Download Patients with crossbite and narrow maxilla treated with surgical rapid

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Patients with crossbite and narrow
maxilla treated with surgical rapid
maxillary expansion
– A follow up study
Helen Merzo Baranto
Handledare: Docent Annika Rosén, Institutionen för odontologi, Avd. för oral diagnostik och kirurgi,
Karolinska Institutet och Institutt for klinisk odontologi, seksjon for oral kirurgi og oral medisin,
Universitetet i Bergen, Norge.
Examinator: Odont. Dr Nikolaos Christidis, Klinisk oral fysiologi, Institutionen för odontologi,
Karolinska Institutet
Patients with crossbite and narrow maxilla treated with surgical
rapid maxillary expansion- a follow up study
Abstract
Purpose: The purpose of this retrospective study was to evaluate treatment effects and
mapping the patients overall opinion of the SARME treatment made in our clinic.
Material and Methods: 43 patients that had been treated surgically with the SARME
technique during a 12 years period were included in this study. All of them had been treated
for crossbite and narrow maxilla. Epidemiologic data was collected from all 43 patients (part
I), then a clinical examination was performed which included responding to a questionnaire
from 30 patients who wanted to participate (part II). Dental casts were taken pre and
postoperatively which were analyzed with a Vernier caliper (part III).
Results: In the questionnaire most of the patients answered that the postoperative pain
(46.7%), swollenness (53.3%) and perception impairment (50.0%) were moderate difficult.
However at the follow up examination the patients experienced that some of the preoperative
problems had changed for the better such as the difficulties with biting or chewing (56.7%),
the uncomfortable biting position (33.3%), the appearance of the dental position (70.0%) and
facial appearance (30.0%) had changed to the better. 3.3% of the patients experienced that the
pain from the jaws and the TMJ had become worse. The patients’ over-all evaluation of the
SARME treatment was positive and very appreciated. 60 % of the 30 patients that were
clinical examined still showed hyposensitivity in the maxillary oral gingiva, 13.3% showed
hyposensitivity on the upper lips. The pre- and postoperative cast models showed that a
significant palatal expansion occurred due to the SARME treatment, and there was also a
significant higher frequency of malocclusion among patients after treatment that had teeth
extracted before treatment. Finally an improved occlusion and aesthetics of the dentition was
achieved.
Conclusions: The majority of the patients in this study received a normal occlusion after
the SARME treatment. The cast model collection showed significant expansion of the maxilla
after SARME treatment and that the majority of the patients received a normal occlusion.
Malocclusion was more common among patients that had their premolar extracted before
surgery. The most common indication for the SARME treatment in this study is crossbite due
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to a narrow maxilla. The majority of the patients were skeletally mature when they received
the SARME treatment. The functional and the esthetical aspects of the dentition and facial
appearance are much better today. Preoperatively information about eventual side effects such
as impaired speech and pronunciations, orofacial muscle- and TMJ- tenderness/pain is,
according to the patients, important information to know.
Keywords: SARME, RME, maxilla/surgery, oral surgical procedures, palatal expansion
technique, osteogenesis, distraction/instrumentation.
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Patienter med korsbett och trång maxilla behandlade med
kirurgisk maxillär suturvidgning -en uppföljningsstudie
Sammanfattning
Syfte: Syftet med denna retrospektiva studie var att utvärdera behandlingseffekterna
och kartlägga patienternas övergripande uppfattning om SARME behandlingen.
Material och metoder: 43 patienter som behandlats för korsbett och trång maxilla
med SARME metoden under en 12 års period inkluderades. Epidemiologisk data
samlades in från alla 43 patienter (del I) och en klinisk undersökning utfördes samtidigt
som ett frågeformulär besvarades av 30 patienter som tackat ja till en efterföljande
undersökning (del II). Alginat avtryck togs pre -och postoperativt. Därefter gjordes
mätningar på preoperativa och postoperativa gjutna modeller med ett skjutmått (del III).
Resultat: De flesta av patienterna rapporterade att den postoperativa smärtan (46.7%),
svullnaden (53.3%) och känselnedsättningen (50.0%) upplevdes som måttligt
obehagligt. Vid den efterföljande undersökningen upplevde en del av patienterna att
svårigheterna med att bita och tugga (56.7%), obekväm ocklusion (33.3%) och
tändernas utseende (70.0%) och ansiktsutseendet (30.0%) ändrades till det bättre. Ett
fåtal patienter upplevde att smärtan från käkar och käkleder blev värre (3.3%).
Patienternas övergripande åsikt om SARME behandlingen var positiv och uppskattad.
60 % av de 30 patienter som undersöktes hade fortfarande hyposensitivitet på maxillans
tandkött och 13.3% av patienterna hade hyposensitivitet på överläppen. Analysen på
pre- och postoperativa studiemodellerna visade att patienterna fick en signifikant
palatinal expansion efter SARME behandlingen, och det visade sig även vara en högre
frekvens av malocklusion hos patienter efter behandling, som hade före behandlingen
fått tänder extraherade. Den dentala ocklusionen förbättrades och en god estetik
uppnåddes.
Slutsatser: Majoriteten av patienterna i denna studie fick en normal ocklusion efter
SARME behandlingen. De samlade studiemodellerna visade betydande expansion av
överkäken efter SARME behandling och att majoriteten av patienterna fick en normal
ocklusion. Malocklusion var vanligare bland patienter som hade sina premolarer
extraherade före operation. Den vanligaste indikationen för SARME behandling var i
denna studie korsbett. Majoriteten av patienterna var skelettalt mogna när de genomgick
SARME behandlingen. De funktionella och estetiska aspekterna av dentitionen och
ansiktsdragen är mycket bättre idag. Preoperativt information om eventuella,
biverkningar såsom försämrat uttal, orofaciala muskel-och TMJ-ömhet/smärta tycker
patienten är viktigt att få information om.
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Introduction
Orthognatic treatment is a well-established and commonly used treatment for patients
with skeletal malocclusions. With surgical-orthodontic treatment such as surgically
assisted rapid maxillary expansion (SARME), symmetrical facial skeletal relationships
can be achieved and occlusal function can be improved (Burden &Pine 1995). Previous
studies have shown that patients seek surgical-orthodontic treatment due to their desire
to improve their facial, dental appearance, and the functional occlusion disabilities
(Burden &Pine 1995, O’Young and McPeek, 1987). Socially the patient can experience
difficulties due to the dental and facial disfigurements. Therefore, with orthognatic
surgery the patient receives not only functional benefits but also psychosocial ones such
as improved self-confidence, body and facial image and social adjustment (Cunningham
et al 1995). An assumption in orthognatic surgery treatment is that long -term benefits
facilitates acceptance of short- term risks and discomfort (O’Young and McPeek, 1987).
According to Cunningham et al (1996), patients who are given accurate information
tend to be satisfied with their treatment. It has previously been recommended that
patients should be well informed preoperatively about the future treatment, which
includes the time estimation. Modig and collegues studied the patients´ perception
regarding the quality of life after orthognatic surgery (Modig et al, 2005). The patients
mentioned mainly functional problems as their reason for seeking this treatment but the
aesthetic improvement was just as important. They also mentioned postoperative
improvements with chewing, appearance and headaches. Modig and collegues
concluded that patient’s perception after orthognatic surgery was generally favorable
but there is still a need for improved information to patients during treatment.
Transverse maxillomandibular discrepancies, also known as posterior crossbite, occurs
when the upper posterior teeth bite inside the lower posterior teeth, on one or both sides
of the mouth, or when the maxilla is more narrow than the mandibular jaw. The origin
of this malocclusion can either be of dental or skeletal origin. When the upper teeth are
tilted and bite inside the lower teeth then the malocclusion is classified as of dental
origin, however, when the maxilla is narrower than the mandible then the origin is
skeletal. Posterior crossbite can cause an abnormal mandibular movement when the jaw
moves from one side to the other to allow the posterior teeth to be in occlusion. Many
believe that the abnormal mandibular movement associated with a crossbite can have
long-term effects on the growth and development of the teeth and jaws. Young children
with posterior crossbite will unlikely experience any pain or have problems with
chewing. On the other hand the abnormal movement of the lower jaw may put a strin on
the jaw muscles and joints, which may cause problems later in life. Studies of teenagers
and adults have shown that patients with a crossbite have an increased risk of
developing mandibular joint problems, such as clicking or locking of the disc (Mohlin
& Thilander1984).
Moreover the individual can experience difficulties with chewing because of unilateral
(crossbite on one side) or bilateral transverse discrepancy (crossbite on both sides).
Other complains can be that the individual with this malocclusion suffers from apnea or
oral breathing caused by a small palate, dental clustering or nasal blockage (Betts &
Ziccardi 2000).
