Download Non-surgical palatal expansion in adult patient: a clinical case report

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Oral Surgery ISSN 1752-2471
CASE REPORT
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Non-surgical palatal expansion in adult patient: a clinical
case report
M.M. Pithon
Southwest Bahia University UESB, Bahia, Brazil; Doctor of Orthodontics at the School of Dentistry, Federal University of Rio de Janeiro – UFRJ, Brazil
Key words:
Hyrax expander, orthodontics, palatal
expansion, young adults
Correspondence to:
Professor M M Pithon
Avenue. Otávio Santos, 395, sala 705, Centro
Odontomédico Dr Altamirando da Costa Lima
Vitória da Conquista, Bahia, Brazil, CEP:
45020-750
Tel.: 55 77 3084-2020
Fax: 55 77 3425-2062
email: [email protected]
Accepted: 2 August 2010
doi:10.1111/j.1752-248X.2010.01097.x
Abstract
Aim: The objective of the present study was to report a case of non-surgical
palatal expansion in an adult patient.
Report of case: A Hyrax-type expander was mounted onto the six upper
teeth of the patient who was instructed to activate the orthodontic appliance twice a day at 12 h intervals.
Results: After 15 days, suture separation was observed, which was confirmed by the presence of midline diastema and widening of the radiolucent
image of the suture on occlusal radiograph. Based on this observation, the
appliance was further activated for 7 days, thus totalising 21 days of activation and expander screw opening of 10.5 mm.
Conclusion: One can conclude that in specific cases, it is possible to obtain
an opening of the midpalatal suture in adult patients, thus avoiding surgical
procedures.
Introduction
Posterior crossbite is one of the most frequent malocclusions in orthodontics1. Possible aetiologies include
prolonged retention or premature loss of deciduous
teeth, crowding, palatal cleft, genetic factors, arch
deficiencies, abnormalities in tooth anatomy or eruption sequence, orodigital habits, mouth breathing
during critical growth periods and a dysfunction of the
temporomandibular joint2,3.
To determine the treatment plan for cases involving
posterior crossbite, it must be decided whether the
posterior crossbite is attributed to a true skeletal origin
or dentoalveolar in origin. Betts et al.4 stated that the
posterior crossbite does not confine itself to dental
dysplasias but is more often related to an underlying
skeletal problem.
The correction of transverse maxillary deficiencies
proceeds through opening of the midpalatal suture.
Maxillary expansion was described by Angell5 and the
clinical protocol was established by Haas in 19616.
Rapid maxillary expansion is extremely advantageous for the treatment of class III cases of real and
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relative maxillary deficiency and of cases of inadequate
nasal capacity exhibiting chronic nasal respiratory
problems7–9.
The procedure has been used effectively in children
and adolescents to obtain more stability related to the
amount of bone expansion and avoidance of tooth
tipping. In adults, it is frequently associated with
failure. This may be attributed in part to the anatomy of
the maturing face; the midpalatal suture and adjacent
circummaxillary articulations become more rigid and
begin to calcify in the mid-20s. In order to overcome
the resistance of the adult sutures to expansion, ‘surgically assisted’ rapid maxillary expansion has been
advocated10,11.
Therefore, the objective of this article was to describe
a clinical case of palatal expansion in adult patient in
which the opening of the midpalatal suture was performed without needing surgical intervention.
Clinical case
A Caucasian female patient aged 28 years old sought
orthodontic treatment complaining of ‘narrow arch
and tilted teeth’. The patient’s medical history was
checked. With regard to her general heath status, the
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Non-surgical palatal expansion
Pithon
(A)
(B)
(C)
(D)
Figure 1 (A–D) Initial photographs.
patient presented with no reported pathology or systemic disorder.
The patient presented with a class III malocclusion
on a skeletal III base (ANB -2°C) with bilateral posterior crossbites and missing teeth lost to caries (16 and
26) (Figs 1 and 2).
Initially, the treatment planning was to achieve a
palatal expansion surgically in association with conventional orthodontic treatment for balancing the
occlusal relationship. First, the patient was referred to
an oral maxillofacial surgeon so that she could be
informed about the surgical procedure to be performed. On the return visit, the patient reported that
she would be inclined to accept the surgery. However,
the patient was told that initially a non-surgical intervention would be tried in order to expand her arch, and
in the case of unbearable discomfort during the first
week and enhanced horizontal movement of the teeth,
appliance activation would be stopped and then she
referred to surgery soon after.
