J Oral MaxillofacSurg

50:110-113.1992

Surgically Assisted Rapid Palatal Expansion:

An Outpatient Technique With Long-Term Stability
ROBERT A. BAYS, DDS,* AND JOAN M. GRECO, DDSt

This study presents the results of surgically assisted rapid palatal expansion
done on an outpatient basis in 19 patients with a mean age of 30 years. Post-
surgical and postorthodontic evaluation (mean, 2.4 years) showed a mean relapse
rate of 8.8% in the canine region, 1% in the premolar region, and 7.7% in the
molar region. These results show that the surgical procedure is feasible on an
outpatient basis and the technique, as outlined, yields a stable long-term result.

In 1860, E. H. Angel’ reported correction of max-
illary transverse width discrepancies by opening the
midpalatal suture. In 196 1, Haas* reintroduced rapid
palatal expansion (RPE, or rapid maxillary expansion,
RME) appliances to correct real and relative maxillary
transverse deficiencies, maxillary collapse, maxillary
retrusion, and skeletal class II division 1 malocclu-
sions.3‘5 In growing children, RPE appliances opened
the midpalatal suture, but the long-term stability re-
mained a problem.6 Although RPE has been relatively
successful in children and adolescents, it has been
fraught with failure in adults.2,6,8-10In adults, ortho-
dontic RPE may result in alveolar bending, periodontal
membrane compression, lateral tooth displacement,
and tooth extrusion.5-8 Haas’ believed that the most
common error was underexpansion, so 50% overex-
pansion was advocated. Even with overexpansion, the
very factors that allowed the expansion are the same
factors associated with relapse and subsequent failure
of the procedure.
Historically, the midpalatal suture was thought to
be the area of resistance to expansion, but Isaacson et
al’ ‘,l* have shown that the facial skeleton increases its
resistance to expansion as it ages and matures, and that
the major site of resistance is not the midpalatal suture
but the remaining maxillary articulations. Haas13 be-
lieves the maxillae separate from each other in a tipping
fashion due to the strength of the zygomatic buttresses.
Lines* and BellI demonstrated that the area of in-
Received from the Division of Oral and Maxillofacial Surgery,
Emory University School of Medicine, Atlanta, GA.
* Chairman.
t Resident.
Address correspondence and reprint requests to Dr Bays: Division
of Oral and Maxillofacial Surgery, Emory University School of Med-
icine, 1327 Clifton Rd, Atlanta, GA 30322.
0 1992 American Association of Oral and Maxillofacial Surgeons
0278-2391/92/5002-0002$3.00/O
110
creased facial skeletal resistance to expansion was not
the midpalatal suture, but the zygomaticotemporal,
zygomaticofrontal, and zygomaticomaxillary sutures.
Wertz” theorized that resistance was caused by the
zygomatic arches.
Identification of these areas of resistance in the cra-
niofacial skeleton stimulated the development of
various maxillary osteotomies to expand the maxilla
laterally in conjunction with orthodontic RPE appli-
ances.‘“19 The osteotomy techniques vary, as does the
time of placement of an active orthopedic expansion
device, but anecdotally all reports note that the surgical
expansion is more stable than orthodontic RPE
alone 7,9,14-22
Indications
The role of surgery with RPE is to first release the
areas of resistance in the maxillae.8 According to Moss,*
whether RPE is done alone or in conjunction with sur-
gery will depend on the patient’s age and the condition
of the midpalatal suture, and not on the maxilloman-
dibular relationship. Lines’ states that orthodontic RPE
is extremely valuable in young patients (growing chil-
dren) exhibiting maxillary collapse, maxihary retrusion,
and/or pseudo class III malocclusions. Haas recognizes
six indications for nonsurgical RPE: 1) real and relative
maxillary deficiency, 2) nasal stenosis, 3) all type class
III cases, 4) the mature cleft palate patient, 5) antero-
posterior maxillary deficiency, and 6) selected arch
length problems.
Determination of the necessity for surgery in a max-
illary transverse deficiency patient requires differentia-
tion between skeletal and dental problems, and an ini-
tial determination of the existence and extent of the
discrepancy. Jacobs et al*’ state that only in rare in-
stances are crossbites (either buccal or palatal) involving
more than one or two teeth not skeletal. They divide
 BAYS AND GRECO
maxillary transverse width discrepancies into two cat-
egories: real and relative. Relative implies that a hor-
izontal discrepancy apparently exists clinically, but the
study models examined in a class I canine relationship
show that the apparent deficiency is in reality the result
of a discrepancy of the maxilla or both jaws in the
sag&al dimension. Absolute implies a true horizontal
width insufficiency. These cases may present clinically
with palatal crossbite or with no crossbite present.
