studies of the research group
of Bruges, Belgium, only the study with the biggest patient sample (Neyt et al., 2002) was included for the total
number of patients because there were overlapping patient samples. Sample size ranged from 8 to 57 patients.
The age ranged from 11 to 43 years.
Maxillary constriction was a developmental deformity
in 121 (76.1%) patients, associated with cleft lip and palate in 16 (10.1%) patients, and 12 (7.5%) patients had
other congenital malformations. In 10 (6.3%) patients
from one study, the origin of the maxillary constriction
was not reported (Gerlach and Zahl, 2003).
Surgical intervention and distraction
A description of the surgical interventions is summarized
in Table 3. Five different distractors were used in the included studies. The Trans Palatal Distractor (TPD; SurgiTec NV, Bruges, Belgium e Pinto et al., 2001; Matteini
and Mommaerts, 2001; Neyt et al., 2002; Ramieri et al.,
2005; Koudstaal et al., 2006b; Scolozzi et al. 2007), the
Rotterdam Palatal Distractor (RPD e Koudstaal et al.,
2006a), the Magdeburg distractor (Martin Medizin-Technik, Tuttlingen, Germany e Gerlach and Zahl, 2003),
the Dresden Distractor (DD e Tausche et al., 2007)
and the Maxillary Widening Device (MWD e Seitz
et al., 2008). An average latency period of 5.6 days
(range 1e7) before the start of activation was found.
The average rate of distraction was 0.66 mm/day (range
0.33e1 mm/day).
No study opted to perform the minimally invasive open
sky surgery as described by Glassman et al. (1984).
Modifications of the Glassman approach were vertical
corticotomy of the piriform aperture (Gerlach and Zahl,
2003; Tausche et al., 2007), midpalatal dysjunction (Pinto
et al., 2001; Ramieri et al., 2005; Koudstaal et al.,
2006a,b; Seitz et al. 2008), pterygoid and midpalatal dysjunction (Matteini and Mommaerts, 2001; Gerlach and
Zahl, 2003), or a unilateral approach in cleft lip and palate
patients (Ramieri et al., 2005; Koudstaal et al., 2006b;
Scolozzi et al., 2007).
In the anterioreposterior direction the distractors were
either placed at the level of the maxillary second premolar (Pinto et al., 2001; Gerlach and Zahl, 2003; Ramieri
et al., 2005; Scolozzi et al., 2007; Tausche et al., 2007;
Seitz et al., 2008) or at the level of the fist molar
(Matteini and Mommaerts, 2001; Gerlach and Zahl,
2003; Ramieri et al., 2005).
Treatment related difficulties
Seven studies were considered for evaluation of treatment related difficulties. A detailed overview is provided
in Table 4. Difficulties related to bone-borne SARME
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170 Journal of Cranio-Maxillo-Facial Surgery
Table 3 e Characteristics of the surgical intervention
Author, year
of publication
Distractor
Location of Osteotomies
distractor
Latency before Distraction
Mean consolidation Fixed orthodontic
start activation rate (mm/day) period (months)
appliances during
(days)
consolidation
Seitz et al.
(2008)
MWD
P2
5
0.6
3
Yes
Tausche et al.
(2007)
DD
P2
2
0.96
3e6
Yes
Scolozzi et al.
(2007)
TPD
P2
1
0.66
2
?
7
1
3
Yes
7
1
3
?
7
Days 1 and
2: 0.33
Other days:
0.66
5
Yes
7
0.4
3
Yes
7
0.33
6
No
7
0.33
4
Yes
Koudstaal et al. RPD
(2006a)
?
Koudstaal et al. TPD
(2006b)
?
Ramieri et al.
(2005)
P2
TPD
M1
M1
Gerlach and
Zahl
(2003)
Magdeburg P2-M1
Matteini and
Mommaerts
(2001)
TPD
M1
Pinto et al.
(2001)
TPD
P2
Bilateral buccal
corticotomies and
midpalatal
suture dysjunction
Bilateral buccal
corticotomies and a
vertical
corticotomy between
11 and 21
Unilateral buccal
corticotomy with
midpalatal
suture dysjunction
Bilateral buccal
corticotomies and
midpalatal
suture dysjunction
Uni/Bilateral buccal
corticotomies and
midpalatal
suture dysjunction
A) Bilateral
buccal corticotomies
and midpalatal
suture dysjunction
without
pterygoid dysjunction
B) Bilateral
buccal corticotomies
and midpalatal
suture disjunction
with
pterygoid dysjunction
C) Unilateral
buccal corticotomies
and midpalatal
suture dysjunction
with
pterygoid dysjunction
A) Bilateral
buccal corticotomies
and a vertical
corticotomy between
11 and 21
B) Bilateral
buccal corticotomies
with
bilateral osteotomy
of midpalatal
suture and pterygoid
dysjunction
Bilateral buccal
corticotomies, midpalatal
suture dysjunction
pterygoid dysjunction
Bilateral buccal
corticotomies and
midpalatal
suture dysjunction
Abbreviations: MWD, maxillary widening device; DD, Dresden Distractor; TPD, tranpalatal distractor; RPD, Rotterdam Palatal Distractor;
?, unknown.