Maxillary expansion as a treatment was first described in 1860 and has since then been
used for both skeletal and dental posterior cross bites (Angell, 1860). Transverse
maxillomandibular discrepancies can be treated with orthodontics in patients younger
than 13 years, or with SARME, in skeletally mature patients, older than 13 years old
(Suri & Taneja 2008). Skeletal maturity of the patient and the magnitude of transverse
maxillary discrepancy are two important factors when choosing between orthodontic
treatment and SARME-treatment.
Children with uni- or bilateral cross bites, cleft lip and palate, and maxillary teeth
crowding are commonly treated with orthopedic maxillary expansion (OME) to gain
arch length (Betts & Ziccardi 2000). Maxillary constriction with posterior crossbite is
shown to be one of the most common clinically encountered dentoskeletal problems
(Angell, 1860).
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Uni- or bilateral transverse hypoplasia in skeletally matured patients can be corrected by
SARME. This treatment is a combination of orthodontics and surgical procedures that
provides dental arch space, a substantial enlargement of the maxillary apical base and of
the palatal vault. This procedure also causes space for the tongue to correct swallowing
and thus preventing relapse (Codivilla, 1905).
Orthopedic maxillary expansion (OME)
Expansion of the maxillary arch usually involves the movement of teeth and changes in
the surrounding alveolar bone. When using rapid expansion of the maxilla as a
treatment, forces of large magnitude will be employed; this causes an opening of the
midpalatal suture and brings about gross and observable changes in the maxillofacial
skeleton. OME is the procedure of choice to treat maxillary width deficiency, in
growing patients (Cleall et al 1965).
In teenage children or in adults where the bone is mature and therefore harder, limited
expansion occurs, often with only dental changes (Byloff & Mossaz 2004).
This can be the cause of many problems in skeletally mature patients, including pain
upon activation of the appliance, extrusion of the teeth, periodontal complications
(Byloff & Mossaz 2004), a significant amount of gingival recession, relapse despite
overcorrection and malocclusion (Betts & Ziccardi 2000).
Classifying malocclusion
Sagittal malocclusion is diagnosed with the help of Angle´s classifications, in three
groups:
Class I (neutrocclusion)- the mesiobuccal cusp of the upper first molar occludes with
the mesiobuccal groove of the lower first molar. Also discrepancies of up to half a cusp
are included in this group.
Class II (post normal relations)- the mesiobuccal cusp of the lower first molar occludes
distal to the Class I position.
Class III (prenormal relations)- the mesiobuccal cusp of the lower first molar occludes
mesial to the Class I position.
Vertical discrepancies are classified as open bite or deep bite.
Open bite anteriorly occurs when there is no vertical overlap of the incisors despite that
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the buccal segment teeth are in occlusion. Posterior open bite occurs when the teeth are
in occlusion and there is still a space between the posterior teeth.
Deep bite occurs when the vertical overlap of the upper and lower incisors is greater
than one-half coverage of the lower incisors.
Transversal discrepancies can be described as cross bite or scissors bite.
Cross bite is defined as when the buccal tips of the lower teeth occlude buccally to the
buccal cusps of the upper teeth.
Scissors bite is when the buccal cusps of the lower teeth occlude lingual to the lingual
cusps of the upper teeth.
Normal occlusion is when the patient shows class I occlusion, no vertical or transversal
discrepancies (Mitchell, 2007).
Skeletal maturation
Studies about the growth and maturation of the maxillary sutural system often consist of
information about the ideal time for treatment of maxillary transverse deficiency. The
maturation of the midpalatal suture has been histologically examined in different
developmental stages. Melsen used autopsy material to do such examination, and is
presented in three stages of midpalatal sutural maturation:
a) The infantile stage
b) The juvenile stage
c) The adolescent stage
The infantile stage is when the patient is up to 10 years of age. In the juvenile stage
(from 10 to 13 years) the suture develops into a more typical squamous suture when the
patient is still growing. The adolescent stage (13 and 14 years of age) is when the
midpalatal suture almost is completely closed (Melsen 1975).
Transverse growth of the maxilla follows velocity and distance curves similar to those
for body height with similar times of growth spurt and growth completion. The closure
of the maxillary sutures occurs around 14 to 15 years of age in females and 15 to 16
years of age in males (Haas 1970).
If the orthodontic part of the treatment is initiated before the pubertal peak in skeletal
growth it is possible to induce significantly more favorable skeletal changes in the
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transversal plane (Melsen 1975). As the sutures mature, the majority of orthopedic rapid
palatal expansion occurs by dental tipping and alveolar bone bending rather than by
skeletal movement (Kurt et al 2010).
Surgically assisted maxillary expansion (SARME)
SARME is a procedure that essentially combines osteogenic distraction with controlled
expansion of soft tissues. SARME is a type of distraction osteogenesis (DO), which is a
method for either expanding congenital defected jaws in the orofacial region or for
restoring atrophic jaws in the vertical dimension (Cheung et al 2010). DO is a method
of clinical tissue engineering with great possibilities, even to treat severe deformities in
the craniofacial area. Patients with hemi-facial asymmetries, extreme retrognatic
maxillas or mandibles can be adjusted to normal positions.
Surgical procedures such as Le Fort I osteotomy, as an alternative to OME, has been
used for widening the maxilla in a transverse dimension (Betts&Ziccardi, 2000). In
general SARME is the treatment of choice when treating adults with maxillomandibular
discrepancy, which can overcome the resistance of ossified sutures with tooth-borne or
bone-borne distractors (Mommaerts, 1999).
Indications
SARME is the treatment of choice when the expansion of the maxilla is not possible
orthopedically because of the patient´s skeletal maturity (Altug et al 2006) or shows
transverse maxillary deficiencies of more than 5mm. SARME should also be considered
when skeletally mature patients show a narrow maxilla associated with a wide
mandible. The maxillary procedure is technically easier than narrowing the mandible
because of the potential negative effects on the condyles. The majority of transverse
deficiencies often show tapered dental arches pronounced in the canine region. Thus to
obtain a functional occlusion the inter-canine width must be increased and the incisors
retracted to produce an elliptical arch form.
SARME is also an ideal procedure if extractions before orthodontics are not desired.
Instead of premolar extractions maxillary expansion with SARME space can be
provided with space alignment of crowded maxillary incisors, which results in
symmetric dental arches (Silverstein &Quinn, 1997). Premolar extractions leave too
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narrowed arches, which gives “dark tunnels” in the buccal areas and when the patients
are smiling it shows. The esthetic result will not be optimal. Therefore decisions about
extraction should be postponed (Chamberland &Proffit, 2008).
The SARME procedure:
The SARME- technique consists of five phases:
-
The fixation of the orthodontic expansion appliances
-
The surgical procedures with osteotomies
-
The latency phase
-
Active distraction of the bone
-
Consolidation
-
Remodeling of the bone. The fixation of the orthodontic expansion appliances
The most common preoperatively placed appliances are the Haas-type-expander (tooth
tissue-borne, figure 1) or the Hyrax-type- (the tooth – borne, figure 2) (Kurt et al 2010).
The main difference between these two types of expanders is that the Haas-type has an
acrylic pad that leans on the lateral walls of the palatal vault. The acrylic pad is used to
reinforce the anchorage for greater orthopedic response and better force distribution
during RME (Haas, 1961). It is also assumed to distribute the expanding force between
the posterior teeth and the palatal vault. The Haas expander is stated to be the only
appliance that might lead to a significant expansion of the maxillary base (Haas AJ,
1973 Interviews).
The Hyrax appliance delivers the force to the maxilla only by the appliance of
supporting teeth (Garib et al 2005). Advantages of the Hyrax expander include its lack
of the acrylic pad and is therefore more hygienic and it also prevents soft tissue
irritation caused by food impaction under the acrylic plate (Biederman 1968). The hyrax
appliance also has the ability to be placed and removed without local anesthesia in the
orthodontic outpatient clinic. On the other hand dental anchorage can lead to several
complications, including periodontal membrane compression and buccal root
resorption, cortical fenestration, possible loss of anchorage, tooth tipping and segmental
tipping (Koudstaal et al 2009). Furthermore, the absence of an acrylic pad is stated to
allow relapse of the orthopedic effect during the retention stage (Haas AJ, 1973
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Interviews).
Devices with bone anchorage have thereafter been exhibited, the transversal palatinal
Surgi-Tec, the Rotterdam Palatal distracter, the Magdeburg palatal distracter and the
Smile distractor (Kurt et al 2010). These types of expanders are becoming more popular
in addition to the usual tooth-borne devices. These expanders are positioned directly on
the palatal bone, thereby avoiding dental tipping, root resorption, cortical fenestration
and orthodontic relapse (Koudstaal et al 2009). It is claimed that the bone-borne device
is of choice to avoid several of the problems associated with the Hyrax expander
(Matteini & Mommaerts, 2001). Never the less bone-borne devices have several
disadvantages such as the risk of damaging the roots of the dentition during positioning
of the device, risk of loosening of the abutment plates or the module, and the need to
remove the distractor under local anesthesia in the outpatient clinic. There has been no
consensus published about the right type of device, the choice should be based on the
individual patient´s requirements (Laudemann 2011).
