British Journal of Oral and Maxillofacial Surgery (2000) 38, 6669 2000 The British Association of Oral and

d Maxillofacial Surgeons DOI: 10.1054/bjom.1999.0274

B R IIT IIS H J O U R N A L O F O R A L BR T SH JOURNAL OF ORAL

& M A X IIL L O FA C IIA L S U R G E RY & M A X L L O FA C A L S U R G E RY

Surgical and orthodontic rapid palatal expansion in adults using Glassmans technique: retrospective study
R. Schimming,* K.-U. Feller,* K. Herzmann,* U. Eckelt *Research Assistants; Professor, Department of Oral and Maxillofacial Surgery, University of Dresden, Germany (Head: Professor Dr Dr U. Eckelt) SUMMARY. In 1984, Glassman et al. described a conservative surgical method of separation of the midpalatal suture in which an osteotomy is done only at the lateral and anterior wall of the maxilla. Between 1991 and 1997, we have operated on 21 patients with maxillary transverse discrepancies using the method that they described. This gave good results in 20 patients. The other, who was operated on at the age of 38 years, developed a fracture of the alveolar process of the maxilla on one side because of ossification of the midpalatal suture. The surgically assisted rapid palatal expansion described by Glassman et al. is suitable for patients up to the age of 30. Older patients require additional surgical separation of the midpalatal suture.

INTRODUCTION A permanent increase in maxillary transverse width is attained routinely in children and adolescents using orthodontic expansion appliances and retention,1,2 and this treatment does not normally cause any problem. However, in skeletally mature adults, attempts at orthopaedic rapid maxillary expansion often cause appreciable problems. Inability to activate the appliance and expand the maxilla is common. The treatment can also result in buccal tipping of the teeth,3,4 and bone dehiscences and gingival recession have been described.5 Overcorrection to compensate for these undesirable changes is often frustrated by unpredictable and uncontrolled relapse after the palatal expansion appliance has been removed.6 Investigations on cadaver skulls by Persson and Thilander showed that the ossification of the midpalatal suture has wide individual variations in different age groups and is unpredictable under the age of 30.7 Initially, the midpalatal suture was identified as an area of bony resistance to palatal expansion in patients after their late teens.7,811 Later studies indicated that the construction of the zygomaticomaxillary buttress is the critical area of resistance to palatal expansion.9,12,13 The procedure for rapid palatal expansion is still controversial and many different methods have been described8,9,1418 since the time of Angell,19 when he presented the first case of correction of maxillary transverse discrepancy in 1860. We present 21 cases treated by rapid palatal expansion without midpalatal or pterygomaxillary surgery. The technique was first described by Glassman et al. in 1984.20

PATIENTS AND METHOD Twenty-one patients with discrepancies in the width of the maxillary arch were treated from 1991 to 1997 by rapid palatal expansion as described by Glassman et al.20 The age of the patients ranged from 14 to 38 years (mean 21) (Table 1). All patients were seen by an interdisciplinary team of orthodontists and oral surgeons and the operations were done by two surgeons. The preparation for the technique by Glassman is to cement an orthodontic Derichsweiler appliance to the first premolar and the first molar preoperatively. The appliance is activated by a centrally placed Hyrax screw (Fig. 1). One screw turn is equivalent to 0.25 mm. If simultaneous first premolar extraction is needed, the Derichsweiler appliance may be cemented to the second premolar and second molar without compromising treatment.

Fig. 1 Model of orthodontic Derichsweiler appliance with central Hyrax screw.

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Surgical and orthodontic rapid palatal expansion by Glassmans technique Table 1 Ages and preoperative and postoperative widths of dental arches (mm) in 21 patients who required separation of the midpalatal suture Preoperatively Case No. 1 2 3 4* 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Age (years) 17 14 18 38 29 20 23 24 19 18 21 20 19 16 18 22 19 21 23 25 20 Anterior dental arch 33.0 38.0 32.0 28.0 32.0 31.0 26.0 32.0 31.0 37.0 26.0 35.0 26.0 31.0 32.0 33.0 31.0 26.0 27.0 32.0 29.0 Posterior dental arch 47.0 51.0 41.0 39.0 43.0 42.0 33.0 44.0 41.0 46.0 33.0 42.0 33.0 41.0 38.0 46.0 42.0 34.0 33.0 41.0 41.0 Postoperatively Anterior dental arch 39.5 42.5 38.0 33.0 38.0 36.0 33.0 39.0 36.0 42.0 33.0 41.0 34.5 38.0 38.0 38.3 36.0 31.0 33.0 38.0 34.0 Posterior dental arch 51.0 53.0 48.0 41.0 48.0 49.0 40.2 48.0 48.0 48.0 41.0 50.5 41.0 48.0 45.0 51.0 49.0 42.0 40.0 46.5 48.5

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*This patient fractured the alveolar process.

