Download Transverse Maxillary Asymmetry Treated with Unilateral Surgically

Shivapuja et a l
CLINICAL
Transverse Maxillary Asymmetry Treated with
Unilateral Surgically Assisted Rapid Palatal
Expansion - A Case Report
Dr. Prasanna - Kumar Shivapuja
Private practice of Orthodontics,
Roseville, Michigan, U.S.A.
Dr. James Lepczyk
Private practice of Oral and Maxillofacial Surgery,
Bingham Farms, Mi chigan.
Adjunct Associate Professor, University of Detro it M ercy
Dept. of Oral and Maxillofac ial Surgery, Detroit, Michigan, U .S.A.
Dr. Lawrence Finn
Private practice of General and Restorat ive Dentistry,
Warren , Michigan, U.S.A.
Abstract
Keywords
Transverse maxillary asymmetry is a relatively uncommon problem; which in adults requires
uni lateral surgically assisted rapid palatal expansion. This case report demonstrates the problem
can be successfully treated with a limited amount of morbidity, and appears to be stable. The
protocol should involve correcting the functional shift prior to diagnosing the problem as
unilateral constriction.
Maxillary asymmetry, surgically assisted RPE.
Summary of treatment
Introduction
Unilateral transverse maxillary deficiency, in adults,
is a difficult problem for orthodontists. Traditionally,
this problem is treated by accepting the crossbite,
treating the crossbite with elast ics or surgically
correcting the crossbite. Treatment with crossbite
elastics flares the teeth buccally; causing changes in
loading pattern and compromisin g the longevity of
teeth. Surgical correction has a hi gher degree of
morbidity and its stability is unpredictable; for correction
greater than 4mm . During the past 40 years, maxi llary
transverse discrepancy has been successfully treated
with surgically assisted rapid palatal expansion. This
procedure involves surgically creating an osteotomy in
the mid palatal suture, the zygomatic buttress and the
pterygoid plates; allowing time for ca llu s to form at the
osteotomy sites, and gradually stretching the callus to
attai n the proper width.
This case report describes the treatment of a patient
with unilateral constriction; using a modified expansion
appliance and a surgical technique to attain unilateral
expansion.
176
Patient's name
Date of birth
Age
Raymond Rosi nski
12/14/52
48 yr.
A. Pretreatment records
Date of Records: OS/2000
Diagnosis
• Skeletal: Cl ass I w ith tendency for Class III
• Dental : Class I w ith tendency for Class III ,
tendency for mandibular protrusion,
norm al vertical facial height.
Favo rable c hin . Narrow maxilla
unilateral posterior crossbite. Minimal
functional shift
• Facial
Orthognathic facial profile. Normal
nasolabial angle, interlabial gap, lip
promin ence, labiomental fold and
chin prominence.
Treatment Plan : 1.
Ascertain centric relation and
evaluate if the existing problem is
J Ind Orthod Soc 2006; 39:176-188
2.
3.
4.
5.
a bilateral constriction or a
unilateral constriction.
Upright mandibular buccal
segments to determine the extent
of expansion needed .
Align maxillary arch
Attain Class' cuspid and molar
relation
Prosthodontic and aesthetic
rehabi Iitation
Treatment:
1. Centric relation splint
2. Mandibular fixed appliance
3. Surgically assisted unilateral rapid
palatal expansion
4. Maxillary fixed appliance treatment
5. Restorative and prosthodontic
rehabilitation .•
•
•
•
•
Initiated Treatment
Appliance Removal
Recall Records
Active Treatment Time:
Recall
Date: 8/10/00
Date: 8/23/03
Date: 8/29/06
Duration: 3yrs
Duration: 3yrs
Facial
Patient presents with a straight facial profile and slight
increase in vertical facial height. Maxillary and
mandibular midline was coincident with the midline
of the face. Chin was deviated 2mm to the left.
Skeletal
Class' dental with tendency for Class "' due to
maxillary retrusion. Vertical facial height was normal,
with tendency for slight increase in lower one third of
the face. Chin prominence was normal. There was a
unilateral crossbite extending from maxillary left lateral
incisor thru the second molar; due to unilateral
transverse maxi lIary deficiency.