Therefore a modified orthodontic appliance/ distractor was developed at the Department
of Oral and Maxillofacial surgery, Karolinska Institutet at the Karolinska University
Hospital. A modified hyrax-appliance (Figure 3), with both tooth and bone anchorage
was used. The treatment effects have not yet been evaluated.
Figure 1:
Figure 2:
Figure 3:
A tooth-tissue
A tooth borne
borne device, Haas- appliance. distractor, Hyrax appliance.
(Chrcanovic & Custódio, 2009). (Chrcanovic & Custódio, 2009).
A toothbone distractor,
Modified expander device.
(Rosén & Sugars 2011).
The osteotomy (osteogenic distraction) and surgical procedures
The suture lines and the maxillary articulations contribute in different degrees to the
resistance of the maxillary expansion. This has led to a variety of osteotomy- and
corticotomy- designs for separation of the hemi- maxillas in skeletally mature
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individuals. Results differ based on the timing, placement of the corticotomies and of
the orthodontic devices. Furthermore all surgical procedures have shown to be more
stable than orthodontic expansion alone according to Bell & Epker (1976). The extent
of surgery depends on the areas of major resistance, with some individualization (Suri
& Taneja, 2008).
SARME
With either 2 segmental or 3 segmental osteotomy and with or without pterygoid osteotomy
The patient undergoes surgery with local and general anesthesia, bilateral blockage of
the superior alveolar nerves, nasopalatine nerve, and bilateral posterior palatine nerve.
Over the maxillozygomatic crest incisions and osteotomies are made bilaterally above
the dental apexes, aiming to preserve their vitality (Chrcanovic & Custódio, 2009). A
Le forte I osteotomy is performed through the maxillary sinus walls, the
infrazygomatico crest, and the lateral nasal walls (Laudemann et al 2011). Next step is
to detach the maxilla at the median palatine suture. When detaching the maxilla the
surgeon protects the palatine mucosa by putting the forefinger in the palate to feel the
bone separation and the chisel´s proximity.
When a pterygoid osteotomy is indicated then the surgeon makes the last osteotomy
from behind the tuberosity area to the pterygoid junction. Pterygomaxillary disjunction
may be effective on patients older than 20 years, whereas patients younger than 20 years
do not have completely ossified sutures so pterygomaxillary disjunction may not be
effective. Pterygomaxillary disjunction may affect the amount of resistance on each
side. If a difference in resistance between the two sides occurs, then the side with the
least resistance will move, leaving the other side stationary (Laudemann et al 2011).
The second surgery procedure
SARME is the treatment of choice when only a transverse change is needed. A second
surgery is required when a repositioning of the maxilla vertically or anteroposteriorly is
needed. The risk of aseptic necrosis and relapse decreases when performing a primary
SARME procedure (Bailey et al 1997). According to Laudemann et al (2011) the
second surgery begins with a Le Fort I osteotomy, and then new incisions are made so
that another osteotomy can be performed a 2 segmental (S) or a 3 segmental osteotomy
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often used to close an open bite. The 2S osteotomy is located between the central
incisors and runs from the anterior nasal spine to the posterior nasal spine. A 3S
osteotomy is performed between the lateral incisors and canines making a V-shape in
the hardpalate and then runs to the posterior nasal spine. The 3S osteotomy is performed
when there is sufficient interradicular space between the lateral incisors and canines and
is promoded to avoid midline diastemas, septal and columellar dislocation, and
assymetric expansion (Laudemann et al 2011). However Multisegmental osteotomies
have shown to result in greater transverse maxillary instability and relapse after the
removal of orthodontic appliances, particularly when used to correct large transverse
maxillary discrepancies (Philips et al 1992).
The latency period
The time interval between the osteotomy and the appliance start-up is the latency
period, and can vary from 0-14 days (Tavakoli et al 1998).
The activation of the distractor
The amount of daily bone distraction is what is considered to be the activation rate; it
varies from 0.25-1.0mm per day. The frequency is the number of times the distractor is
activated per day (Iliazarov, 1989 part I). A reliable patient is needed to expand the
device each day and it also requires a long retaining period with orthodontic treatment
(Saulacic et al 2009). It is of great importance to remember that in adults the appliance
should be turned, at most once per day since the suture is unlikely to split in adults and
can therefore cause discomfort. In children the appliance can be turned on to four times
a day (Handelman, 1997). The activation time depends on the individual needs.
Maxillary expansion in the midpalatal suture occurs when the force applied to the
dentoalveolar structure exceeds the limit required for the orthodontic movement,
activating the cell reaction in the periodontal ligament, and diverts the forces on the
maxillary sutures. The width of the midline diastema at the maximum expansion point
is highly correlated with the first molar expansion. Therefore the development of a
diastema is a predictor that adequate molar expansion is occurring (Laudemann et al
2011).
The retention period
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The retention period varies from 1 to 6 months, and is necessary for the palatinal suture
to overcome the resistance of the recidivating forces and to prevent relapse.
It is recommended that the retention period should last 6 months so that good
mineralization of the bony suture can be accomplished (Iliazarov, 1989 part I). Reported
side effects such as infections, bone morbidity, distractor fractures and patientdiscomfort have been reported (Saulacic et al 2009)(Iliazarov, 1989 part I).
Stability of the expansion and relapse
The skeletal maturity of the suture lines is directly related to the long-term stability of
the expansion. Recently, a three year follow-up study was reported where OME and
SARME were compared with a control group. The control group consisted of untreated,
skeletal Class I subjects matched to the OME group in order to assess the effects of
normal skeletal growth. The study showed that both the OME and the SARME
procedures gave stable results after three years with some amount of post retention
relapses compared with the control group (Kurt et al 2010).
Bone repair
When an osteotomy is performed a biological process of bone repair is triggered.
Thereafter a blood clot appears and will be replaced by granulation tissue. The
granulation tissue consists of inflammation cells, which fill the distracted bone space
and stimulate the osteocytes to produce bone-tissue (Cheung et al 2010). To ensure that
bone repair occurs in osteogenic distraction, some principles must be followed:
maintenance of blood supply in the region of the distraction, stability of the distractor
and bone fragments set, adequate latent period; adequate rate and frequency of
activation, and observance of the retention period. The preservation of the blood supply
requires an appropriate surgical procedure; with careful manipulation of soft tissues and
that the periosteum remains intact. The periosteum is a highly vascular connective tissue
which functions as a rich cell source for bone tissue engineering. During
osteodistraction the regenerative potential of the periosteum is benefitial due to its
ability to simultaneously increase the bone length and the volume of surrounding tissue.
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The contact between the periosteal flap and the underlying bone stimulates osteogenesis
(Mahayan, 2012). The more rigid the distractor bone fragments ensemble the more
efficient bone repair will be (Ilizarov, 1989 part II). To prevent postoperative infections,
the osteotomy needs to be covered with a tensionfree flap without any gaps in the
incision area (Kahnberg 2010).
Alternative SARME treatments
Segmentalized Le Forte osteotomies may be indicated in certain circumstances instead
of SARME. It should be considered when transverse discrepancies coexist with vertical
or sagittal discrepancies. Segmental orthodontics and alignment of the segments with a
partitioned Le Forte osteotomy is the treatment of choice when patients show moderate
transverse discrepancies (< 7mm), apertognathia, and severe curve of Spee.
The difference between the SARME procedure and the segmental Le Forte osteotomy is
that the segmental Le Forte osteotomy produces more expansion in the molar region
than at the canine sites. The produced molar expansion in segmental Le Forte osteotomy
occurs when the posterior articulations of the maxilla are not separated with the
SARME technique, the lateral nasal walls and palatine processes are left intact, limiting
posterior expansion (Silverstein & Quinn, 1997).
Another alternative to SARME is a surgical procedure in one session. Four premolars
are extracted. Thereafter orthodontic treatment, to gain symmetric arches, continues for
a year and the treatment end with bimaxillary surgery and often a chin plasty occur.
Bimaxillary surgery is a technique that is performed in both the maxilla, Le Fort I
osteotomy, and in the mandible, vertical ramus osteotomy. It is often used to correct
malocclusion of angle III, which can occur separately or with other malocclusions such
as crossbite (Mucedero et al 2008).
Hypothesis/aim
The purpose of this retrospective study was to evaluate treatment effects and mapping
the patients overall opinion about the SARME treatment made in our clinic.
