Caso Clínico

Vertical incisions in SARPE

Incisiones verticales en SARPE

J. Gonzalez Lagunas, J.A. Hueto Madrid, G. Raspall Martín

Recibido: 11 de noviembre 2004

Aceptado: 21 de marzo 2005

Servicio de Cirugía Oral y Maxilofacial
Hospital Universitario Vall de Hebrón, Barcelona, España

Correspondencia:
Dr. Javier Gonzalez Lagunas
Gnation
Casanova 101 Pral-1º
08011 Barcelona, España

Introduction

Surgically assisted rapid palatal expansion (SARPE) is, together with orthopedic disjunction of the maxilla and the segmented Lefort I osteotomy, one of the techniques that are available for correcting transverse defects of the upper maxilla. Transverse problems of the upper maxilla affect 9.4% of the population, although in the group of patients requesting treatment for dento-facial deformities this can reach 30%.^1,2

We present a technical modification of the procedure that minimizes surgical trauma and is aimed at reducing postoperative morbidity.

Technique

We prefer operating the patient with a precemented Hyraxtype disjunction appliance. Following local anesthesia infiltration, two vertical vestibular incisions are made with a Colorado tip between the canine and the first premolar (Fig. 1). The outer face of the maxilla is tunneled carefully between the nasal notch and the zygomatic- maxillary buttress, with a minimum vertical extension. The Obwegeser separator is introduced and rested on the tuberosity. With an oscillating saw or a fissure burr the osteotomy line is made, making sure with a chisel that there is no resistance, especially by the zygomatic-maxillary buttress (Fig. 2). The osteotomy of the median palatine raphe is made in a transmucosal manner by introducing the chisel into the interincisal space. The chisel is introduced gently until the surgeon can feel it coming out through the palate, but without perforating its fibrous membrane. The osteotomy is continued to the back of the hard palate, while controlling at the same time its position underneath the palatine mucosa.

Once the osteotomies have been carried out, the disjunction appliance is activated, while verifying the interincisal separation.

Results

This technique has been applied consecutively in four patients requiring SARPE due to transverse maxillary collapse. The demographic data of the patients included two males and two females between the ages of 24 and 39. In one of the cases this was an isolated procedure, in another bimaxillary surgery has since been carried out, and the other two patients are awaiting definitive treatment with another type of osteotomy.

With this procedure a greater incidence of complications has not been observed, either intraoperatively or postoperatively, than with the technique used previously. A better response has been noted in soft tissues with better postoperative edema.

Discussion

The experience of these authors with SARPE has been included in a previous article.³ In these last cases, and with the aim of reducing the discomfort for patients, technical modifications have been introduced for minimizing surgical trauma. A revision of the literature permits confirming the existence of numerous technical SARPE modifications and, with regard to stability, there do not appear to be any significant differences. Brown in 1938 described an isolated midpalatal osteotomy.⁴ Later, lateral wall corticotomies were introduced in order to treat maxillary collapse,^5,6 and in 1975 Lines combined the midpalatal osteotomy for the first time with lateral wall corticotomies.⁷ Bell and Epker later applied the complete Lefort I osteotomy but without the down-fracture, or without separating the lateral nasal wall.^2,8-10 In the decade of the 80s, less aggressive techniques were applied that could be carried out under sedation: lateral wall corticotomies with interincisal osteotomies,¹¹ lateral wall corticotomies with midpalatal osteotomies through a paramedial palatal incision¹² or a transpalatal incision,^13,14 or palatal osteotomies through the pyriform aperture.¹⁵ There is no clinical evidence as to the need for carrying out pterygomaxillary osteotomies, and they have only been recommended in an experimental study on models.¹⁶

Our revision of the literature confirms that there are no significant clinical differences as to results and stability, independent of the technique used. It is therefore possible to experiment with modified techniques so that surgical procedures are made easier and the subjective discomfort of the patient is reduced. In a lateral wall corticotomy, the anterior and posterior ends are easily accessed with vertical incisions. In addition, for those patients requiring a conventional Lefort 1 osteotomy, raising mucoperiosteal flaps is made easier as the mucosa is not cut in an anteroposterior sense.

Conclusions

We present a technical modification that consists in carrying out SARPE through three small vertical incisions. It consists only in a lateral corticotomy and a transincisal palatal osteotomy. The technique minimizes surgical trauma and there are no significant complications.

References

1. Proffit WR, Philips C, Dann CIV. Who seeks surgical orthodontic treatment. Int J Adult Orthod Orthognat Surg 1990;3:153-60.        [ Links ]

2. Betts NJ, Vanarsdale RL, Barber HD. Diagnosis and treatment of transverse maxillary deficiency. Int J Adult Orthod Orthogn Surg 1995;10:75-96.        [ Links ]

3. Gonzalez J, Hueto J.A. Raspall G. Expansión rápida de paladar asistida quirúrgicamente. RCOE.        [ Links ]

4. Brown GVI. The Surgery of Oral and Facial Diseases and Malformations; ed 4, Londres: Kimpton 1938;p.p.507.        [ Links ]

5. Koele H. Surgical operations on the alveolar ridge to correct occlusal abnormalities. Oral Surg 1959;12:515-29.        [ Links ]

6. Converse JM, Horowitz SL. The surgical orthodontic approach to treatment of dentofacial deformities. Am J Orthod 1969;55:217-43.        [ Links ]

7. Lines PA. Adult rapid maxillary expansion with corticotomy. Am J Orthod 1975;67:44-56.        [ Links ]

8. Bell WH, Epker BN. Surgical orthodontic expansion of the maxilla. Am J Orthod 1976;70:517-28.        [ Links ]

9. Turvey TA. Maxillary expansion. A surgical technique based on surgical orthodontic treatment objectives and anatomic considerations. J Maxillofac Surg 1985;13:51-8.        [ Links ]

10. Mossaz CF, Byloff FK, Richter M. Unilateral and bilateral corticotomies for correction of maxillary transverse discrepancies. Eur J Orthod 1992;14:110-6.        [ Links ]

11. Bays RA, Greco JM. Surgically assisted rapid palatal expansion: an outpatient technique with long term stability. J Oral Maxillofac Surg 1992;50:110-3.        [ Links ]

12. Racey G. Surgically assisted rapid palatal expansion: an outpatient technique with long term stability: (discusión). J Oral Maxillofac Surg 1992;50:114-5.        [ Links ]

13. Pogrel MA, Kaban LB, Vangervik K. Surgically assisted rapid maxillary expansion in adults. Int J Adult Orthod Orthognath Surg 1992;7:37-41.        [ Links ]

14. Kraut RA. Surgically assisted rapid maxillary expansion by opening the midpalatal suture. J Oral Maxillofac Surg 1984;42:651-5.        [ Links ]

15. Zahl C, Gerlach KL. Fine edge osteotome for submucous palatal osteotomy. Br J Oral maxilllofac Surg 2004;42:49-50.        [ Links ]

16. Shetty V, Mendoza J, Caputo A, Chaconas SJ. Biomechanical rationale for surgical-orthodontic expansion of the adult maxilla. J Oral Maxillofac Surg 1994;52:742-9.        [ Links ]