can be associated with the distractor, with the permucosal
entry side of the distractor or associated with the surgical
intervention itself. In 147 patients, 61 episodes of treatment related difficulties were reported (one patient can
have more than one treatment related difficulty). More
than half of the reported difficulties were appliance
related (33/61). No big differences of distractor related
problems were seen between patients with a congenital
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Effects of bone-borne surgical assisted rapid maxillary expansion 171
Table 4 e Clinical report of treatment related difficulties
Author, year of
publication
N
Follow-up
(months)
Distractor
Appliance related
difficulties (N distractor)
Permucosal
difficulties (N patients)
Surgical difficulties
(N patients)
Seitz et al. (2007)
22 D
3
MWD
1 loosening of distractor
Not reported
2 midline shift
2 vertical displacement
Scolozzi et al. (2007)
8C
12e36
TPD
1 abutment
plate loose
No difficulties
Koudstaal et al. (2006a)
5D
8C
3
RPD
No difficulties
1 dislocation of distractor
No difficulties
No difficulties
No difficulties
1 additional
hyrax needed
due to extreme
opening in front
region in a osteopatia
striata case
Koudstaal et al. (2006b)
10 C
3
TPD
3 loosening of distractor
1 abutment
plate loose
1 oronasal fistula
1 palatal abscess
No difficulties
Ramieri et al. (2005)
27 D
12
TPD
5 loosening of distractor
2 dislocation of distractor
8 palatal ulceration
1 mucosal
ulceration in the
vestibule
No difficulties
3 abutment
plate loose
Gerlach and Zahl (2003)
10
6
Magdeburg
No distractor failure
1 oronasal fistula
No difficulties
Neyt et al. (2002)
57 D
3e6
TPD
14 loosening of distractor
3 abutment plate loose
3 palatal ulceration
1 infraorbital hypoaesthesia
1 nasal bleeding
2 wound infections
3 cheek haematomas
Abbreviations: D, developmental deformity; C, Congenital deformity.
Table 5 e Evaluation of the orthodontic effects
Author, year of publication
Objective method used
N
T2 (weeks)
Buccal tipping
in degree (SD)
% of expansion
relative to IMD
Ratio ICD:IMD
ICD
IPD
IMD
Tausche et al. (2007)
3D cephalometrics on virtual
axial computer tomography
model
10
17
Ramieri et al. (2005)
Digitized plaster
dental cast
11*
16#
2e3
2e3
23.1
22.2
19.6
20.5
14.9
21
1:0.65
1:0.95
Matteini and Mommaerts (2001)
Digitized plaster
dental cast
20
2e3
22.4
21.9
20.8
1:0.93
Pinto et al. (2001)
Digitized plaster
dental cast
20
2e3
28.8
25.9
20.4
1:0.71
Right P1: 3.0
Left P1: 3.9
Right M1: 3.5
Left M1: 2.5
P1: 0.9 (9.9)
M1: -/-8.3 (9.6)
Abbreviations: SD, standard deviation; ICD, intercanine distance; IPD, interpremolar distance; IMD, intermolar distance.
* Without pterygoid dysjunction.
#
With pterygoid dysjunction.
malformation (6/26) and patients with a developmental
deformity (28/113). Most distractor failures, such as
loosening or dislocation, occurred during the consolidation period and an intervention to solve the problem
was not always needed.
Difficulties associated with the permucosal entry side
(ulceration of the palatal mucosa, palatal abscess and
oronasal fistula) were reported 15 times.
Surgically related difficulties were reported in 12
cases, of which four had an asymmetric opening of the
maxillary segments and one case with osteopatia striata
[OMIM: %166500] needed an additional hyrax-appli-
ance because the bone-anchored expander alone did not
result in posterior opening of the midpalatal suture
(Koudstaal et al., 2006a).
Orthodontic and orthopaedic effects
Five studies were identified, which assessed the orthodontic and orthopaedic effects of the expansion: in four of
them measurements were performed on dental casts
(Matteini and Mommaerts, 2001; Pinto et al., 2001;
Gerlach and Zahl, 2003; Ramieri et al., 2005) and in one
on 3D CT data (Tausche et al., 2007). The study of Gerlach
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172 Journal of Cranio-Maxillo-Facial Surgery
and Zahl (2003) could not be evaluated because the landmarks were not defined. Also two different surgical procedures were used without presenting the outcome data
separately. Detailed information is provided in Table 5.
