18 Revista Brasileira de Ciências Médicas e da Saúde 2 (2) Janeiro/Dezembro 2013 www.rbcms.com.br Rev Bras Cien Med Saúde. 2013;2(2):18-22 cASe report mAXIllAry trANSVerSe DefIcIeNcy correctIoN through SurgIcAlly ASSISteD rApID eXpANSIoN leonardo perez fAVerANI 1, gabriel rAmAlho-ferreIrA 1, gustavo Augusto groSSI-olIVeIrA 1, Éllen Cristina GAetti- JArDIm 1, Sabrina ferreira 2, Cláudio Maldonado PAStORi 3, Idelmo rangel gArcIA-JÚNIor 4 Abstract Fundamentation: The correction of maxillary transverse deficiencies involves orthodontic and surgical procedures that can be performed before or after skeletal maturity. The surgically assisted rapid maxillary expansion (Sar Me) is performed by osteotomies through the lateral walls of the maxilla, zygomatic and canines buttresses, palatal and pterygomaxillary sutures, causing the maxillary disjunction. Followed by activation of the expander to the desired over-expansion in order to correct intercuspal later. Objective: The purpose of this study was to discuss the issues involved in the diagnosis of maxillary atresia, Sar Me indications, as well as surgical technique, through a case study. Methods: The male patient, 19 years old, had severe transverse maxillary deficiency with facial pattern iii , Class iii , with great lip incompetence. The patient underwent general anesthesia in a hospital environment, the osteotomies was done according to the technique described by epker and Wolford (1980). Postoperatively, the patient underwent activations daily for 15 days and after 6 months, the orthodontist installed fixed orthodontic appliance to prepare the patient to orthognathic surgery later. conclusion: The diagnosis by clinical evaluation and models study is essential for the indication of Sar Me and this procedure provides good predictability in the correction of transverse deficiency, with minimal morbidity. Key-words: maxillary; maxillary expansion; atresia. resumo Fundamentação: a correção das deficiências transversais da maxila envolve procedimentos ortodônticos e cirúrgicos, que podem ser realizados antes ou após a maturidade esquelética. a expansão rápida da maxila cirurgicamente assistida (er MCa) é realizada por meio de osteotomias nas paredes laterais da maxila, pilares zigomáticos e caninos, sutura palatina mediana e sutura pterigomaxilar, ocasionando a disjunção maxilar. Seguido da ativação do aparelho expansor até a sobre-expansão desejada visando a correta intercuspidação posteriormente. Objetivo: o propósito deste trabalho foi discutir a respeito do diagnóstico da atresia maxilar, bem como as indicações e a técnica cirúrgica da er MCa, por meio de caso clínico. Métodos: Paciente do sexo masculino, 19 anos de idade, apresentava severa deficiência transversal da maxila, com padrão facial iii , Classe iii , com grande incompetência labial. o mesmo se submeteu a er MCa sob anestesia geral, em ambiente hospitalar, pela técnica descrita por epker e Wolford (1980). no pós-operatório, o paciente realizou as ativações diárias por 15 dias e após 6 meses, o ortodontista instalou aparelho fixo e prosseguiu com a mecânica ortodôntica para posterior Cirurgia ortognática. Conclusão: o diagnóstico por meio da avaliação clínica e dos modelos de estudo é essencial para a indicação da er MCa e este procedimento proporciona boa previsibilidade na correção da deficiência transversal, com mínima morbidade. Palavras-Chaves: maxila; expansão maxilar; atresia. 1 Doutorandos em Cirurgia e Traumatologia Buco Maxilo Facial pelo programa de Pós-graduação em odontologia promovido pela Faculdade de odontologia de araçatuba, da Universidade estadual Paulista (UneSP). 2 Mestranda em Cirurgia e Traumatologia Buco Maxilo Facial pelo programa de Pós-graduação em odontologia promovido pela Faculdade de odontologia de araçatuba, da Universidade estadual Paulista (UneSP). 3 Coordenador e Professor do Curso de residência em Cirurgia e Traumatologia Buco Maxilo Facial promovido pela associação Hospitalar de Bauru – Hospital de Base da 7ª região. 