Semirapid Maxillary Expansion and Mandibular Symphyseal

Distraction Osteogenesis in Adults: A Five-Year Follow-up Study

Sddk Malko, Haluk I seri, and Ercan Durmus(Semin Orthod 2012;18:152-161.)

Tooth size-arch size discrepancies can be treated by either decreasing tooth mass or increasing arch
perimeter.
Extraction therapy has been a treatment approach for patients with moderate to severe crowding, and it can
produce good treatment results that remain stable
However, sometimes extractions can be problematic in patients with crowding, excessive overjet, convex
profile, deep curve of Spee, or a combination of these occlusal and skeletal discrepancies.
Interproximal stripping is an effective approach for adults with limited amounts of misalignment.
Non-extraction treatments that increase arch length to resolve crowding have been shown to be unstable,
with up to 89% of patients demonstrating clinically unsatisfactory alignment at long-term follow-up.
According to Little et al, the mandibular arch should be neither expanded nor changed in arch form.
Therefore, an important dilemma may also exist between the choice of long-term stability and aesthetics.
Arch form plays a pivotal role in the transverse dimension of the smile.
Recently, much attention has been focused on the use of broad, square arch forms in orthodontic treatment.
When the arch form is narrow or collapsed, the smile may also appear narrow and therefore present
inadequate transverse smile characteristics.
Expansion of a narrow arch form can dramatically improve the smile by decreasing the size of the buccal
corridors and improving the transverse smile dimension.
RME became a routine procedure in orthodontic practice when the constricted maxilla and upper dental
arch demanded orthopedic widening.
RME has been shown to be a valuable aid in the orthodontic treatment of young patients exhibiting
transverse maxillary deficiency, pseudo-Class III malocclusion, rhinologic and respiratory ailments, and
cleft lip and palate.
Mandibular transverse skeletal deficiencies are common problems usually associated with narrow basal
bone and dentoalveolar structures and dental crowding.
Distraction osteogenesis (DO) has great potential for correcting transverse mandibular deficiencies.
Mandibular symphyseal distraction osteogenesis (MSDO) was initially reported by Guerrero et al and
described as an efficient surgical alternative to orthognathic surgery for the treatment of transverse
deficiencies.
Methods
In all patients, fixed upper (between laterals) and lower (between canines) lingual retainers were used after
the end of orthodontic treatment during the 5-year follow-up period.
Custom-made, intraoral, rigid tooth- and bone-borne distraction devices were used in all the study patients.
The distraction device consisted of a hyrax screw and 2 footplates (Fig. 1).
The distractor was positioned in front of the lower incisors at the gingival level, and the opening holes of
the screw were placed on the mandibular symphysis.
The upper arms of the screw were bent to match the mandibular anterior arch form and fitted into the first
mandibular premolar braces, which were welded on the bands horizontally.
The premolar bands, onto which the braces were welded horizontally, were applied 1 day before the
distraction operation.
The footplates were fixed to the tip of the lower arms and were adjusted according to the form of the
symphysis.
The distraction device was activated by the patient twice a day, once in the morning and once in the
evening, with a total amount of 1 mm per day.
Patients were examined regularly until the desired mandibular widening was completed.
The necessary amount of mandibular widening was determined according to mandibular lower arch space
deficiency, anteroposterior position of lower anterior teeth, maxillary expansion necessity, and lower and
upper intercanine width harmony.
SRME was performed with a full-coverage acrylic bonded device in all 14 patients as described elsewhere.
After bonding the RME appliance, the patients parents were instructed to activate it by turning the screw 1
turn in the morning and another turn in the evening for the first 5-7 days.
Each turn of the screw produced 0.2 mm of expansion. After it was determined from the occlusal films that
the suture was opened, the expansion was continued by 3 activations a week.
After the retention phase of SRME (4.57 _ 0.65 months), orthodontic treatment was completed with fixed
appliances (Table 1).
The following measurements were made by using the landmarks marked on the PA films:
1) Orbital width (OrbW) (mm):
2) Zygomatic width (IZygW) (mm):
3) Upper nasal width (UNasW) (mm):
4) Lower nasal width (LNasW) (mm):
5) Nasal angle (NasAn) (degrees):
6) Bimaxillary width (BMaxW) (mm):
7) Upper molar width (UMolW) (mm):
8) Upper incisor interapex width (Uiap) (mm):
9) Upper incisor intercrown width (Uicr) (mm).
10) Bicondylar width (BCoW) (mm):
11) Bigonial width (BGoW) (mm):
12) Biantegonial width (BAngoW) (mm):
13) Ramal angle (Rang) (degrees):
14) Lower molar width (LMolW) (mm):
15) Lower incisor interapex width (Liap) (mm):
16) Lower incisor intercrown width (Licr) (mm):

