Oral and Maxillofacial Surgery

https://doi.org/10.1007/s10006-021-00968-6

ORIGINAL ARTICLE

Effect of vomer position following surgically assisted rapid palatal

expansion
Fábio Lourenço Romano1,2 · Cássio Edvard Sverzut3 · Alexandre Elias Trivellato3 ·
Maria Conceição Pereira Saraiva4 · Tung Tahan Nguyen5

Received: 23 October 2020 / Accepted: 5 May 2021

© The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature 2021

Abstract
Purpose To evaluate the effect of vomer position and prevalence of periodontal dehiscence in patients who underwent surgi-
cally assisted rapid palatal expansion (SARPE). The null hypotheses were the following: (1) vomer position in the coronal
plane does not influence the degree of skeletal and dental expansion; and (2) there is no association between expansion,
periodontal dehiscence and vomer position.
Methods Twenty-one patients were evaluated before treatment (T0) and immediately after SARPE expansion (T1). After
SARPE, the vomer was in the right side in 11 patients and in the left in 10 patients. Skeletal and dental effects were evalu-
ated using CBCT, landmarks and measurements.
Results The maxilla and the nasal cavity expanded asymmetrically. The side containing the vomer had less skeletal expansion
but more dental tipping. Dehiscence increased significantly from T0 to T1 and was associated with the amount of skeletal
displacement, especially when greater than 3.20 mm. In the first premolars region, there was more than 2 mm of asymmetric
expansion observed in 38.5% of the patients.
Conclusion The null hypotheses were rejected. The side containing the vomer had less skeletal expansion of the maxilla
and nasal cavity but more dental tipping. Dehiscence increased after expansion, but there were no differences between sides.

Keywords Vomer · Nasal bone · Palatal expansion · Maxillary osteotomy · Orthognathic surgery · Alveolar bone loss

Introduction SARPE corrects posterior crossbite [5–7], through opening

of the midpalatal suture, with the differential expansion of
Surgically assisted rapid palatal expansion (SARPE) is a the anterior and posterior segment dependent on type and
commonly used procedure to correct posterior crossbites in position of the expander [8–10]; produces dental and seg-
adults. It is efficient and has few minor complications [1–4]. mental tipping [5, 11–13]; has periodontal side effects [9,

2
* Fábio Lourenço Romano Department of Orthodontics, School of Dentistry, University
fabioromano@forp.usp.br of North Carolina, Chapel Hill, NC, USA
3
Cássio Edvard Sverzut Department of Oral and Maxillofacial Surgery
cesve@forp.usp.br and Periodontics, School of Dentistry of Ribeirão Preto,
University of São Paulo, Av. do Café, s/n Monte Alegre,
Alexandre Elias Trivellato
Ribeirão Preto, SP 14040‑904, Brazil
eliastrivellato@forp.usp.br
4
Department of Paediatric Dentistry, Epidemiology,
Maria Conceição Pereira Saraiva
School of Dentistry of Ribeirão Preto, University of São
mdsaraiv@umich.edu
Paulo, Av. do Café, s/n Monte Alegre, Ribeirão Preto,
Tung Tahan Nguyen SP 14040‑904, Brazil
tung_Nguyen@unc.edu 5
Department of Orthodontics, School of Dentistry, University
1 of North Carolina, Campus Box #7450, Chapel Hill,
Department of Paediatric Dentistry, Orthodontics, School
NC 27599‑7450, USA
of Dentistry of Ribeirão Preto, University of São Paulo, Av.
do Café, s/n Monte Alegre, Ribeirão Preto, SP 14040‑904,
Brazil