4 Professor adjunto da Disciplina de Cirurgia e Traumatologia Buco Maxilo Facial dos programas de graduação e Pós-graduação em odontologia promovida pela Faculdade de odontologia de araçatuba, da Universidade estadual Paulista (UneSP). autor para correspondência: Leonardo Perez Faverani rua afonso Pena, 2000 edifício aguilera Bloco 4, apartamento 11 Cep: 16011-195 - novo Umuarama/ araçatuba – SP email: leobucomaxilo@gmail.com Telefone: (18) 8112-1750 19 Revista Brasileira de Ciências Médicas e da Saúde 2 (2) Janeiro/Dezembro 2013 www.rbcms.com.br INtroDuctIoN Dental occlusion is considered normal when the upper and lower teeth are aligned in their bony bases in the center of the alveolar ridge and in relative class i1. Thus, the upper dental arch needs to be proportionately greater than the lower arch, making the palatal cusps of the premolars and molars fit properly to occlusal pits of the premolars and mandibular first molar1. When there is any deviation from a morphological characteristics of nor- mal occlusion and manifestation in the senses of space, including the transverse dimension, it is called malocclu- sion. The result of atresia of the upper dental arch in front of the inferior arch of normal dimensions is the posterior crossbite2. The diagnosis of posterior cross bite is very easy, since the normal reference morphology is near, at the lo- wer arch. Thus, we can define the posterior crossbite as the upper arch atresia without compensation of the lower arch. However, the posterior crossbite is not the only in- dicator of maxillary atresia. The maxillary atresia may be present in the case of simultaneous atresia of the lower dental arch. This implies the absence of posterior cross bite. Thus, the cross-sectional diagnosis should be based on inter- and intra-arch relationship2,3. For the treatment of maxillary atresia, rapid Ma- xillary expansion (rMe) was described and originally per- formed by angell (1860)4 and later by Hass (1961)5 in the United States, and it was advocated that the ideal age ran- ge for the rMe through orthodontic- orthopedic appara- tus corresponds to the young patients, with maximum age ranging from 14 years for women and 16 for men, in which the median palatine sutures have not completed the ossi- fying process6. in individuals who have reached skeletal maturi- ty, the surgical separation is indicated in order to provide separation of the median palatine suture with consequent maxillary expansion and the decrease in ortodontic gra- dient effects7. This is known as Surgically assisted rapid Maxillary expansion (SarMe) in which the use of a con- ventional expander is indispensable, and it may be tooth- supported or tooth-mucous-supported with the activator screw should be appropriate to the amount of expansion required. it can be performed under general anesthesia or local anesthesia, and this procedure is aimed at sepa- rating the sutures to prevent palate disjunction, through the techniques proposed by epker and Wolford (1980)8 in which an osteotomy of Le Fort i type is performed asso- ciated with a osteotomy with chisel and hammer of pte- rigomaxilares sutures (not performed in cases under local anesthesia) and median palatine sutures (Figure 1). Pos- toperatively, the patient promotes the daily activation of the expansion device, up to the over-expansion controlled by the orthodontist, so that after completion of the pro- cess of bone repair (6 months), the professional proceeds with necessary orthodontic mechanics2,6,10,11. obJectIVe Given the dento-skeletal changes that maxillary atresia causes to patients, as well as the lack of technique and its indications, such issues justifies this study, by dis- cussing them through a clinical case treated by Surgically assisted rapid Maxillary expansion (SarMe). methoDS AND reSultS Male patient, leucoderma, 19 years old, sought ou- tpatient accompanied by his father, with referred by an orthodontist for evaluation of severe malocclusion. The patient had a medical history of arthrogryposis, a disorder characterized by multiple congenital rigid deformities of joints, which limits the locomotor development. figure 1 - Diagram showing the osteotomies performed during SarMe. figure 2 – Facial aspect in which the patient had lip incompetence, iii facial pattern with horizontal maxillary deficiency, combined with horizontal mandibular excess. 