The hypothesis: A normal occlusion is achievable after surgical assisted rapid maxillary
expansion treatment without premolar extraction. The patients are pleased with the
16
treatment results.
Materials and Methods
Study design
The structure of this study is based on a cohort of patients that has been treated
surgically with the SARME technique during a 12 years period. The cohort has been
retrospectively studied, with a descriptive research methodology. This study was
executed in three different parts, collection of epidemiologic data from the patients’
medical journals (part I), clinical follow-up with collection of data from questionnaires
and clinical examinations (part II) and pre- and postoperative cast model analysis (part
III).
Ethical considerations
The ethical committee in Stockholm, Sweden approved the conduction of this study.
The patient’s personal data was encrypted and each patient was given a specific number
in order to keep the patient anonymous.
Review of the literature
The first phase in the construction of this study was a review of the literature. The
research for previous studies in this field was mainly found by the search-engines
PubMed and Medline by using keywords such as SARME, RME, maxilla/surgery, oral
surgical
procedures,
palatal
expansion
technique,
osteogenesis,
distraction/
instrumentation. The selection of the studies was based on their content and how
relevant they were for this study.
Subjects
Inclusion and exclusion criteria
The inclusion criteria were transverse maxillary deficiency, narrow maxilla, dental
17
crowding or lack of dentoalveolar basis. Patients had to be older than 15 years but
younger than 50 years in order to be a part of the study. A given consent to participate
was also needed. If the patient could not fulfill these essential criteria they were
excluded.
The patients that were selected to participate in this study had been surgical treated for
narrow maxillas with crossbite using the SARME- method and a modified tooth and
bone-anchored device.
Surgical technique
A modified expander device was used that consisted of both a teeth and bone
anchoraged device. The SARME- treatment started with that two screws were attached
during local anesthesia in the palate, one on each side of the midline, before the device
(a modified- hyrax appliance) was fabricated. Thereafter the device was cemented to the
molars and supported to the two screws in the palate of the upper jaw. The surgical
procedure was made under general anesthesia. A Le Fort I osteotomy was performed
and the midline was opened with an osteotom to make it possible for the maxilla to
expand during the distraction phase. The patient was hospitalized during one night
before entering home. After about 1 week the patient started to activate the modified
hyrax appliance according to directions from the surgeon. The distraction lasted for
approximately 14 days or until the expansion was big enough. The patients obtained an
expansion up to 15mm, visualized between the central incisors. The distraction device
remained attached to the teeth and palate for about four to six months (retention-period),
to maintain the palatinal expansion and to allow the bone to heal. During the retentionperiod, the orthodontists placed braces on the upper and lower teeth, to achieve
consistent dental arches; this treatment lasted for about one year. Finally a new
examination was performed to evaluate if the patient needed a second surgery procedure
to locate the jaws to a normal occlusion of the teeth.
18
Part I: Collection of epidemiologic data from patient´s
records
Selection of patients
A total of 43 patients (19 women and 24 men) were included in the study (Figure 4).
These patients were remitted to the department of oral- and maxillofacial surgery at
Karolinska University Hospital from the orthodontic clinics where they were diagnosed
with crossbite and a narrow maxilla. The patients were selected after a mutual meeting
between the oral surgeon, the orthodontist and the patient with the parents, where they
had given consent to receive the SARME- treatment (Figure 5).
All of them had been treated for crossbite and narrow maxilla with the SARME
technique, during a time period of 12 years, Mars 2001 to April 2013. There are
approximately 3.6 patients per year (43 patients /12 years) in the department of Oral and
Maxillofacial surgery at the Karolinska University Hospital that receive the SARME
treatment. The age of the patients during the SARME procedure ranged from 14 to 40
years of age. The mean age among the women was 19.0 years and among men 19.1
years (Figure 6).
Figure 4 Chart showing gender distribution of patients (N=43).
19
Different stages in the SARME treatment
Figure 5 A flow chart showing the different stages in the SARME treatment.
20
Figure 6 Chart showing mean age and standarsdeviation among each gender group. The blue staples in
the figure represent the mean age among men (19.1) and among women (19.0). The two vertical black
lines on the two blue staples in the figure represent the standard deviation among men (3.67) and among
women (6.74).
Dropouts
At the basis of this study, epidemiologic data was collected (part I) in 43 patients.
However, during the clinical follow up (part II) which included responding to a
questionnaire and a clinical examination, 30 patients (70%) participated (12 women and
18 men). The main reasons regarding why 13 patients (30%) could not participate in the
postoperative examination were due to the geographical distance (8 patients), 3 of the
patients did not give their consent to participate and 2 patients had postponed their
SARME-treatment and could therefore not be included in this study.
During part III, 43 pre- and postoperative study-casts were to be analyzed. According to
the patients records these preoperative study-casts were found in 9 different clinics were
the patients received their orthodontic treatment. However during the collection of the
preoperative study- casts it was found that 14 of them were missing. The main reason
why some of the preoperative study casts could not be found was that some of the
orthodontic clinics did not save preoperative cast models ten years after completed
treatment. A total of 38 postoperative cast models were collected and analyzed. 30 of
21
them were produced after the clinical examinations where alginate impressions were
made and the remaining 8 postoperative cast models were collected from the
orthodontic clinics.
The patients were selected through a review of the patient’s records in a digital medical
journal system, Take Care (CompuGroup Medical). The patient’s records were
reviewed by using their social security number. The medical staff at the Karolinska
University hospital uses the digital medical journal system.
Collection of data from patient’s records
The following data was of interest for this study: gender, age, address, telephone
number, orthodontic status before orthodontic or surgical treatment, orthodontic clinic
where the patient received the orthodontic treatment, time when the patient acquired the
SARME-treatment, number of operations, uni-or bimaxillary surgery and noted sideeffects postoperatively. All collected data was protected with a password and coded
before the information was inserted in to a Microsoft excel document.
The orthodontic clinics
The patients received their orthodontic treatment in nine different orthodontic clinics,
orthodontic department of Folktandvården in Södertälje and in Handen, Karolinska
Institute, and 6 other private orthodontic specialist clinics (Figure 7).
22
Figure 7
Distribution of patients from different orthodontic clinics.
Part II: Clinical follow up examination and questionnaire.
Patient´s consent to participate in this study
Patients were contacted through a phone call and received information about this study.
If the patients showed interest to participate, an appointment was scheduled and the
patients got the opportunity to give written consent to be a part of the study. When the
patient received written information and approved to participate, then a clinical followup examination could be executed.
23
Protocol for clinical examination
A total of 30 patients participated in the clinical follow up examination. The mean age
among these thirty patients when they received the SARME treatment was 18.8 years,
ranged from 14 to 31 years. The distribution among men and women was 18:12. Prior
to the clinical examination following personal data was collected: patients name, age,
telephone number, social security number and medical health history. Due to the
structure of this retrospective study an evaluation of the treatment effects was performed
by executing an objective and a subjective postoperative examination. A standardized
protocol was designed for this study, which the examiner followed (see appendix 1).
One clinician executed all clinical examination.
The protocol started with an examination of: the oral mucosa, the gingiva, the dentition,
and the occlusion/articulation, with the help of extraoral- intraoral- digital photographs,
a dental mirror, a dental probe, a toothbrush, occlusion foil, alginate impressions of the
upper and lower jaw. The digital photographs were taken in order to mark eventual
esthetic changes. The dental mirror and probe were used to observe gingival scar tissue,
changes in the structure of the oral mucosa, tooth discoloration, which indicates tooth
necrosis, the occlusal and angle relations between the upper and lower dentition and
grinding facets, which indicates teeth grinding.
Assessment of TMJ- function
The clinical follow up also contained an assessment of the TMJ function by executing
an objective and subjective examination of the TMJ.
The objective assessment of the mandibular movement function included; maximum
opening capacity, laterotrusion (LTR), mediotrusion (MTR), protrusion (PTR), and
eventual clicking or crepitation-sounds from the joint.
The clinician noted if the patient showed any signs of impairment or reduced capacity of
the mandibular movement, in millimeters.
The TMJ-examination consisted of palpation of the TMJ and the myofascial muscles
(the masseter muscle, the insertion of the masseter muscle and the lateral pterygoid
muscle). The patient estimated pain upon palpation of the TMJ and during mandibular
side- opening- and closing- movement by using a scale from 0 to 3 where 0 was no
pain, 1 mild, 2 moderate and 3 severe (Fumal & Schoenen, 2005).
24
Assessment of pain and perception
During the clinical follow up the patients were asked to grade how much pain they
experienced one week after surgery on a visual analogue scale (VAS-scale) and how
much pain they experience at the time of the appointment. The VAS scale consisted of a
graded ruler where the endpoints 0 represent “no pain” and 10 represent “worst pain
imaginable” (Wewers & Lowe 1990).