13
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12, 13]; improves airway dimensions [14, 15]; and results in
changes of facial soft tissues [14]. Many studies have shown
effective maxillary expansion [4, 16] using study casts [3,
5], 3D models [9], cephalometric data and cone-beam com-
puted tomography (CBCT) scans [7, 11, 12]. However, few
studies have evaluated the causes and consequences of asym-
metric expansions [1, 2]. Some studies using CBCT found a
decrease in buccal alveolar bone thickness after SARPE, but
no immediate clinical effects on the periodontium [11, 13].
SARPE is usually performed using a conventional LeFort
I osteotomy and midline fracture between central incisors,
with or without pterygoid disjunction [4, 7, 16]. If the ante-
rior separation was performed exactly in midline palatal
suture, the vomer will be randomly positioned in the right
or left side after and its position may affect expansion. No
studies have correlated vomer position with the degree of
skeletal and dental expansion or presence of alveolar defects,
particularly periodontal dehiscences after SARPE.
This study evaluated the effect of vomer position on the
pattern of expansion and the occurrence of periodontal
dehiscence in patients who underwent SARPE. The null
Fig. 1  Inclusion and exclusion criteria
13
Oral and Maxillofacial Surgery
hypotheses were the following: (1) vomer position in the
coronal plane does not influence the degree of skeletal and
dental expansion; and (2) there is no association between
expansion, periodontal dehiscence and vomer position.
Material and methods
Ethical approval and study population
This study was approved by the Institutional Review Board
(#56,387,616,600,005,419) of the institution where it was
conducted, and informed consent was obtained from all par-
ticipants. A convenience sample was used in this retrospec-
tive study. Patients underwent SARPE in the Department of
Surgery of the School of Dentistry of Ribeirão Preto, Uni-
versity of São Paulo, Brazil. Forty-seven consecutive adults
were examined from 2009 to 2014. Inclusion and exclu-
sion criteria are described in Fig. 1, and the study design
in Fig. 2.
Oral and Maxillofacial Surgery
Fig. 2  Study design. CBCT was
used for diagnosis and follow-
up after SARPE
Orthodontic and surgical procedures
All patients had a posterior crossbite greater than 5 mm with
transverse maxillary deficiency, and were treated with Hyrax
tooth-borne expanders with extensions to canines and sec-
ond molars. The same surgical protocol for SARPE used
in all the cases consisted of conventional bilateral LeFort I
osteotomy and midline separation between central incisors,
without pterygoid disjunction or down fracture.
Two oral and maxillofacial surgeons (C.E.S. and A.E.T.)
performed the operations at a public hospital in Ribeirão
Preto, Brazil. All patients were under general anaesthesia.
Nasotracheal intubation was performed with patients in
a supine position. According to the hospital protocol, 2 g
of cefazolin sodium and 10 mg of dexamethasone were
administered intravenously as antibiotic and antiemetic
prophylaxis.
A topical solution of 10% povidone-iodine was used for
intraoral and facial asepsis. After the placement of ster-
ile surgical drapes and oropharyngeal protection, 6 mL
of an anaesthetic solution of 2% lidocaine with 1:100,000
epinephrine was administered along the buccal sulcus of
the maxilla. Using a #15 blade mounted on a #3 scalpel
handle, an incision was made in the buccal sulcus of the
maxilla (vestibule) at a distance of about 4 mm from the
mucogingival junction, extending from the mesial surface
of the first molar to the mesial surface of the canine. After
mucoperiosteal flap elevation, the surface of the maxillary
bone was exposed from the zygomatic buttress to the most
inferolateral point of the piriform aperture. Osteotomy was
performed from this point to a slightly posterior point in
the zygomatic buttress, 5 mm above the roots of the pos-
terior teeth, using a #702 taper fissure crosscut carbide bur
under abundant saline irrigation. The same procedure was
performed in the other side. An incision was made in the
maxillary labial fraenum sagittally, and an osteotomy was
performed using a #701 taper fissure crosscut carbide bur
under abundant saline irrigation after mucoperiosteal flap
elevation and placement of a retractor (Minnesota-Sverzut;
Quinelato, Rio Claro, Brazil).
The midline osteotomy was completed using a chisel and
mallet following the path of the intermaxillary suture (Sver-
zut, Quinelato, Rio Claro, Brazil) (Fig. 3). When the frac-
ture was completed, the vomer moved to the right or to the
left side randomly, although the osteotomy was performed
exactly along the midline.
After the fracture was made, the expansion screw was
activated 2 mm (eight ¼ turns) and then deactivated 1 mm
to open a 1-mm diastema between the maxillary central
incisors. Seven days after surgery, the patient started daily
activations of two ¼ turns in the morning and two ¼ turns in
the evening. For most patients, the screw was activated at a
total of 7 to 9 mm. Activation time was about 15 to 21 days.
Expansion was stopped when overcorrection was achieved,
and the expander was kept in the maxilla for 6 months for
retention.
CBCT analysis and evaluation of alveolar defects
CBCT scans before treatment (T0) and immediately after
expansion (T1) (Fig. 2) were obtained for all patients using
an i-CAT scanner (International Imaging Sciences, Hatfield,
PA). For CBCT scanning, patients were positioned with the
Frankfort plane (FP) parallel to the floor, and the teeth were
placed in centric occlusion. The scanning parameters were
120 kV, 5 mA, 0.4-mm voxel, 40-s exposure time and FOV
of 16 cm × 22 cm. CBCT DICOM files were converted to the
13