However, with study models positioned in a class I
canine relationship, a unilateral or bilateral palatal
crossbite is evident. Models mounted in centric relation
are required for determination of unilateral versus bi-
lateral crossbites.
Relative bilateral or unilateral transverse maxillary
deficiency requires no surgical treatment. Orthodontic
intervention can routinely coordinate the arches, with
or without extractions. Some cases have an apparent
maxillary deficiency due to ectopic eruption of one or
two posterior teeth. This is purely dental in nature and
also can be treated with orthodontics. Absolute trans-
verse maxillary deficiency requires determination of
other factors, such as whether the expansion should be
achieved through lateral maxillary osteotomies and
RPE or by segmentalizing the maxilla to achieve trans-
verse, vertical, and/or sag&al correction. A recent study
indicates that multiple-piece osteotomies may exhibit
up to 40% long-term transverse relapse.”
Surgical Technique
After introduction of intravenous (IV) sedation, local
anesthesia is obtained by infiltration bilaterally in the
mucobuccal fold of the maxilla, infraorbital nerve
blocks, posterior superior alveolar nerve blocks, a na-
sopalatine nerve block, and greater palatine nerve
blocks. Infiltration anesthesia also is achieved around
the base of the nose, along the anterior nasal spine,
and in the area of the lateral piriform rims. This may
be supplemented intraoperatively as one dissects if the
patient begins to experience some sensation. It has
proved helpful to inject into the most superior aspect
of the nasopalatine canal to achieve obtundation of
pain in the area of the nasal septum.
Bilateral mucoperiosteal incisions are made from the
piriform rims to zygomatic buttresses. Subperiosteal
dissection exposes the lateral maxilla from the ptery-
gomaxillary junction anteriorly to the piriform rims.
An incision is not made from canine to canine to retain
major support of the alar bases and anterior aspect of
the upper lip.
Bilateral osteotomies are performed from the piri-
form rims to low in the pterygomaxillary junction (Fig
1). This procedure is feasible on an outpatient basis
because no attempt is made to separate the maxilla
from the pterygoid plates and the pterygomaxillary
junction is not invaded. Osteotomies also are made
111
FIGURE I. Diagram showing bilateral from piriform rim to low
in area of pterygopalatine junction.
through the anterior 1.5 cm of the lateral nasal wall,
which is the thickest portion. A separation ofthe hemi-
maxillae is performed by driving a spatula osteotome
between the central incisors parallel to the palate for
approximately 1.O to 1.5 cm (Fig 2). No soft-tissue in-
cision is necessary in this area; the spatula osteotome
can be driven directly through mucosa and bone. The
midline sectioning then progresses superiorly from the
alveolar crest to the anterior nasal spine, one chisel
width at a time, until the chisel can be felt parallel to
the palate. The jackscrew of the palatal expansion de-
vice is then turned until separation is noted, usually
four or five one-quarter turns.
Both segments are aggressively mobilized by prying
until equal mobility is seen bilaterally (Fig 3). Mobi-
lization is continued until approximately a 1.5- to 2.0-
mm gap is opened between the central incisors. The
wounds are then irrigated copiously and closed.
No expansion is attempted for 5 days postoperatively
to facilitate patient comfort. Thereafter, a one-quarter
turn every other day is done until the patient returns
to ,the orthodontic office, usually 7 to 10 days post-
operatively. Thereafter, quarter turns are done once
per day until the desired expansion is achieved. No
overexpansion or retention is needed. Avoidance of
two sources of potential hemorrhage, manipulation of
the pterygomaxillary junction and separation of the
nasal septum from the nasal crest of the maxilla, allows
this procedure to be done on an outpatient basis.
Materials and Methods
Between 1982 and 1989, the senior author treated
33 patients with this standardized surgical RPE tech-
nique for the purpose of correcting transverse maxillary
deficiencies. Patients were included in this retrospective
study based on the following criteria: availability of
preoperative and preorthodontic models, availability
of models taken after surgery and at the time of de-
banding, and being in postretention for at least 6
112
FIGURE 2. Diagram showing separation of maxillae with osteo-
tome driven between the incisors.
months. Nineteen patients met these criteria. Models
were taken at T 1 (prior to any orthodontic and surgical
intervention), T2 (immediately after removal of ortho-
dontic appliances), and T3 (at least 6 months after
completion of all treatment, including orthodontic re-
tention). There were 16 females and 3 males, with a
mean age at the time of surgery of 30.2 f 9 years