Finally an examination of the facial-skin and oral mucosa was made. Sensory
perception was measured with a simplified version of quantitative sensory testing by
probing with a dental probe, brushing with a toothbrush and pinching the cheek and lips
with the fingers (Yekta et al 2010). The clinician noted hypo-or hypersensitivity of the
facial skin around the cheeks, lips, chin and the oral mucosa on the alveolar bone of the
upper and lover jaws. Before testing the area where the SARME operation had been
performed, an untreated area was used as a reference point so that the patient could
estimate if there was a difference in the perception.
Collection of data from questionnaire
A questionnaire was used during the clinical follow up examination, where the patient
got the opportunity to express their opinions regarding the effects of the SARMEtreatment, which gave a subjective postoperative evaluation. The questionnaire
contained of ten questions (appendix 2). Improved functions, aesthetics, experienced
pain, orofacial perception-impairment, were subjective factors of importance for this
study. A total of 30 patients had given consent to participate, and the answering
frequency was 100%.
X-rays
X-ray pictures were taken only if there were indications of pathology, according to the
national guidelines of oral radiology.
25
Part III: Cast analysis
Dental casts were taken before the SARME treatment and impressions were made at the
follow up recall. 29 preoperative cast models were collected from the nine orthodontic
clinics and 38 postoperative cast models were also collected. 30 of the postoperative
cast models were produced after the clinical follow up examination and the remaining 8
cast models were collected from the orthodontic clinics. The 29 pre- and postoperative
cast models were used to analyze the treatment effects and the palatinal expansion
however the remaining 9 postoperative cast models were included only when the dental
occlusion was analyzed. Direct measurements were taken to the nearest 0.1 mm with
Vernier caliper, which is a measurement tool that indicates the distance between two
marks. One clinician made thereafter measurements on 29 preoperative and 38
postoperative cast models.
The following dimensions were measured and registered on the postoperative cast
models:
1. Maxillary intermolar width
The distance from the right to the left first molar measured from the gingival
margins at the palatinal groves. The measurements were made on the 29 pre- and
postoperative cast models (Figure 8).
2. Maxillary intercanine width
The distance from the right to the left canine measured from the gingival margin
at the midline of the tooth. The measurements were made on the 29 pre- and
postoperative cast models (Figure 8).
Magnusson et al (2009)
26
Figure 8
Direct measurements on the pre- and postoperative study models were made with a sliding
Vernier caliper. Intermaxillary measurements were taken at two anterior and two posterior reference
points. C denotes the distance between the most prominent cervical points of the palatal ridge on the
canines (two anterior reference points). M denotes the distance between the most cervical points of the
palatal fissure on the first molars (two posterior reference points).
3. Palatal height
The distance from the mid- deepest part of the palate to the line connecting the
left and the right disto-lingual cusp tips of the upper first molars was taken as
palatal depth. The measurements were made on the 29 pre- and postoperative
cast models (Figure 9).
Sokucua et al 2009
Figure 9 The distance from the mid- deepest part of the palate to the line connecting the left and
right disto-lingual cusp tips of the upper first molars was taken as palatal depth.
4. Registration of dental occlusion status.
The occlusion status was registered on the 29 pre- and 38 postoperative cast
model.
Statistical analysis
All data collected from reviewing patient records and from examining patients´ pre and
postoperative cast models were numeric in nature, compiled and statistically analyzed
using Microsoft Excel working sheets and the statistical program Statistica®. Shapiro-
27
Wilk test was used in order to examine if the data was normally distributed. The
differentiation of the numerical data was calculated through t-test and Man- Whitney Utest. Percentage number was calculated through Chi2-test. All charts and diagrams
presented in this study are also produced with the use of Microsoft Excel.
28
Results
Part I: Collection of epidemiologic data from patient’s
records
The epidemiologic data indicated that the patients that were treated with SARME
showed preoperative malocclusions such as postnormal-, prenormal occlusion, open
bite, deep bite or uni- or bilateral cross bite as a result of a narrow maxilla. Some
patients showed more than one of these angle occlusions (se table 1). According to the
patients records the most common preoperativ malocclusion was cross bite 79.1%.
These data proved that the most common indications for the SARME treatment were
cross bite and prenormal occlusion due to a narrow maxilla. To close an open bite a
second surgery was needed.
Further on, after approximately one year a new examination was made by the surgeon to
evaluate if the patient, that had received a SARME operation, was in need for a second
uni- or bimaxillar surgery to achieve a normal occlusion. Most of the patients needed a
second surgery. However, 26.8% of the patients were satisfied and could be finished. In
some cases when the surgeon recommended a second surgery one patient declined the
offer due to the fact that she felt esthetical and functionally pleased with the results. One
patient did not cooperate and was therefore not recommended a second surgery.
Table 1 The distribution among 43 patients, different malocclusions, teeth extractions before the SARME
treatment and if they received a second surgery are noted.
29
30
Part II: Clinical follow up examination
Results from the questionnaires
Q1-Q2: About preoperative information and participation of the treatment
planning
29 patients answered the first question (Figure 10), 83.3% felt that they had received
sufficient preoperative information; 6.9 % felt that they had not been given enough
information and the other 6.9% felt that they were given too much information.
According to the 30 patients who answered the second question, they all felt that they
had a part in the treatment planning. 6.7% of the patients felt that they had to little to
say during the treatment planning, 10. 0% felt that they were being too much involved
during the therapy planning. The remaining 83.3% of the patients felt that they had just
enough to say.
31
Figure 10 Bar graph showing the patients answers to the first and second question in the questionnaire.
Q3- Q4. Postoperative subjective discomfort:
The results show that the 30 patients answers were inconsistent regarding the third
question about how they experienced eventual a) pain, b) swollenness and c) perception
impairment. The majority of patients found the postoperative pain, swollenness and
perception impairment as moderate difficult (see table 2).
32
Table 2 Presentation of the 30 patients´ (N total) answers to the third question in the questionnaire, about
how they experienced a) pain, b) swollenness and c) perception impairment.
Q3: The days after the operation, how did you experience eventual a) Pain? b) Swolleness c) Peception impairement No difficulties N (%) Moderate difficulties N (%) Severe difficulties N (%) 13 (43.3%)
14 (46.7%)
3 (10.0%) 7 (23.3%)
16 (53.3%)
7 (23.3%) 14 (46.7%)
15 (50.0%)
1 (3.3%) The patients were also asked if the pain, swollenness and perception impairment was
equivalent, less than or more than what was expected.
Regarding the expected pain, 28 patients answered, 23 of them (77%) felt that the pain
was as expected, five patients (16%) felt less than what was expected.
The patients’ answers (N=27) according the expectations regarding the swollenness,
63.0% (N=17) felt swollen as they expected, 33.3 % (N= 9) felt much more, 3.7%
(N=1) felt less than what was expected.
Finally 22.2% (N=6) of the 28 patients felt that the perception impairment
postoperatively was much more than what they expected, 59.3 % (N=16) thought that it
was equivalent to what was expected. However, the other 22.2% (N=6) felt less
impairment than what they thought they would feel.
The fourth question (Q4) was about the perception impairment a) did not bother? b)
bother? c) or was not something they thought about? d) did not appear at all? In the
same question the patients were also asked where it appeared on the cheek, chin, lips
and/or the gingiva? 23 patients answered, see table 3.
a) Two patients answered that they had received perception impairment but it did
not bother them. One patient experienced it on the cheek, chin, upper lip, and
maxillary gingiva. The other patient experienced perception impairment on the
chin and on the upper lip.
b) There were two patients that received perception impairment on the upper lip
33
that they felt was uncomfortable.
c) Four patients received perception impairment but they did not think about it. In
one patient it occurred on the cheek, chin, upper lip and maxillary gingiva. The
other three patients experienced it on the maxillary gingiva.
d) The other remaining 15 patients did not receive any perception impairment at
all.
Table 3 Presentation of the 23 patients (N total) answers to the fourth question in the questionnaire,
regarding eventual perception impairment that occurred due to the SARME surgery on the cheek, chin,
lips or on the gingiva.
Q4. If you received perception Cheek impairment after surgery, where Total n=23 is it and how does it feel? a) Did not bother them: 1 (4.3%) b) Did bother them: c) Was not something they thought about: d) Did not appear at all: 1 (4.3%) 21 (91.3%)
Chin Total n=23 Lips Gingiva Total n=23 2 (8.7%) 2 (8.7%) 1 (4.3%) 2 (8.7%) 1 (4.3%) 1 (4.3%) 4 (17.4%) 20 (87.0%) 18 (78.2%) 18 (78.2%) Q5-Q10. Subjective evaluation of the treatment results
The fifth question was a multiple choice question where they were asked if their
preoperative problems, had changed after the operation to the better, much better, the
same, worse, much worse, was no problem to begin with (Figure 11).