A modified Hyrax-type expander was used for such a
procedure. These modifications were obtained by using
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Figure 2 Initial upper occlusal radiograph.
teeth 17 and 27 instead of teeth 16 and 26 (missing
ones) and inclusion of teeth 15 and 25 in conjunction
with teeth 14 and 24.
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© 2010 John Wiley & Sons A/S
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Non-surgical palatal expansion
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(A)
Figure 3 Photographs following cementation of expander.
(B)
Figure 5 (A–B) Photographs
retention).
Figure 4 Post-expansion upper occlusal radiograph.
After cementation of the appliance (Fig. 3), the
patient’s caregiver was instructed to activate the appliance twice a day for 7 days at 12 h intervals. After this
period of time, the patient returned and complained of
no discomfort or pain, and molar and premolar teeth
maintained their position as well. Because of these
results, the appliance was kept activated for additional
7 days. On the 15th day, a palatal suture opening was
observed, which was confirmed by the presence of
midline diastema and widening of the radiolucent
image of the suture on occlusal radiograph (Fig. 4).
Based on these observations, the appliance was
further activated for 7 days, thus totalising 21 days of
activation and expander screw opening of 10.5 mm.
On the 22nd day, the patient returned for stabilisation
of expander appliance with Transbond light-curing
composite (3M Unitek, Monrovia, CA) for a 6 month
period (Fig. 5).
Oral Surgery •• (2010) ••–••.
© 2010 John Wiley & Sons A/S
following
expansion
(beginning
of
During the stabilisation period, the lower fixed
orthodontic appliance was mounted according to
the edgewise technique in order to accelerate the
treatment.
Discussion
In adults, the Haas expander has the ability to
expand the posterior dentition with its alveolar
housing, perhaps by bending the alveolus with bone
remodeling11,12. This outcome is also expected when
a Hyrax-type appliance is used. Handelman13 suggested that after the age of 18, it is often impossible
to open the midpalatal suture. However, increased
anchorage by bands in the second premolars favours
an increase in the orthopaedic effect10. This appliance
can increase the possibility of opening the midpalatal
suture, and by keeping this idea in mind, we have
tried to open the midpalatal suture with no surgical
intervention.
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Non-surgical palatal expansion
Ribeiro et al.10 have achieved palatal expansion with
no surgical intervention by using a modified Hasstype appliance in which all premolars and first upper
molars were banded, and the second molars were
incorporated by bonding a wire segment extending
from the appliance’s acrylic base to their palatal
surfaces.
However, in our case, the Hyrax-type appliance
was chosen because of the possibility of surgery if no
suture opening can be achieved and ease of oral
hygiene maintenance. The Hyrax-type expander is
the best option when there is a possibility of surgical
intervention.
In order to increase the support for optimal distribution of the screw forces, six upper teeth were
banded instead of using four teeth as usual. This
increased anchorage allows forces to be better distributed, thus avoiding overload on these teeth and
possible fracture of the buccal bone plate and gingival
retractions.
One fundamental point regarding the use of nonsurgical midpalatal expander in adult patients is that
they should be informed that the outcome is not guaranteed, and in the event of failure, surgical-assisted
expansion is the only option to perform the expansion.
With this in mind, the patient was initially told that the
only way of achieving a successful correction would be
through surgery. Therefore, the patient was prepared
for a surgical intervention. The patient was referred to
an oral maxillofacial surgeon who explained the details
of the procedure as well as post-operative complications and side effects.
The decision for a non-surgical intervention was
based on the fact that the supporting teeth were free
of gingival recessions and had good bony support
and free of disease. Thus, if the suture was not
opened despite dental tipping, the roots would not be
exposed.
This kind of procedure requires increased clinical
attention, and in our case, the patient attended the
clinic every week and the orthodontist called her every
day to find out if there was any discomfort. This care is
important to detect and prevent possible undesirable
and irreversible effects from occurring.
After achieving the midpalatal suture opening,
the expander screw was stabilised in order to keep
its positioning. Stabilisation lasted 6 months, which
was enough to allow bone maturation in the area of
recently expanded midpalatal suture.
The use of a modified Hyrax appliance with increased
anchorage was thus shown to be effective for correcting
maxillary deficiency in patients with suture maturation. These findings suggest that some precautions
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must be taken, including knowing the skeletal age and
the patient’s level of cooperation. If these factors are
taken into account, satisfactory results can likely be
reached, with improved function and aesthetics and a
minimal morbidity.
Conclusion
According to the findings described in this clinical
report, one can conclude that non-surgical intervention in adult patients can be performed if judiciously
indicated, thus favouring a transverse correction of the
maxilla without the drawbacks of the orthognathic
surgery.
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