Post-expansion results, without additional orthodontic
interventions, showed more movement of the dorsal part
of the palate when pterygoid dysjunction was part of the
procedure and the distractor was placed at the level of the
first molar. Using this procedure, the ratio between increases of intercanine to intermolar width was 1:0.93
(Matteini and Mommaerts, 2001) and 1:0.95 (Ramieri
et al., 2005). Without pterygoid dysjunction and placement of the distractor at the level of the second premolar
the ratio was 1:0.71 (Pinto et al., 2001), and 1:0.65
(Ramieri et al., 2005). In the latter three studies, patients
had a developmental deformity and a TPD was used.
In the CT study (Tausche et al., 2007) the percentage
of the transmitted expansion of the screw was calculated
by dividing the width increment of the anatomical structures by the amount of screw expansion. However, orthodontic intervention with fixed appliances had already
started before the SARME. This bias makes it difficult
to calculate the orthodontic effects of bone-borne
SARME per se.
Tipping of the teeth which would be used for anchorage in teeth-anchored SARME, was assessed in two studies but the CT study (Tausche et al., 2007) was biased for
the above mentioned reason. Measured on dental casts
the average tipping for first maxillary premolars and first
maxillary molars was 0.9 buccal tip and 8.3 palatal tip,
respectively (Pinto et al., 2001).
Adverse dental effects and pain
Ramieri et al. (2005) evaluated periodontal health and
thermal sensitivity of the central incisors, premolars
and molars. At follow-up 1 year after expansion, a slight
increase of gingival recession was seen in 7% of the
teeth and a loss of thermal sensitivity in 15% of the teeth.
One study evaluated pain perception rated on a visual
analogue scale ranging from 0 to 100. The pain did not
exceed a level of 20 (Gerlach and Zahl, 2003). These figures should be interpreted with caution as the methods
and descriptions of the results were not detailed.
DISCUSSION
This systematic review dealt with the effects of boneborne SARME and concerns an overall sample of 159
patients. The inclusion criteria that were used focused
on larger studies with at least 5 patients. 23 publications
were found on bone-borne SARME of which 10 were
included in this review. Of the publications considered,
three reported qualitative clinical experience, and 7 performed quantitative measurements. The heterogeneity
of the retrieved publications and the wide variety of outcome variables posed serious restrictions in this attempt
to review the literature in a quantitative systematic manner, and thus meta-analysis of combined data was not
possible.
Since the introduction of bone-borne SARME in 1999
(Mommaerts, 1999), the distractors as well as the surgical
experience have been developing continuously. The TPD
was the first bone-borne expander introduced and in 6 out
of 10 studies included in this systematic review a TPD
was used. Most of the reported difficulties associated
with bone-borne SARME were found using the TPD, because all three studies with complications as main outcome variable used it. For the other appliances, no
studies were found with complications as the main outcome variable. Two studies (Neyt et al., 2002; Ramieri
et al., 2005) classified the difficulties encountered during
surgery, distraction and consolidation according to Paley
(1990). According to this classification, minor difficulties
that are self-resolving (i.e., ulceration around the distractor) were also reported. As not all papers consistently
reported complications and problems, it is not possible
to draw any definitive conclusions about the difficulties
associated with bone-borne SARME. It is possible that
studies were compromised by the early experience of
the surgeon, using early versions of the distractors.
Differences were found using the transverse maxillary changes according to the associated surgical procedure. Without pterygoid dysjunction, and with the
distractor placed at the level of the second premolar,
the transverse opening between the maxillary halves
was V-shaped with more expansion anteriorly than posteriorly. With pterygoid dysjunction and the distractor
placed at the level of the first molar, the expansion
was more parallel.
For the assumed advantages of bone-borne SARME
compared with tooth-borne SARME, very weak evidence
was found for less tipping of teeth normally used for
anchorage with tooth-borne appliances. Average buccal
tipping of teeth in tooth-borne SARME is 6.48 for premolars and 7.04e9.63 for molars (Chung and Goldman,
2003; Byloff and Mossaz, 2004). In contrast, in boneborne SARME this was 0.9 buccal tip and 8.9 palatal
tip, respectively (Pinto et al., 2001). However these
results are based on only one case series study on 20
patients without a control group. For other assumed advantages no evidence was found from the data available
in the studies.
Although SARME, tooth-borne or bone-borne, is
a well accepted treatment modality, no strict consensus
exists for the surgical protocol, the distraction protocol
as well as the consolidation (retention) of the SARME.