Dental
Class , molars and cuspids. Overjet 4mm and end to
end overbite at the central incisors. Crossbite maxillary
left lateral incisor thru the left molar.
B. Post treatment records
Date of Records
8/23/03
Retention
Maxillary splint
Mandibular 3-3 fixed retainer
Anterior teeth were crowded with a 5mm space
discrepancy. Maxillary and mandibular incisors were
normally positioned anterior-posterior over thei r
respective apical bases.
Pa!ient had multiple
restorations with missing maxillary"left first and second
molars and maxillary right second molar. Edentulous
areas showed significant bone loss with pneumatization
of the maxillary sinuses.
Status of retention
Functional
Currently patient is using maxillary superior
repositioning splint at night and has requested to have
the 3-3 fixed retainer be left in place. Patient has been
followed for 3 yrs. and has maintained a stable result.
Patient will be maintained on long-term splint wear to
protect the restorative work.
Mounted models in centric relation showed minor
functional shift with a prematurity on the maxillary left
cuspid and the lateral incisor.
Treatment Plan
•
History and Etiology
48 year old Caucasian male was referred to the office
by the general dentist for an evaluation for correction
of left anterior crossbite; to enable restoration of the
failing maxillary left central incisor. Patient has an
unremarkable medical history. Patient had regular
dental check-ups and a very high caries index with no
extraneous habits. Etiology of the problem is unknown.
•
•
Mandibular full-coverage superior repositioning
splint to deprogram the musculature and acquire
correct centric relation.
Mandibular fixed appliance with pre-angulated,
pre-torqued brackets to align the dentition and
upright the mandibular buccal segment.
After the prematurity was alleviated, mounted
models were attained to evaluate the extent of
true maxillary transverse asymmetry. This
process revealed a left side maxillary collapse.
Diagnosis:
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Shivapuja et al
•
•
•
Bonded maxillary Hyrax expander, with bit~
blocks thick enough to clear the vertical,
enabled jumping the lateral incisor over the
lower teeth.
Maxillary fixed appliance, level and align the
maxillary arch and reestablish arch form.
Maxillary anterior aesthetic reconstruction.
Replacement of the left maxillary posterior fixed
prosthesis. Accept the left maxi Ilary second
molar space.
•
•
Specific Objectives of Treatment
Maxilla
•
•
•
: Maintain
A-P
: Maintain
Vertical
Transverse: Increase maxillary width by
expanding left maxilla 6mm
Mandible
• A-P
Maintain
• Vertical: Mai ntai n
Maxillary Dentition
•
•
•
•
Maintain
A-P
Maintain
Vertical
Inter-cuspid width: Maintain dental width,
correct skeletal width
Inter-molar Width: Constrict left third molar
dental width by 2mm
Mandibular Dentition
A-P: Maintain
Vertical: Maintain
Inter-molar: Upright left molar until the lingual
cusp is 1mm below the buccal cusp
Inter-canine Width: Maintain
Facial Esthetics:
•
•
Face from Front: Maintain nasal width.
Prevent
nasal
septal
deviation during expansion.
Improve anterior smile line.
Profile
: Maintain.
Appliances
•
•
178
Mandibular full-coverage splint to deprogram the
muscles and acquire centric relation.
Mandibular fixed appliance therapy with GAC
Straight-wire appliance. Wire sequence
progressed from 0.014 nitinol thru 0.0 18 x 0.025
•
inch nitinol to 0.019 x 0.025 inch stainless steel.
Buccal crown torque was applied on the left side
to upright the left buccal segment.
Hyrax type rapid palatal expander with occlusal
blocks thick enough to create clearance to allow
correction of lingual position of maxillary left
lateral incisor and cuspid.
Maxillary fixed appliance therapy with GAC
straight-wire appliance. Wire progression was
from 0.014 inch nitinol to 0.018 x 0.025 inch
nitinol. Once in, 0.019 inch x 0.025 inch steel
45 degree palatal crown torque was applied on
the left third molar to facilitate correction of the
buccal flaring. Maxillary fixed appliance was
placed with the expander in position to allow
correcting crossbite and reorganize spaces to
allow increasing the width of the left central
incisor.