A total of 30 patients answered:
a) The majority of the patients 56.7 % answered that the biting and chewing
function was much better due to the SARME treatment. 13.3 % of the patients
felt that the biting and chewing function did not change after the treatment. No
patient experienced deterioration.
b) Most of the patients 33.3% felt that their biting position had improved and was
much better, 23.3% of the patients felt no difference before and after the
treatment. None of the patients experienced deterioration.
34
c) The question if the appearance of the teeth position had changed, 70.0%
answered that it had changed and was much better, 3.3% felt that there was no
problem with the teeth positioning to begin with.
d) The majority of the patients, 40.0 %, felt that their facial appearance was not a
problem to begin with, 30.0% felt that their facial appearance changed and was
much better. None of the patients felt that their facial appearance was worse
after the SARME treatment.
e) The patients were asked if their eventual pain upon the jaws had changed after
the SARME procedure, 80.0% felt that they had no problems with the jaws. 6.7
% felt that their jaw pain reduced after treatment, however 3.3% of the patients
felt that the jaw pain became worse after treatment.
f) 70.0% of the patients did not feel pain upon the temporomandibular joint,
however 6.7% felt that their pain reduced after the SARME treatment and 10%
felt that their pain became worse after the treatment.
g) The majority of the patients, 56.7%, did not experience any speech difficulties to
begin with. 3.3% of the patients felt that the speech- pronunciation was much
better. However 6.7% of the patients felt that their pronunciation became worse
and 3.3% felt that it became much worse.
h) 6.7% of the patients experienced other problems that had changed after the
SARME treatment. 3.3% of the patients felt that the frequent headaches had
reduced in power and frequency and another 3.3% reacted to the increased
amount of calculus that surrounds the lingual retention bar on the lower front
teeth.
i) Most of the patients, 40.0%, reported that their self-esteem was better after the
treatment, 33.3% noticed that it was much better, 20.0% felt that they had no
self- esteem issues before the treatment.
35
Figure 11 Bar graph showing the 30 patients answers to the fifth question regarding the eventual changes
on the preoperative problems (a-i), due to the SARME treatment, if they had changed to the a) better? b)
much better?, c) the same, d) worse, e) much more worse, f) was not a problem to begin with.
j) The 30 patients answered that the most important change due to this treatment
were category c) the teeth appearance 32. 6%, a) difficulties with biting or
chewing? 27.9%, i) self esteem, 25.6%, b) uncomfortable biting position, 7.0%,
d) facial appearance, 4.7%, h) Headache, 2.3%.
The following question was about the patient opinion regarding the treatment results
(Q6). This question was a multiple-choice question and could be answered in three
different ways, bad, good and very good. 25 patients thought that the treatment results
were very good; the other 5 patients thought it was good.
The patients’ respond to the seventh question (Q7) showed that none of the 30 patients
regretted the SARME treatment with the modified distractor device. The patients were
also asked if they would recommend this treatment to other patients (Q8) with the
similar oral status, all 30 answered yes.
36
The ninth question was formulated so that the patients would have the chance to express
their opinions regarding the recommended improvements for future treatments. The
patients were also asked if they were satisfied or unsatisfied (Q10) with the treatment
results.
Five patients recommended that better information should be available, especially
regarding the screws that were placed in the palate preoperatively and also the eventual
complications that can occur during this procedure such as bleeding. One patient
thought that the communication between the surgeon and the orthodontist was lacking
and could improve for future patient-treatments. Another patient felt that the hospital
staff could be more considerate during the recovery at the hospital. One patient felt that
it was embarrassing to share room with other patients in the hospital due to the
swollenness after surgery. The other 22 patients answered that no improvements were
necessary.
Only five patients answered the tenth question (Q10). One patient was unsatisfied with
the perception impairment that he had received after surgery. The other patients were all
happy with the results and complemented the surgeons.
One patient´s answer this question “this operation gave me my smile back, I can show
my teeth on camera for the first time in ten years.”
Assessment of oral status
The 30 patients showed no oral mucosal changes however 20 patients (67%) showed
scar tissue in the operation area.
Three out of the 30 patients (10%) presented gingivitis, due to poor oral hygiene. One
patient showed a tooth discoloration that appeared after the SARME treatment, however
the patient’s dentist confirmed that the tooth is still vital and is under regular check up.
Another patients tooth became necrotic after the SARME-treatment and had to be
endodontic treated. Two of the patients were also under implant treatment due to other
causes that do not involve the SARME treatment. One patient had a mandibular fracture
after the second surgery, a bimaxillary operation. The surgeon confirmed that the
fracture had healed and the patient did not experience any other symptoms according to
the fracture during the follow up examination. 22 patients showed neutral angle class I
37
relations, vertical overjet of 1-3mm and no transversal discrepancies. Four patients
presented angle class II relations; one of them had 4 premolars extracted, two of them
showed anterior open bite and the forth one showed normal vertical overjet (1-3mm)
and no transversal discrepancies. Another patient had angle class III relations; and had
had one premolar extracted from the lower jaw on each side, none of these patients
showed transversal discrepancies. The three remaining patients showed neutral angle
class I occlusion, normal vertical overjet (1-3mm) and cross bite (two patients had
unilateral, one patient bilateral). A total of four patients had teeth extracted due to teeth
crowding.
Assessment of the TMJ function
None of the patients showed impairment or reduced capacity of the mandibular
movement. All patients showed a maximal opening capacity at least 40mm, laterusion
(LTR) of at least 7mm to both sides and protrusion (PTR) of at least 5 mm.
Nine patients showed (4 unilateral, 5 bilateral) clicking sounds during opening and
closing of the jaws. No crepitations were reported.
The TMJ-examination followed palpation of the TMJ and of the myofascial muscles,
the masseter muscle, the insertion of the masseter muscle and the lateral pterygoid
muscle. One patient felt pain upon palpation of the TMJ and estimated the pain to grade
2 upon palpation on the masseter muscle, on the temporalis muscle grade 1, the
insertion of the masseter grade 1. Another patient experienced pain upon palpation on
the temporo-mandibular joint on the right side, grade 1. One patient suffered from
bruxism witch the patient currently is being treated for.
Assessment of pain
A total of 30 patients described the experienced pain 1 week after the first surgery, the
SARME treatment and the day of the follow up examination (see table 4). The majority
of the patients (N=11) scored 5 on the VAS scale when they described the pain one
week after surgery. 29 patients chose the VAS score 0 to describe the pain at the follow
up examination, however one patient scored VAS 2 due to the tenderness of the facial
muscles.
38
Table 4 Presentation of the patients´ assessment of the postoperative pain after the first SARME
surgery. During the follow up examination the majority of the 30 patients (36.6%) estimated their pain 1
week after surgery to be a 5 in the VAS scale.
Assessment of pain one week after surgery
Assessment of perception
The clinical follow up continued with an examination of the perception. The results
show that 18 patients were hyposensitive on the vestibular oral mucosa in the maxilla
and one patient in the mandibular oral gingiva. The examination also showed that four
patients were hyposensitive on the upper lip and one patient on the lower lip. Two
patients were hyposensitive on the cheeks closest to the nose and one patient on the
chin.
Further on three other patients showed hypersensitivity on the vestibular oral mucosa in
the maxilla and another patient on the cheek when using the pinprick examination with
the probe.
Table 5 Presentation of the results from the clinical follow up examination of perception using pinprick,
brushing- or pinching test. 60.0% of the 30 patients that were examined showed hyposensitivity on the
maxillary oral gingiva, 13.3% showed hyposensitivity on the upper lips.
X-rays
The 30 patients that were examined showed no conditions that indicated taking x-rays.
Part III: Cast model analysis
A total of 29 preoperative and 38 postoperative cast models were collected either from
the clinical follow up examination or from the nine orthodontic clinics. As previously
mentioned the 29 pre- and postoperative cast models were used to analyze the treatment
effects and the palatal expansion (see table 6) however the remaining 9 postoperative
cast models were included when only the dental occlusion was analyzed (see table 7).
The preoperative cast models confirmed the epidemiologic data in the patients´ records
(see part I collection of epidemiologic data from patients´ records). The most common
malocclusion was cross bite (79.1.%).
The analysis of the postoperativ castmodells showed that the SARME treatment
improved the occlusion and the esthetics of the dentition. In 76.3 % a normal occlusion
had been achieved and in 86.8 % no teeth had been extracted. Three of the five patients
that had teeth extracted before the SARME treatment still showed a malocclusion
40
during the follow up examination, one patient had postnormal angle class II occlusion
and the other two had angle class III occlusion. These results show that a normal
occlusion was not achieved on 60% of the patients that had teeth extracted before the
SARME treatment.