Fig. 3  Surgical procedure used for SARPE
gipl.gz format using the ITK-SNAP 3.6 open-source soft-
ware (www.​itksn​ap.​org).
Dehiscences in canines, first premolars and first molars
were evaluated qualitatively and quantitatively at 164 buccal
sites on the right and left sides of the maxilla at T0 and T1.
The distal and mesial roots of the molars were evaluated sep-
arately. Each tooth was initially examined on an axial view
to determine the number of slices necessary to capture the
image of the crown mesiodistally. Buccal bone height in the
region of molars and premolars was measured on the coronal
view and in the region of canines, on a cross-sectional view.
Bone defects were classified as dehiscence when the alveo-
lar bone height, measured from the CEJ, was greater than
2 mm. If the bone defect was adjacent to the roots and did
not involve the alveolar crest, it was classified as fenestra-
tion [17–20]. Two orthodontists (FLR and TTN) performed
all evaluations independently, and any discrepancies were
resolved by consensus.
CBCT scans were used to evaluate vomer position at T0
and T1. At T0, vomer was centred in all patients, without
any deviations to the left or to the right. At T1, vomer was
in the right side in 11 patients and in the left side in 10
(Figs. 1 and 4). Based on that finding, the patients were
divided into two groups according to vomer position: in the
Fig. 4  Vomer position. A vomer centred before SARPE (arrow and contour); B vomer deviated to right side immediately after expansion (yellow
arrow and contour); C superimposition showing different positions of vomer. Green, T0 (white arrow), and red, T1 (yellow arrow)
13
Oral and Maxillofacial Surgery
right side (VR) and in the left side (VL). Skeletal and dental
changes were compared between groups using landmarks in
3D digital models and direct examination of CBCT scans.
Model construction, cranial base registration, visualization
and assessment of treatment outcomes were performed using
methods describe in the literature [21–24].
The Editor tool in the Slicer 3.1 software (http://​www.​
slicer.​org) was used for segmentation of the maxilla and the
skull. Automatic voxel-based registrations were performed
using CBCT scans obtained at T0 as a reference. Scans
obtained at T1 were superimposed and registered to T0 scans
at the anterior cranial base, specifically the endocranial sur-
faces of the cribriform plate of the ethmoid bone and the
frontal bone, using the ITK-SNAP 3.6 software (http://​itksn​
ap.o​ rg). This region was selected because it is not affected by
growth or treatment changes resulting from SARPE. Slicer
3.1 was used to generate the registered 3D models of the
maxilla and the skull. The registered T0 and T1 models were
reoriented using the same coordinate system. The axial plane
was oriented according to the Frankfort plane (FP), defined
by the right and left porion and the right and left orbitales.
The sagittal plane was determined by crista galli and basion
[23], and the coronal plane, by the tangent to the articulare,
perpendicular to the FP. The 3DMeshMetric 1.4 software
Oral and Maxillofacial Surgery

(http://​www.​nitrc.​org./​proje​ct/​meshv​almet) was used to

measure skeletal and dental changes from the registered and
superimposed T0 to T1 3D models (Table 1, Fig. 5).
Three-dimensional closest-point surface distances from
T0 to T1, displayed as colour maps, measured the differ-
ences between the superimposed 3D images. In the quan-
titative colour maps, areas at the red end of the spectrum
have positive mean surface-distance values and represent an
outward movement, and areas at the blue end have negative
mean surface-distance values and represent an inward move-
ment. Green indicates minor changes with little or no overall
movement [25]. Points were marked in the first molars, first
premolars, canines, centre of resistance of maxilla (CRM)
and nasion (N) (Table 1, Fig. 5), and the displacement was
automatically measured in mm by the software to reduce
operator measurement errors. For all points, positive values
indicated buccal movement, and negative values, lingual
displacement.
Fig. 5  Landmarks for comparisons between sides according to vomer
position using 3DMeshMetrics software
Error of the method