Fig. 3 Derichsweiler appliance in place during intraoperative activation. Fig. 2 Diagram on model of osteotomy described by Glassman et al.20

The principle is to weaken the anterior and lateral maxillary wall 5 mm above the apices of the teeth from the piriform rim to the zygomatic maxillary buttress (Fig. 2). General anaesthesia is used. In addition, a local anaesthetic consisting of saline solution mixed with 1/100 000 epinephrine is injected into the vestibular mucosa around the alveolar process. An incision is made in the top of the buccal vestibule between the mesial area of the first molar and the distal area of the canine. The lateral and anterior maxillary wall is exposed by mucoperiostal elevation from the lateral aspect of the piriform rim across the zygomatic maxillary buttress, then posteriorly to the pterygomaxillary

fissure by a subperiosteal tunnelling technique. An osteotome is used to make an osteotomy about 5 mm above the apices of the teeth from the piriform rim to the zygomatic maxillary buttress, ending anterior to the pterygoid fissure. Care is taken with the anterior part of the surgical osteotomy by using a elevator as a tissue guard to avoid rupturing the nasal mucoperiosteum. The preoperative cemented orthodontic appliance is activated by 12 turns (3 mm) at the time of operation (Fig. 3). This is held stable for 3 min. Afterwards the appliance is decompressed by eight turns (2 mm). As a result, the separation of the midpalatal suture is clinically visible. The wound is then closed using 3/0 absorbable or non-absorbable sutures.

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British Journal of Oral and Maxillofacial Surgery

Fig. 4 (A & B) Condition of patient before rapid palatal expansion with bilateral crossbite.

Fig. 5 (A & B) The same patient one week after rapid palatal expansion with visible diastema between the middle upper incisors.

The Derichsweiler appliance is activated postoperatively by the patients themselves one turn (0.25 mm) a day until the adequate and planned expansion of the maxilla has been achieved. The appliance is then left in place for at least six months as a retainer in a passive position. Additional orthodontic procedures or surgical corrections can now be done as planned in the beginning of the combined treatment strategy. Postoperative control of separation of the midpalatal suture was judged clinically (Figs 4 & 5), or with ultrasound, or with maxillary occlusal radiographs (Fig. 6). In addition, study models were made and the width of the anterior and posterior dental arch before and after operation was measured (Fig. 7).

Fig. 6 Postoperative maxillary occlusal radiograph showing separation at the midpalatal suture.

RESULTS Of the 21 operated on using the technique mentioned above, successful separation of the midpalatal suture and subsequent maxillary expansion was obtained in 20. In one patient who was operated on at the age of 38 years, a fracture of the alveolar process occurred unilaterally during the intraoperative activation of the orthodontic appliance because of complete ossification of the midpalatal suture. No other complications mentioned by Glassman et al.,20 such as sinus infection, devitalization of teeth, extrusion of teeth fixed to the Derichsweiler appliance, or nasal bleeding developed. Postoperative oedema was considered to be within normal limits. The results of all patients are shown in Table 1. Satisfactory maxillary expansion was achieved in a mean time of 31 days (range 2040). The mean (SD) expansion between the first premolars was 5.9 (1.0) mm (width of the anterior dental arch) and 6.0 (2.0) mm for the first molars (width of the posterior dental arch).