Table 6 A presentation of pre- and post-treatment palatal width and height.
Table 7 Analysis of the 38 postoperative cast models showed that 76.3 % of the patients received a
normal occlusion. 86.8 % did not have any teeth extracted.
Postoperative cast model analysis
Statistics
Table 6 shows that there is a significant difference in the palatal width and height before
and after the SARME treatment according to the t-test used on the 29 patients ´pre- and
postoperative cast models. The table also shows that a significant palatinal expansion
has been achieved due to the SARME-treatment in the inter canine and inter molar
space.
Chi2-test was used to estimate the frequency of malocclusions after the SARMEtreatment among patients with and without extracted teeth. Figure 12 shows that there is
a significant higher frequency of malocclusion among patients that had teeth extracted
before treatment in comparison with patients that did not have any teeth extracted.
41
Figure 12 There is a significant (p<0.05) higher frequency (%) of malocclusion after treatment among
patients that had teeth extracted before treatment in comparison with patients that did not have any teeth
extracted.
42
Discussion
The present study analyzed the objective and subjective treatment effects of SARME
performed in patients with crossbite and retrognatic maxilla.
The results from the epidemiologic data showed that the mean age of the subjects was
among men 19.0 and, among women 19.1, which clarifies that the majority of patients
were skeletally mature. Skeletal maturity of the patient is an important factor when
choosing between RME or SARME-treatment. Byloff & Mossaz (2004) have stated that
if the patient is skeletally mature and treated with RME instead of SARME, many
problems can occur including pain upon activation of the appliance, extrusion of the
teeth, periodontal complications. However, Betts & Ziccardi (2000) have mentioned
additional complications due to RME treatment on skeletally mature patients such as a
significant amount of gingival recession, relapse despite overcorrection and
malocclusion. Therefore, it is of great importance to investigate if the patients are still in
a growing phase or has reached skeletal maturity before the treatment begins. However,
it is essential to point out the fact that the skeletal maturity is an individual factor that
needs to be taken into consideration during treatment planning.
Further, the collection of the epidemiologic data shows that the most common
indication for the SARME treatment is cross bite. However, some of the patients that
received the SARME treatment and did not have a cross bite or a retrognatic maxilla
often show malocclusions in the vertical dimension, and a second surgery was needed to
correct the open or deep bite. A total of 26.8% of the patients were not in need for a
second surgery witch indicates that a second surgery is not always needed to achieve a
normal occlusion due to the SARME treatment.
The results from the questionnaire stand for the subjective part of this study. The
majority of patients felt that they had received sufficient information and that they took
great part in planning the treatment. The remaining patients (6.9%) did not share the
same opinion due to the lack of information they were given about the treatment
procedure. From their point of view they (6.7%) were also not given the opportunity to
participate in the treatment planning. Sufficient preoperative information is a standard
part of the SARME procedure therefore the percentages of uninformed and uninvolved
43
patients in this study are high. These results show that in some cases when treatment
involves patients younger than 18 years, it is easy to neglect them and instead inform
and involve the parents. The main problem that may occur under these circumstances is
that the patient is not fully aware of the SARME-treatments extent and the postoperative
discomforts that follow. Patients that have been given accurate information regarding
the proposed treatment tend to be more satisfied (Modig et al 2006). Therefore it is
essential for the outcome to involve and inform the patient about the up-coming
treatment, which requires great motivation and cooperation. During the treatment
planning with the patients and the parent it is not only important to inform them about
the treatment but also to acknowledge if the patient has enough motivation to undergo
the treatment. If there is a lack of motivation then the results might not be optimal.
According to Kiyak et al (1986) the expectations of the treatment results are often based
on a combination of functional and aesthetics. In the questionnaire patients were asked
weather or not some of their pre-treatment problems had changed due to the SARME
treatment? The majority of patients answered that the difficulties with biting or
chewing, the uncomfortable biting position and the appearance of the dental position
had changed and is much better today. This shows that the patients feel that the SARME
treatment does not only have a great functional importance but also an esthetical one.
Most of the patients also experienced that their self-esteem had changed to the better.
Kiyak et al (1986) also mentioned that many of these patients are motivated for these
operations due to the hope of an improved appearance. Therefore, it is important to
highlight the functional results of this treatment but one must not forget that the
esthetical outcome of SARME is also important for the patient. Further on, according to
the questionnaire some patients experienced that the pain from the jaws and the TMJ
had become worse. According to Mohlin & Thilander (1984) posterior cross bite can
cause an abnormal mandibular movement when the mandibular jaw may have to move
from one side to the other to allow the posterior teeth to be in occlusion. Hence the
abnormal movement of the lower jaw may put a strin on the jaw muscles and joints,
which may cause problems in later life for example clicking or locking of the disc in the
jaw joint.
These results can indicate that the symptoms such as bruxism, pain upon palpation the
TMJ or the orofacial muscles and the clicking sound from the TMJ are either a result
44
from the patient’s earlier malocclusion or derived from the SARME treatment whereas a
new occlusion has been achieved. This may have caused stress on the jaw muscles and
joints. Considering that these patients feel that the pain from the jaws and TMJ has
evolved to the worse are more likely associated with side effects of the SARME
treatment than the pre-treatment malocclusion. This shows that patients should be
preoperatively informed about eventual orofacial muscle- and TMJ- tenderness/pain due
to the SARME treatment and that the risk may be higher if the patient show
preoperative signs of TMJ-disorders or orofacial pain. Also the orthodontist and
surgeon should take these results into consideration when planning the treatment, and
try to minimize the risk for future TMJ disorders or myofascial pain.
The results from the questionnaires show that some patients in this study also felt that
the speech difficulties became worse after the SARME-treatment. The impaired speechcapability may be due to the changed position of the teeth, anatomic structure of the
palate and dental arches. It is of great importance to inform the patient about eventual
complications such as speech difficulties before treatment and if speech-capability
decreases then the patient should be referred to speech therapist. The majority of the
treated patients experienced difficulties due to the SARME-treatment such as pain,
swollenness and perception impairment. However, none of the 30 clinically examined
patients regretted this treatment according to the questionnaire and they would
recommend the SARME-treatment to other patients with the same malocclusions. This
is in accordance with the study from Modig et al (2006). This verifies that the patients’
over-all evaluation of the SARME treatment is positive and is shown to be very
appreciated.
The clinical follow up examinations showed that the SARME treatment was effective
however a few side effects have been noted such as tooth necrosis, experienced pain
long after treatment, perception impairment and as previously mentioned TMJ- and
myofacial pain.
The clinical examinations revealed that one patient had a necrotic tooth after the
SARME treatment. No studies can be found about necrotic teeth due to the SARME
treatment in previous literature. The necrotic tooth was discovered after the SARME
45
treatment but it is difficult to know exactly what caused the necrosis of the tooth. The
patient received endodontic treatment for the necrotic tooth later on.
The patients in the study were told to estimate the pain one week after surgery. A long
time has passed and it can be difficult to remember the postoperatively pain but a
majority of the patient answered moderate pain one week postoperatively. Today most
of the patients are without pain symptoms. This clarifies that the SARME treatment
causes short-term pain. Long-standing pain after surgery is a rare side effect of SARME
treatment. According to the results one patient still experienced pain and scored 2 on the
VAS scale, which was explained as tenderness of the temporomandibular muscles. As
previously mentioned myofaciell tenderness may be caused by a change in the occlusion
and articulation movement due to the SARME treatment.
Further on, the clinical examinations in this study revealed that 73.3% showed
perception impairment, either hypo- or hypersensitivity of the cheek, upper/lower lip,
chin or the maxillary vestibular mucosa. The majority of the patients received
hyposensitivity on the maxillary oral gingiva closest to where the incisions were made;
other patients received a hyposensitivity on the lips, the chin or the cheek, which
represents the area for the trigeminal nerve. Hypersensitivity was not as common as
hyposensitivity (see table 5). Hypo- or hypersensitivity on the gingival oral mucosa is
not as noticeable for the patient as a hypo- or hypersensitivity on the lip or cheek, which
many can find disturbing. One patient showed remaining hyposensitivity on the upper
lip, which shows that some hyposensitivities that occur due to the SARME treatment
may be permanent. According to the results in this study there is a 20% risk for
perception impairment in the lips after SARME treatment. It is in some way a high risk
and therefore it is important to inform the patient before the treatment. However, it is
important to emphasize the fact that many operational procedures cause perception
impairment, which is in some cases difficult to avoid. In previous studies there is
limited information about perception impairment and therefore there future research
about SARME and perception impairment is needed.