We found four different surgical protocols, the rate of
distraction varied from 0.33 to 1.0 mm daily, most studies had a latency period (before start of activation) of 7
days, but 1 and 2 days were also found (Scolozzi et al.,
2007; Tausche et al., 2007).
Most studies were performed using dental casts but
SARME has not only an influence on the position of
the teeth and the alveolar bone, but also on the hard
and soft tissues in the mid-face, as the nasal floor, nasal
cavity and the width of the nose. With currently available
technology, a 3-dimensional volumetric analysis would
be preferable to fully understand the changes that are produced by SARME.
Although most encountered treatment difficulties were
minor, the high incidence of distractor loosening
Author's personal copy
Effects of bone-borne surgical assisted rapid maxillary expansion 173
suggests the need to develop a better anchored distractor.
Cost-effectiveness and patient perception have not been
studied. Since more expanders are commercially available now there is a need for more research on the effects
of tooth-borne and bone-borne SARME. A search in the
International Clinical Trials Registry Platform of the
World Health Organization (www.who.int/trialsearch)
as well as in the International Clinical Trials Registry
of the U.S. National institutes of Health (www.
clinicaltrials.gov, both accessed April 11, 2008) did not
reveal any ongoing controlled randomized clinical trials
in this field. This might be due to the fact that the technique is still developing and performing a randomized
clinical trial might be difficult. For this reason, another
approach was chosen with the Eurocran Distraction
Study. In this study patients to be treated by distraction
osteogenesis in fourteen participating centres in Europe
have been enrolled in a prospective registry and followed
in a standardised way until 24-month after surgery (Shaw
et al., 2002; Kuijpers-Jagtman and Wijdeveld, 2005).
Future research on bone-borne SARME should aim to
demonstrate the following features:
Randomized clinical trial design.
Control group of tooth-anchored SARME.
3-dimensional volumetric analysis of bony and soft
tissue changes.
Standardised surgical protocol.
Standardised distraction protocol.
Standardised reporting of treatment difficulties.
Interim follow-up of 3 months after removal of the distractor.
Follow-up of at least 1 year after the completion of the
combined orthodontic-surgical treatment.
CONCLUSION
This systematic review has demonstrated currently there
are no RCT’s or CCT’s published on bone-borne
SARME. The expected advantages when compared
with tooth-borne SARME show that so far only very
weak evidence exist that there is less buccal tipping of
the teeth used as anchor teeth in tooth-borne expansion.
The heterogeneity of the retrieved publications and the
wide variety of outcome variables posed serious restrictions on the review of the literature in a quantitative systematic manner. There is a need for well designed clinical
trials research on the effects of tooth-borne and boneborne SARME.
ACKNOWLEDGMENTS
The chairperson of the Eurocran Distraction Osteogenesis
Group is Prof. Anne Marie Kuijpers-Jagtman and the members
are: Hospital of Plastic Surgery, Polanica Zdrój, Poland, Prof.
K. Kobus; Free University Medical Centre, Amsterdam, The
Netherlands, Dr. E. Becking; Radboud University Nijmegen
Medical Centre, Nijmegen, The Netherlands, Prof. P. Stoelinga, Dr. W. Borstlap; Morriston Hospital, Swansea, United
Kingdom, Dr. A.W. Sugar; Blackburn Royal Infirmary, Blackburn, United Kingdom, Dr. M. Morton; Erasmus Hospital and
Queen Fabiola Children’s Hospital Université Libre de
Bruxelles, Brussels, Belgium, Prof. C. Malevez; General Hospital Sint Jan, Bruges, Belgium, Prof. M. Mommaerts; Medical
University Hannover, Germany, and General Hospital Sint Jan,
Bruges, Belgium, Dr. G. Swennen; Medical University Leipzig, Germany, Prof. A. Hemprich, Dr. T. Hierl; Hôpital Trousseau, Paris, France, Dr. P.A. Diner, Dr. C. Tomat; Helsinki
University Central Hospital, Helsinki, Finland, Dr. J. Hukki,
Dr. K. Hurmerinta; Bellaria Hospital University of Bologna,
Bologna, Italy, Dr. A. Bianchi; St. Anna University Hospital,
Ferrara, Italy, Prof. L. Clauser. Their input in this systematic
review is highly appreciated.
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Prof. A.M. KUIJPERS-JAGTMAN, DDS, PhD, FDSRCS (Eng)
Department of Orthodontics and Oral Biology
Radboud University Nijmegen Medical Centre
309 Dentistry
PO Box 9101
6500 HB Nijmegen
The Netherlands
Tel.: +31 24 3614005
Fax: +31 24 3540631
E-mail: [email protected]
Paper received 1 September 2008
Accepted 3 June 2009