After 2 weeks, six patients (about 30%) were randomly
selected for a repeat evaluation of dehiscence and meas-
urement of landmarks by one of the examiners (FLR) to
assess intra-examiner reliability. Intraclass correlations were
calculated. The kappa coefficient for intra-observer agree-
ment was 0.92 for all measurements with a 95% confidence
interval. Agreement between first and second evaluations
was excellent.
Statistical analysis
vomer had an effect on tooth movement to the right or to
the left side, we subtracted the displacement of each tooth
in the right side from that of the contralateral tooth. The
effect of the vomer on the displacement side was estimated
using multinomial logistic regression for correlated data.
Only shifts greater than 0.5 mm to either side were recorded
because of the precision of CBCT scanning. This analysis
was made using the Fisher exact test. The level of signifi-
cance was set at 0.05.

Multiple surfaces were evaluated for each participant. Data

correlations were analysed using the SUDAAN software
(RTI International, Research Triangle Park, NC) as a call-
able add-on to the SAS 9.3 (SAS Institute Inc., Cary, NC)
statistical package. Variables that were not normally dis-
tributed were compared using the non-parametric Wilcoxon
test for two groups or the Kruskal–Wallis test for two or
more groups. A Poisson regression model for correlated
data with robust estimators of relative risk and a 95% confi-
dence interval (CI) were used for the multivariate analysis of
dehiscence incidence after SARPE. To investigate whether
Results
This study included 21 patients (9 women) aged 15.9 to
54.1 years, with a median age of 27.0 years (24.0–31.9).
The women in all groups were older (mean age = 28.0,
25.8–37.2) than men (mean age = 26.4, 23.2–31.0) but this
difference was not statistically significant (p = 0.39). During
SARPE, vomer position had a similar distribution between
right (52.4%, 11 patients, 5 women and 6 men) and left
(47.6%, 10 patients, 4 women and 6 men) sides. There were

Table 1  Landmarks used Landmarks Description

to compare dental and bone
changes between sides after
SARPE according to vomer
position
Colour maps Models Tip cusp* Point in the MB and B tip cusp
N Point in the most lateral of the nasal cavity (right and left)
CRM Centre resistant of the maxilla between first and second
upper premolars approximately in the middle of the root
*
Points marked in upper first molars, first premolars and canines bilaterally; MB, mesio-buccal; B, buccal
CRM, centre resistant of the maxilla; N, nasal

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 Oral and Maxillofacial Surgery

no differences in vomer position between men and women Table 3  Crude and adjusted relative risks (RR) of incidence of dehis-
(p = 0.72) or age groups (p = 0.15). cence after SARPE
Table 2 shows the distribution of dehiscences at T0 RRcrude ( 95% IC) * p RR adj ( 95% IC) *
(n = 28) and the incidence of dehiscences from T0 to T1
Vomer
(n = 88). Dehiscences were evenly distributed (p = 0.73)
Left 1.00 0.33 1.00 0.40
between the right (18.1%) and the left (16.0%) sides and
Right 1.09 (0.91–1.31) 1.07 (0.91–1.27)
between sides at which vomer was positioned at SARPE
Age (years)
(p = 0.43). Only tooth type was statistically associated with
< 25 1.00 0.50 1.00 0.59
the occurrence of dehiscence (p = 0.00), which was more
25–35 1.01 (0.81–1.25) 0.99 (0.80–1.23)
frequent in molars (22.6%) and premolars (18.4%) than in
> 35 0.90 (0.73–1.11) 0.91 (0.74–1.12)
canines (4.8%). Dehiscence was associated with displace-
Teeth
ment, particularly when greater than 3.20 mm per side
Canine 1.00 0.00 1.00 0.00
(Table 3). Teeth with dehiscence had a greater displacement
1st premolar 6.97 ( 2.73–17.81) 6.86 (2.66–17.7)
(mean: 3.48 mm; 95% CI 3.01–3.95) than those without it
1st molar 6.89 (2.65–17.963) 6.96 (2.69–18.01)
(mean: 3.11 mm; 95% CI 2.69–3.52) (Table 3).
Cusp tip quartiles
The effect of vomer position on expansion was tested
< 2.50 1.00 0.16 1.00 0.52
at T1 because most expansion occurred immediately after
2.51 – 3.46 1.08 (0.75–1.54) 1.00 (0.71–1.42)
SARPE. The effect of vomer position on right or left dis-
3.47 – 4.25 1.44 (0.99–2.08) 1.18 (0.86–1.67)
placement was analysed using multinomial logistic regres-
> 4.26 1.16 (0.79–1.69) 1.19 (0.88–1.61)
sion to compare right and left displacement with no dis-
placement. This analysis revealed that teeth tended to move *
Relative risk and 95% confidence interval
in the same direction as the vomer. If vomer was on the right
side, the odds for movement in the same direction were 3.52
(95% CI 1.92–6.45) times greater than for no displacement