In table 6 and 7 the analysis of the pre-and postoperative cast models show that the
majority of the patients in this study received a normal occlusion after the SARME
treatment and this also verifies that the modified expander device that was used is
46
reliable. However nine of the 38 patients´ cast models (23.7%) show that these patients
still have malocclusion. This could either signify a relapse or less optimal treatment
results. Thus, the postoperative malocclusions that occurred among some patients were
not as severe as it was preoperatively. However, the patients that still had malocclusions
after a second surgery indicate that some preoperative malocclusions are very severe
and hard to treat.
The majority of the subjects in this study did not extract any teeth before the SARME
treatment. A total of five patients had their teeth extracted before they came, and three
of them still showed malocclusions. This confirms previous statements about pretreatment extractions leaving to narrow dental arches and less optimal results. Tooth
extractions for alignment of dental arches are often unnecessary (Silverstein & Quinn
1997). The result from the cast model analyse show that extractions of premolars are not
necessary to achieve a normal occlusion with the modified expander device.
Interestingly the results in figure 12 show a significant higher frequency of
malocclusion after treatment among patients that had teeth extracted before treatment.
However the patients in the study that had teeth removed before treatment were few,
therefore a recommendation for future studies is to have a larger group of patients with
extracted teeth in order to confirm the conclusion in this study.
It is of great importance to highlight that some confounders in this study may have
affected the results, such as when the patients were to estimate if they had received
sufficient preoperative information, or when they were asked to grade the pain they felt
one week after surgery according to the VAS-scale. Due to the fact that years had gone
by since the patients received their SARME operation some patients found it difficult to
remember if the preoperative information that was given was sufficient or the actual
pain that they experienced after surgery. Another component that could have influenced
the results was during the clinical examination of the perception. Although one clinician
performed all clinical examinations, there may have been some differences in probing
and brushing pressure, which may have caused differences in the experience of
perception. In this study a control group was not used. As previously mentioned a threeyear follow-up study was reported where OME and SARME were compared with a
control group. Since this recent study showed that both the OME and the SARME
47
procedures remained stable after three years with some amount of post retention
relapses in both groups compared with the control group (Kurt et al 2010), there was no
need for a control group in our study to evaluate the stability and the effects of normal
skeletal growth. However there was a need to evaluate the treatment effects of the
SARME treatment, the patients´ opinion regarding the procedure and also when the
SARME treatment should be chosen instead of the OME treatment. Moreover if a
control group had been used in this study then it might have been optimal to choose
subjects in the same age group and without any malocclusions to evaluate the palatinal
expansion and the effects of the SARME treatment compared to normal skeletal growth.
Nevertheless there would have been difficulties to assemble this control group due to
the difficulties of finding cast models on these subjects; the clinician rarely take
impression on children when there is no indication for treatment. When looking back on
this study we conclude that the need of a control group was not necessary due to the fact
that the importance of this study was to find out the treatment effects of SARME, the
patients opinion regarding the outcome of the procedure.
There is a need for future research on the side effects due to surgically assisted rapid
maxillary expansion. The TMJ- and orofacial muscle status should be carefully
examined preoperatively, so that the SARME treatment effects on the TMJ- and
orofacial function can be studied.
48
Conclusions
We can conclude that the most common indication for the SARME treatment in this
study is cross bite, and the majority of patients were skeletally mature when they
received the SARME treatment. According to the questionnaires the functional and the
esthetical aspects of the dentition and facial appearance are much better after treatment.
It is essential to involve and inform the patient about the up-coming treatment and also
to acknowledge if the patient has enough motivation to undergo surgery. Patients should
be preoperatively informed about eventual, impaired speech pronounciations, orofacial
muscle- and TMJ- tenderness/pain due to the SARME treatment and that the risk may
be higher if the patient show preoperative signs of TMJ-disorders or orofacial pain.
The clinical examinations showed that 3/4 of the patients received over going
perception impairment either hypo- or hypersensitivity of the cheek, upper/lower lip,
chin or the maxillary vestibular mucosa. The lip is the most common place for
perception impairment. The results from the cast model collection showed significant
expansion of the maxilla after SARME treatment and that the majority of the patients
received a normal occlusion. Malocclusion was more common among patients that had
their premolar extracted before surgery.
Acknowledgements
First I´d like to dedicate a special acknowledgement to my supervisor Annika Rosén for
being a great inspiration and for all her feedback and support during these years.
Second, I would like to thank all the staff of the dept. of Oral and Maxillofacial Surgery,
Karolinska Institute, Huddinge, for their patience, assistance and helpfulness.
Thanks to all the patents that made this study possible by voluntarily participate.
Finally, I wish to thank Gabriel and my family for his patience and support during this
period and for their great confidence in me, which motivated me to accomplish the final
part of this master thesis.
49
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Appendix 1
Postoperative protocol for patients treated with SARME using a modified
distractor device:
Objective evaluation of the treatment effects of SARME:
1. Extra oral photographs (2 front, 2 profile):
2. Intraoral photographs, 5:
3. Clinical examination:
a. Oral mucosa:
b. Gingiva:
c. Teeth (root resorptions, necrotic teeth, endodontic treated teeth
postoperative, reduced sensibility, periodontal injuries):
d. Jawbone (bone resorption, bone defect, fractures):
4. Occlusion: Angle class ____ relation.
5. Articulation:
MTR/LTR/PTR:
IP/RP:
Maximum opening capacity:
TMD/TMJ-pain during palpation?
(Scale 0-3)
Myofascial pain during palpation?
(Scale 0-3)
Bruxism?
6. X-rays:
If indicated.
7. Pre- and postoperative castmodell analysis:
a) Occlusion diagnosis:
Sagital:
Vertical:
Transversal:
b). Maxillary transversal expansion (mm):
Intercanin distance:
Intermolar distance:
Preop:
55
Postop:
c) Palatal height:
Subjective evaluation of the SARME- treatment effects:
Questionnaire answered (Yes/No):
Improved aesthetics (Yes/No):
1 week after operation:
Follow -up:
Pain (VAS-scale):
Postoperative perception impairment:
Cheek
Gingiva (max/mand.) Chin
Lip (Upper/Lower)
Ref point:
Ref point:
Ref point:
Ref point
Pinch:
Brush:
Pin-prick:
56
Appendix 2
Questionnaire
Q1. Did you receive sufficient preoperative information?
a) not enough
b) enough
c) too much
Q2. Do you feel that you took part in planning the treatment?
a) not enough
b) enough
c) too much
Q3.The days after the operation, how did you experience eventual:
a) Pain?
No difficulties / Moderate difficulties / Severe difficulties
b) Swollenness?
No difficulties / Moderate difficulties / Severe difficulties
c) Perceptionimpairment?
No difficulties / Moderate difficulties/ Severe difficulties
d) Were these symptoms regarding…
-pain:
less than expected? / as expected? /more than expected?
-swollenness: less than expected? / as expected? /more than expected?
-perceptionimpairment:
less than expected? / as expected? /more than expected?
Q4. If you received perception impairment after surgery, where is it and how does
it feel?
a) Cheek:
none/ bothering/ not bothering/ does not think about it
b) Chin:
none/ bothering/ not bothering/ does not think about it
c) Lip:
none/ bothering/ not bothering/ does not think about it
d) Gingiva:
none/ bothering/ not bothering/ does not think about it
Q5. Did your problems before the operation such as….
a) Difficulties with biting or chewing change….
57
to the better? / much better? / the same?/ worse?/ much worse?/ was no problem to begin with
b) Uncomfortable biting position?
to the better? / much better? / the same?/ worse?/ much worse?/ was no problem to begin with
c) Appearance of the dental position?
to the better? / much better? / the same?/ worse?/ much worse?/ was no problem to begin with
d) Appearance of the face?
to the better? / much better? / the same?/ worse?/ much worse?/ was no problem to begin with
e) Pain from the jaws?
to the better? / much better? / the same?/ worse?/ much worse?/ was no problem to begin with
f) Pain from the temporomandibular joint?
to the better? / much better? / the same?/ worse?/ much worse?/ was no problem to begin with
g) Speech difficulties?
to the better? / much better? / the same?/ worse?/ much worse?/ was no problem to begin with
h) Have your other problems changed?
to the better? / much better? / the same?/ worse?/ much worse?/ was no problem to begin with
i) Self- esteem?
to the better? / much better? / the same?/ worse?/ much worse?/ was no problem to begin with
j) Which of these problems became the most important change for you after the
surgery?
Q6. How du feel about the operation results?
Bad/ Good / Very good
Q7. Do you regret the operation?
Yes/ No
Q8. Would you recommend this treatment to other patients?
58
Yes/No
Q9. What do you feel could improve the total treatment?
Q10. Is there something you are very satisfied with, or something you are
unsatisfied with this treatment?
59