(Table 1). The postoperative follow-up period after
surgery, including retention, ranged from 6 months to
5 years, with an average of 2.4 f 1.3 years.
Stability of maxillary transverse dimensions was
based on measurement of the distance between specific
occlusal antimeres of the canines, first premolars, and
first molars for each time period (Tl to T3). If first
premolars or first molars were missing, the next tooth
posterior was used. The measurements were made with
calipers from occlusal pit to occlusal pit in the chosen
FIGURE 3. Diagram showing mobilization ofthe maxilla by twist-
ing the osteotome.
SURGICAL PALATAL EXPANSION
Table 1. Age of the Patient Population
Age Group (yr) No. of Patients
15-20 3
20-30 4
30-40 9
>40 3
posterior teeth to insure accuracy. For the canine, the
height of contour of the most distobuccal surface was
used The linear measurements were determined to the
nearest one tenth of a millimeter.
The difference between T 1 and T2 showed the effect
that surgical-orthodontic treatment had on the max-
illary transverse width. The difference from T2 to T3
showed the long-term stability of the surgical-ortho-
dontic treatment. The teeth were also evaluated for
tipping, and the gingival papillae between central in-
cisors were evaluated for blunting. A one-tailed Stu-
dent’s t test was used to determine the significance for
the time period T 1 to T2. A two-tailed Student’s t test
was used for the time period T2 to T3.
Results
The only complications seen were a slight blunting
of one gingival papilla and a minor posterior nosebleed
that was controlled with packing.
After careful review of the data on tooth tipping, it
was determined that significant variation existed be-
tween patients, and the measurements were so erratic,
that the results were skewed and the data misleading.
A larger sample size will be necessary before a conclu-
sive statement can be made regarding tooth tipping.
However, there was no apparent influence on the clin-
ical results observed.
The net expansion (Tl to T3) at the canines was 4.5
f 3.28 mm, with a mean relapse of -.39 f .79 mm
(8.8%) (Fig 4). At the premolars, expansion was 5.76
f 2.56 mm, with a mean relapse of .064 * 1.0 mm
( 1.O%)(Fig 5). The first molars were expanded a mean
of 5.78 + 2.68 mm and relapsed -.45 f .69 mm (7.7%)
(Fig 6).
Discussion
Surgically assisted rapid palatal expansion has been
an integral part of orthodontic therapy for many years.
However, until recently, no long-term studies have
been performed to evaluate the stability of the various
procedures advocated. The senior author has been us-
ing this same method for 10 years with excellent suc-
cess, which was the stimulation for this retrospective
study.
Due to the significant differences in techniques de-
scribed over the years, it has been difficult to determine
which surgical maneuvers were necessary to facilitate
BAYS AND GRECO
PATIENTS
FIGURE 4. The canine region width changes in 19 patients. No
values appear for cases 2,5, and 6 because there were no net changes
between Tl and T2 and Tl and T3 in these patients. 0, Tl to T2;
n . Tl to T3.
surgically assisted rapid palatal expansion. This study
indicates that the surgical protocol described is appro-
priate for surgical expansion of the maxilla, with trans-
verse stability that is significantly better than when a
multiple-piece maxillary osteotomy is used21 and that
involves minimum morbidity. Avoidance of the pter-
ygomaxillary fissure and the nasopalatine vessels makes
this procedure acceptable for outpatient use, because
the chance of intraoperative and postoperative bleeding
is minimal.
As the results of expansion and relapse represent
both skeletal (surgical) and dental changes, conclusions
cannot be drawn as to the relative contribution of each.
In some cases canines may have been orthodontically
narrowed after surgically assisted rapid palatal expan-
sion to accommodate arch width compatibility. How-
ever, in no case was the maxilla overexpanded as is
recommended with nonsurgical RPE.’
No retention was used in this group of patients. This
is a major advantage to the orthodontist because im-
mediate orthodontic therapy can be initiated without
concern for relapse.
Surgically assisted rapid palatal expansion is an ex-
tremely valuable operation that should be considered
whenever maxillary expansion is needed, especially in
adults. The relative lack of complications and the ex-
cellent stability are important reasons for considering
this procedure.
8 1984
PREMOURS ’ 19. Kennedy JW III, Bell WH, Kimbrough OL, et al: Osteotomy as
6 an adjunct to rapid maxillary expansion. Am J Orthod 70:
5 123. 1976
.
3
2
1
0
mm
FIGURE 5. The premolar region width changes in 19 patients. 0,
TI toT2;&Tl toT3.
113
PATIENTS
FIGURE 6. The molar region width changes in 19 patients. Cl, Tl
to T2; n, Tl to T3.
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