Discussion
The stability of RME and factors, such as age of patient, rate of expansion, design of device, duration of
retention and cooperation during retention period, severity of maxillary deficiency, resistance of midpalatal
suture and surrounding maxillary structures, and adaptation of the soft tissues
Long-term evaluation has shown a relapse tendency in patients who were treated with conventional type of
RME appliances.
Haas, Hyrax, Minne expander, cap splint, and quad-helix appliances are used for RME.
These RME appliances increase the transverse dimension of the maxillary arch by separation of the suture
and by buccal movement of the posterior teeth and alveolar processes.
Tipping and extrusion of the maxillary posterior teeth along with alveolar bending result in posterior
rotation of the mandible, which also tends to open the bite.
However, bonded RME appliances with occlusal coverage have been reported to have certain advantages
over conventional devices.
Memikoglu andIseri demonstrated that RME therapy could be maintained during orthodontic treatment
in terms of dentoskeletal expansion by using a bonded RME appliance.
Rapid displacement of the facial bones would result in a marked amount of relapse, whereas relatively
slower expansion of the maxilla would probably produce less tissue resistance in the nasomaxillary
complex.
Therefore, the authors suggested 2 turns each day for the first 5-7 days and then 3 turns each week.
This would stimulate the adaptation process in the nasomaxillary complex and would result in reduction of
relapse in the postretention period.
Different types of symphyseal distraction appliances are available commercially.
Expansion by DO with a tooth-borne device can result in greater expansion of the teeth than of the basal
bone.
This can incorporate some transverse dental relapse potential negating some of the expansion achieved.
Tooth- and bone-borne or bone-borne devices can minimize this effect but might also require secondary
minor surgery to remove the device.
Rate of distraction can be an important factor.
Too fast a rate can lead to poor bone quality, and too slow a rate can lead to premature consolidation and
inability to obtain the desired amount of activation. A typical rate of distraction is reported as 1 mm per
day.
A clinically efficient rhythm has been 0.50 mm twice a day and was also used in this study.
In our approach, the lower anterior teeth were bonded, and tooth movement to the distraction site was
immediately started following distraction.
However, previous studies recommended that orthodontic tooth movement should not begin until radiographic
evidence of consolidation and also suggested that allowing the teeth to move into the gap too early could end up
with periodontal and bony defects, as well as tooth loss.
However, Liou et al demonstrated that orthodontic tooth movement into newly distracted bone 2 weeks after the
distraction period accelerates the maturation process of the new bone regenerate.
They suggested that orthodontic tooth movement into newly distracted bone is possible, and new alveolar bone was
created through orthodontic tooth movement. According to our clinical experiences, which were based on our
clinical cases, no periodontal bone loss, periapical pathology, or soft-tissue recession was evident.
Moreover, tooth vitality was maintained in all the study cases.
It is well-known that age and maturation stage of the patient are important factors when considering the effects of
maxillomandibular expansion on craniofacial structures.
Many investigators were agreed that maxillary expansion is more stable in growing subjects than in young adults
and adults.
With advancing maturity, rigidity of the craniofacial skeleton limits the long term stability.
Gradual distraction of the skeletal structures associated with soft-tissue envelope, such as muscles of mastication,
subcutaneous tissues, and skin.
This softtissue expansion has been associated with little or no skeletal relapse.
A consolidation period of at least 3 months is suggested for mandibular widening with the exact time based on
radiographic visualization of cortical bone in the distraction regenerate.
Conclusions
Effects of SRME with rigid bonded device and MSDO on maxillary and mandibular structures were evaluated in
adult patients.
The results indicated that dental and skeletal changes achieved with SRME and MSDO in the transverse dimension
were stable at the end of a 5-year postretention period.
Long-term findings of this study indicated that SRME and MSDO is an efficient non-extraction treatment alternative
for maxillomandibular transverse deficiency patients.