20 Revista Brasileira de Ciências Médicas e da Saúde 2 (2) Janeiro/Dezembro 2013 www.rbcms.com.br on extraoral examination, the patient had lip in- competence, facial pattern iii, transverse deficiency and vertical maxillary excess, combined with horizontal man- dibular excess (figure 2). in the intraoral examination, it was noted posterior and anterior crossbite, Class iii and anterior open bite (fi- gure 3). in the analysis of models of inter-arch study, lea- ding them from the occlusion clinically observed for Class i occlusion, we confirmed the absolute cross bite, with a severe maxillary atresia. We proposed SarMe under general anesthesia in a hospital for correction of maxillary atresia. First, the or- thodontist installed the tooth-supported device (Hyrax) with screw of 13 mm long. The surgery began with incision and mucoperios- teal detachment in the region of the upper gengivolabial groove (distal 16-26) (figure 4). Then the billateral oste- otomy from the nasal aperture to maxilla wall was per- formed using reciprocating saw (Striker®)5 mm above the apex of the teeth (figure 5). Then, separation of the nasal septum (cartilage and vomer bone) using chisel with guide and hammer (figure 6) was performed. at this time, using his index finger, the surgeon should palpate the boundary between the hard palate and soft palate, so that during the separation of the septum up to the posterior limit it can be noticed by the surgeon. The pterygomaxillary disjunction was performed bilaterally with curved chisel and hammer, blind, and the index finger of the opposite hand of the surgeon palpates pterygoid hamulus and maxillary tuberosity, in order to feel the separation of these structures when the disjunc- tion of the pterygomaxillary suture occurs. During this os- teotomy the chisel should remain at all times under the periosteum and be directed from lateral to medial and upper to bottom (figure 7). at this time, the expanding device is activated (8-fold), which corresponds to 2 mm of expansion, with the intent of maintaining a tension in the palate. Then, a straight chisel was placed on the median palatine suture between the maxillary central incisors, and application of blows with the hammer. Clinically, when it occurs the separation of the jaws, one inter- spacing diastema is no- ticed, which is enhanced by prior activation of the expan- ding device (figure 8). on the second day after surgery the patient was instructed on daily activations being 0.5 mm expansion per day until over-expansion is achieved. The screw was locked using acrylic resin for a period up to 6 months after installation of braces. Still, as treatment plan orthodontic mechanics for decompensation and alignment and leve- ling of the teeth will be performed, and later orthognathic surgery. figure 8 - osteotomy of the median palatine sutures. The maxillary expansion with inter- incisor diastema is noted. figure 3 - in the intraoral examination, anterior and posterior cross bite , Class iii and anterior open bite. figure 4 – Jaw access, followed by incision and mucoperiosteal detachment in the region of the upper gengivolabial groove. figure 5 – osteotomy using reciprocating saw (Striker®) from the nasal aperture to the jaw posterior wall bilaterally. figure 6 - osteotomy of the nasal septum using chisel with guide and hammer. figure 7 - Pterygomaxillary disjunction bilaterally with curved chisel and hammer. 21 Revista Brasileira de Ciências Médicas e da Saúde 2 (2) Janeiro/Dezembro 2013 www.rbcms.com.br DIScuSSIoN one of the most important aspects in the maxillary atresia is the correct diagnosis. The maxillary expansion is shown in transverse maxillary deficiencies, either absolu- te or relative, regardless of the stage of development of occlusion, from the deciduous dentition, since in the pre- sence of posterior crossbite. When there is no posterior crossbite, transverse mechanics may start from the mixed dentition. However, there is a limit to the predictability of the outcome in relation to orthopedic patient age. From the clinical point of view, it is clear that the procedure of orthopedic maxillary expansion is fairly predictable until late adolescence. Thereafter, it becomes unpredictable and unlikely with increasing age. Given this circumstance, there is the option of eliminating the structural strength of the maxilla through osteotomies through the side walls and above the jaws (which break the zygomatic and cani- nes buttress), median palatine sutures and pterigomaxilla- ry suture, favoring the maxillary dysfunction even after adolescence2, 5, 10. Therefore, in addition to clinical evaluation, analysis of dental casts is