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References
1. Wertz RA. Skeletal and dental changes accompanying rapid midpalatal suture opening. Am J Orthod 1970; 58: 4166. 2. Hass AJ. Palatal expansion: just the beginning of dentofacial orthopedics. Am J Orthod 1970; 57: 219255. 3. Moss JP. Rapid expansion of the maxillary arch. I. J Pract Orthod 1986; 2: 165171. 4. Moss JP. Rapid expansion of the maxillary arch. II. Indications for rapid expansion. J Pract Orthod 1968; 2: 215223. 5. Thilander B, Nyman S, Karring T, Magnusson I. Bone regeneration in alveolar bone dehiscences related to orthodontic tooth movements. Eur J Orthod 1983; 5: 105114. 6. Melsen B. A histological study in the influence of sutural morphology and skeletal maturation on rapid palatal expansion in children. Trans Eur Orthod Soc 1972; 499507. 7. Persson M, Thilander B. Palatal suture closure in man from 15 to 35 years of age. Am J Orthod 1977; 72: 4251. 8. Bell WH, Epker BN. Surgicalorthodontic expansion of the maxilla. Am J Orthod 1976; 70: 517528. 9. Lines PA. Adult rapid maxillary expansion with corticotomy. Am J Orthod 1975; 67: 4456. 10. Melsen B. Palatal growth studied on human autopsy material. Am J Orthod 1975; 68: 4254. 11. Timms D. The relationship of rapid maxillary expansion to surgery with special reference to mid-palatal synostosis. Br J Oral Surg 1981; 19: 180196. 12. Bell WH, Jacobs JD. Surgical orthodontic correction of horizontal maxillary deficiency. J Oral Surg 1979; 37: 897902. 13. Kennedy JW, Bell WH, Kimbrough OL, James WB. Osteotomy as an adjunct to rapid maxillary expansion. Am J Orthod 1976; 70: 123137. 14. Steinhuser EW. Midline splitting of the maxilla for correction of malocclusion. J Oral Surg 1972; 30: 413422. 15. Timms DJ, Vero D. The relationship of rapid maxillary expansion to surgery with special reference to midpalatal synostosis. Br J Oral Surg 1981; 19: 180196. 16. Progrel MA, Kaban LB, Vargervik K, Baumrind S. Surgically assisted rapid maxillary expansion in adults. Int J Adult Orthod Orthognath Surg 1992; 7: 3741. 17. Strmberg C, Holm J. Surgically assisted, rapid maxillary expansion in adults. A retrospective long-term follow-up study. J Craniomaxillofac Surg 1995; 23: 222227. 18. Morselli PG. Surgical maxillary expansion: a new minimally invasive technique. J Craniomaxillofac Surg 1997; 25: 8084. 19. Angell EH. Treatment of irregularities of the permanent or adult tooth. Dental Cosmos 1860; 1: 540547. 20. Glassman AS, Nahigian SJ, Medway JM, Aronowitz HI. Conservative surgical orthodontic adult rapid palatal expansion: sixteen cases. Am J Orthod 1984; 86: 207213.

Fig. 7 Model of dental arch width measurements as described by Pont.

There were no obvious relapses during the followup period of between 6 months and 6 years. Five patients underwent a second operation to complete the combined orthodonticsurgical treatment plan.

DISCUSSION There is a focus on effort in all fields of reconstructive surgery to develop suitable and less aggressive techniques. The hope is to have minimum tissue trauma and fewer potential complications, guarantee a less painful and more expeditious postoperative convalescence, and achieve the same or better cosmetic results than conservative methods. The surgically assisted rapid maxillary expansion in adults with a mature skeleton has been done for a long time and using different technical procedures. The method described by Glassman et al.20 has several apparent advantages over other techniques. No palatal approach is necessary and operating on the pterygomaxillary suture is avoided. Operative bleeding and trauma to the incisive canal are therefore minimized by avoiding separation of the palate. In addition, the operating time is reduced and the postoperative treatment is simplified. The initial activation of the preoperative cemented orthodontic appliance while the patient is under general anaesthesia substantially reduces the pain during the following activation period compared with non-surgical rapid maxillary expansion. The technique provides greater flexibility on the part of the orthodontist as well. Advantages are a reduction of treatment time and avoidance of severe side-effects such as buccal tipping of the teeth, bone dehiscence, gingival recession, resorption of the apices of the teeth, and relapse. This method of surgically assisted rapid palatal expansion is a suitable procedure for adolescents and adults with transverse maxillary deficiencies. As ossification of the midpalatal suture can be completed by the age of 30, older patients require a simultaneous surgical separation of the midpalatal suture to avoid additional complications.

The Authors
R. Schimming MD, DMD K.-U. Feller MD, DMD K. Herzmann MD Research Assistants U. Eckelt MD, DMD, PhD Professor and Head Department of Oral and Maxillofacial Surgery University of Dresden Dresden, Germany Correspondence and requests for offprints to: Professor Dr Dr U. Eckelt, Department of Oral and Maxillofacial Surgery, University of Dresden, Fetscherstr. 74, D-01307 Dresden, Germany. Tel: +49 (0)351 458 3382; Fax: +49 (0)351 458 5382 Paper received 2 October 1998 Accepted 8 November 1999