Restorative phase included replacing the bridges
on the maxillary left and right buccal segments
and crowns on maxillary left central and lateral
incisors. Direct bonding on max illary right
central incisor. Patient declined bone grafting
and implant restoration; for reasons of cost.
Treatment Progress
Treatment progress was unremarkable. Patient wore
the splint for 3 months. Mandibular appliances were
on for 6 months prior to rapid palatal expansion. The
expander was inserted using gold sealant and ceramic
preparation.
Surgery was performed (Fig 1) in a unilateral Lefort I
pattern leaving the nasal septum with the right maxilla.
The pterygoid plates were separated to provide minimal
resistance for movement of the left buccal segment. A
five day latency period was allowed for soft tissue
healing and initial osteoid formation. The appliance
was turned 2 times (0.25x2=0.5mm) per day until the
desired width was achieved. After completion of the
expansion, the appliance was removed after 2 months
to remove forces on the teeth of the un-operated side;
(to prevent undermining resorption) and the width was
maintained with a passive cemented full occlusal
coverage 3mm Bio-Star splint.
Orthodontic realignment of the posterior teeth was
initiated after 4 months. Thereafter, the orthodontic
treatment was routine. Prior to de-banding, mounted
models were attained to evaluate tooth position and
for construction of a tooth positioner. Patient was
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J Ind Orthod Soc 2006; 39:176-188
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Table 1: Cepha lometric summary
Measurement
A
B
*Diference
A-B
Maxilla to
Cranial Base
SNA
80.8
78.0
2
Mandible to
Cranial Base
SNB
FMA
78.9
22.8
78
24.3
0.8
1.5
MaxilloMandibular
ANB
Witts
1.9
-2.1
0
-2.3
1.9
-.02
5.3
19.1
7.6
24.4
2.3
5.3
1 to NB (mm)
1 to Md plane
5.8
88.7
6.7
92.8
0.9
4.1
Esthetic Plane
Nasolabial angle
-5 .1
111.9
-4.1
110.4
1
1.5
Area
1 to NA (mm)
1 to NA (deg).
Maxillary
Dentition
Mandibular
Dentition
Soft Tissue
A: Pre-treatment records
Table 2:
B: Post treatment records
Maxillary Arch Width Change
Inter-canine width
Inter first molar width
Inter second molar width
Pre-Treatment (T1)
29.60
44.00
50.70
Pre-Expansion (T2)
29.60
44.00
Immediate Post Expansion (13)
38.90
47.42
Post Treatment (T4)
37.81
48.85
3 years Post Treatment (T5)
38.61
47.98
Change in arch width
Pre-Treatment Final (T1-T4)
8.21
4.85
Inter-canine width
Inter first molar width
Inter second molar width
25.7
41.03
47.17
26.53
40.96
26.53
40.96
25.89
, 41.18
25.27
41.18
0.19
0.15
Table 3:
==~
Mandibular Arch Width Change
Change in arch width
Pre- Treatment Final (T1-T4)
Table 4: Arch Width As Measured From Mid Palatine Raphae
Pre Treatment
Post Treatment
Right side
. Left side
Right side
Left side
Canine to Raphae
14.73
14.73
15.85
21.23
First molar to Raphae
21.94
22.44
22.83
24.83
Second molar to Raphae
25.75
24.64
27.16
27.68
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Shivapuj a et al
Fig. 1: D iagram show ing surgica l bo ne cuts
Fig. 2: Demonstrati o n of arch w dth
measurement fro m mid pa latine
ra ph ae
Fig. 3 : Pre-treatment Intraora l and Extraora l Photographs
Fig. 4 : Pre-treatment models in centric occlu sion
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J Ind Orthod Soc 2006; 39 :176-188
Fig. 5: Pre-treatment post splint mounted models in centric relation
Fig. 6: Pre-treatment pan-tomogram
Fig. 8: Pre-treatment lateral cephalogram
Fig. 9: Pre-treatment lateral
cephalogram tracing
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Shivapuja et al
Fig. 10: Progress models in centric relation after mandibular arch reconfiguration
(note: the extent of unilateral crossbite)
Fig. 11: Pre-surgery PIA cephalogram
Fig. 12: Tracing pre-surgical PIA
cephalogram
instructed to wear the tooth positioner for three months
after which the teeth were equilibrated. This concluded
the active orthodontic phase of treatment.