paramount. This is because it is necessa- ry to determine whether the problem is dental or skeletal, and whether transversal deficiency is absolute or relative. The absolute deficiency is characterized by unilateral or bilateral crossbite after evaluation of plaster models with respect to Class i, often perceived in the evaluation of pa- tients with retrognathia. in transversal relative disability, when the study models are placed in Class i, posterior crossbite is not observed, commonly seen in the assess- ment of patients with dentofacial deformity with Class iii malocclusion. in the first situation ortho-surgical interven- tion to correct these deformities is required, and in the second no surgical treatment for correction of maxillary transverse dimension is indicated1, 10, 13. in this report, the patient was 19 years old, and corroborated with intraoral clinical examination and of plaster models, then we found the absolute crossbite, a fact that fully justified the indica- tion for SarMe. There is a great debate in the literature regarding the performance of this surgical procedure under general or local anesthesia with or without sedation. Glassman, nahiogian, Medway (1984)14 in order to perform this pro- cedure on an outpatient basis, described SarMe without osteotomy of the nasal septum and pterygomaxillary su- ture, in order to provide greater comfort and safety to patients because it is a less invasive technique. However, controversies have arisen to determine which one would be less invasive procedure to be performed without affec- ting the amount of expansion achieved and the stability of such expansion over time, especially in severe jaw atresia. in this context, the authors of this study are con- sistent in indicating conservative approaches where pos- sible, to avoid subjecting the patient to surgery under ge- neral anesthesia, which is more costly since the operation performed in a hospital environment presents additional costs of hospitalization of the patient and anesthetist’s fees. However, we also agree that reSaM through the os- teotomy of all skeletal reinforcement, ensures greater sta- bility in the correction of transverse maxillary deficiency, and further expansion in the molar region. This time, ba- sed on this philosophy, we indicate to the patient of this study the surgery in a hospital environment. The genetic defect presented by the patient (arthrogryposis), not inca- pacitated him to undergo an operation of such magnitude, since it does not alter the systemic functions, but only the locomotor autonomy. regarding the surgical technique, the SarMe is a procedure that requires from surgeon specific maxillofa- cial training, in view of the possible complications. The main complications are vascular lesions during disjunc- tion of pterygomaxillary suture due to disruption of the pterygoid venous plexus or maxillary artery branches2, 9. as well as the incorrect positioning of the chisel during os- teotomy of the median palatine sutures, in cases on which the roots of the central incisors are very close it can result in fracture between the tooth root and the alveolar bone wall of central incisor15, 16. in this case there was no com- plications, and it is mandatory for any procedure the im- proved knowledge of the surgical technique by surgeons. Based on the literature and presentation of clinical- surgical report, we conclude that the surgical technique provided good predictability in the correction of transver- se deficiency, with minimal morbidity, the diagnosis by clinical evaluation and study models is essential for the in- dication of SarMe; performing this surgery under local or general anesthesia will depend on the degree of maxillary atresia, the SarMe before orthognathic Surgery will help orthodontic mechanics of decompensation, alignment and leveling of the teeth. refereNceS 1. Bratu DC, Bratu ea, Popa G, Luca M, Bălan r, ogodescu a. Skele- tal and dentoalveolar changes in the maxillary bone morpholo- gy using two-arm maxillary expander. rom J Morphol embryol. 2012;53(1):35-40. 2. Lippold C, Stamm T, Meyer U, Végh a, Moiseenko T, Danesh G. ear- ly treatment of posterior crossbite - a randomised clinical trial. Trials. 2013 Jan 22;14:20. doi: 10.1186/1745-6215-14-20. 3. Silva Filho o, Freitas SF, Cavassan ao. 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