Results Achieved
Maxilla
• A-P: SNA reduced by 2 degrees
• Transverse: Transverse dimension was increased
by6.12mm
182
Fig. 13: 4 months post expansion PIA
cephalogram
Mandible
: Significant change was noticed
• A-P
• Vertical: No significant change noticed
Maxillary Dentition
: Maxillary dentition was
• A-P
advanced
by
2mm,
maxillary molar angulation
improved
Maxillary
incisors were
:
• Vertical
extruded
by
2mm,
J Ind Orthod Soc 2006; 39:176-188
Fig. 14: Post-Treatm ent Intraoral and Extraoral Photographs
Fig. 15 : Post treatment mounted models in centri c relati o n
m ax ill ary m o l ars w ere
extruded 1mm
• Inter-canine Width: D ental width in c rease d
2mm (Tabl e 2)
• Inter-molar Width : D ental w idth in c rease d
1 mm
du e to
toot h
m o vem ent o n th e unoperated right side. {Tabl e 2)
Mandibular Dentition
• A-P
: M andibul ar inciso rs had no
si gn ifi ca nt b o dil y Al P
pos iti o na l c h ange; bu t
advanced angul arl y by 3
d eg rees.
M andibul ar
mo lars showed signi ficant
upri ghting
183
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Shivapuj a et a l
Fig. 16: Post treatme nt pan-to mography
Fig. 17: Post treatme nt lateral cepha logram
Fig. 18: Post treatme nt late ra l cepha logram trac ing
Fig. 19: Post
treatme nt PiA
ceph a logra m
18 4
Fig. 20: Trac ing post surgical PiA cepha logram
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J Ind Orthod Soc 2006; 39 :176-188
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Fig. 21 : 3 years post treatment Intraoral and Extraoral photographs
Fig. 22: 3 years post treatment mounted models in centric relation
• Vertical
: Mandibular incisors had no
significant vertical change,
mandibular molars were
extruded 1mm
• Inter-canine Width: Dental width increase was
insignificant (TabJe 3)
.lnter-molarWidth : Dental width increased
minimally (Table 3)
Facial Esthetics: Overall, cephalometric facial
aesthetics remained unchanged. There was, however,
a significant improvement in his smile line.
185
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Shivapuja et al
Fig. 23: 3 years post treatment pan-tomogram
Fig. 24: 3 years post treatment lateral cephalogram
Fig. 24: 3 years lateral cephalogram tracing
Fig. 25: 3 years post
treatment
PIA
cephalogram
186
Fig. 26: 3 years post treatment PIA
cephalogram tracing
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J Ind Orthod Soc 2006; 39: 176-188
Fig. 27: Comparison occl usa l views
1. Pre-treatm ent 2. Post treatment 3. 3 years Post treatment
Superimpositions
\)
!
Fig. 28: Overall superimpositio n done on Sella -Nasion at
Sella
Fig. 29: Region al superimpositio n:
1. Basion-Nasion at Nasio n
2. Palatal plane at Anterior nasa l spine
3. Corpus axis at PM. Point
Retention: Patient is retained with a 3-3 fixed retainer
in the mandibular arch and a max illary heat-cured splint
to protect the restorative dental work.
Fig. 30: Superimposition PI A cephalogram- Pre-surgica l
(black), post treatment (red), 3 years post treatment
(green)
Final Evaluation of Treatment: Final outcome of the
case is ve ry good. Patient is happy and restoration s are
mo re functio nal then would be otherwise. There was a
significa nt improvement of the periodontal status on
the non-operated side. Thi s indi cates that unilatera l
surgica l expansion is a viable option of treatment for
cases with true unilateral max illary constriction. The
important factor is to deprogram the patient with a splinS
and co nfi rm that the situation is truly a unilateral
constri ction . If not, a bilateral expa nsion needs to be
pl anned.
187
Shivapuja et al
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