Table 2  Bivariate analysis Total T0 (n = 28/164) Incidence T0–T1 (88/136) p value

of dehiscences at T0 and the
incidence of dehiscence during n % (SE*) p value Total n % (SE)
the study
Age
< 25 55 13 23.6 (5.8) 0.2973 42 28 66.7 (7.2) 0.7309
25–35 56 7 12.5 (4.2) 49 33 67.3 (6.7)
> 35 53 8 15.1 (4.9) 45 27 60.0 (7.4)
Sex
Male 93 13 14.0 (3.2) 0.1251 80 53 66.3 (3.4) 0.5382
Female 71 15 21.1 (3.2) 86 35 62.5 (5.0)
Teeth
Canine 42 2 4.8 ( 3.4) 0.0009 40 5 12.5 (5.6) < .0001
1Pre-molars 38 7 18.4 (4.3) 31 27 87.1 (4.3)
1 Molars 84 19 22.6 (3.6) 65 56 86.1 (4.7)
Side
Right 83 15 18.1 (4.2) 0.7329 68 40 52.8 (6.0) 0.1564
Left 81 13 16.0 (4.1) 68 48 70.6 (5.5)
Vomer
Right 87 13 14.9 (3.8) 0.4374 74 46 62.2 (5.7) 0.4980
Left 77 15 19.5 (4.4) 62 42 67.7 (6.0)
Cuspid displacement
< 2.50 37 9 24.3 (6.0) 0.1075 32 16 51.1 (8.7) 0.6150
2.51–3.46 31 2 6.4 (4.3) 38 18 62.1 (7.7)
3.47–4.25 45 9 20.0 (4.9) 26 25 69.4 (5.7)
> 4.26 51 8 15.7 (5.0) 40 29 67.4 (6.7)
*
SE = standard errors
Note: both SE and p value considering the clustering of dehiscence within sides and individuals

13
Oral and Maxillofacial Surgery
(p < 0.0001). Of patients, 38.5% showed more asymmetric
expansion (1.5 mm) at the first premolar on one side com-
pared the other. A difference of 2 mm in expansion between
sides was found in the groups of molars (20%) and canines
(15.0%). However, there were no statistically significant dif-
ferences between types of teeth.
There was a greater expansion of the nasal cavity (N)
in the side opposite the vomer (p = 0.04). The nasal cavity
moved to the left side in 63.6% of the patients whose vomer
was in the right side, but to the right in 60% of those whose
vomer was in the left side. CRM also moved in the opposite
direction to the vomer. When vomer was in the right side,
81.8% moved to the left.
Discussion
Surgeons and orthodontists use SARPE to treat patients with
transverse maxillary deficiencies. Treatments with conven-
tional technique SARPE include osteotomies of the lateral
walls of the maxilla and a midline fracture. The midline frac-
ture is performed exactly along the midpalatal suture during
surgery, and then, the vomer position with this technique is
unpredictable and the vomer will be in the right or on the
left side after SARPE. Some surgeons have used different
types of corticotomy, such as a triangle or a trapeze, parallel
or not to the occlusal plane [7, 10]. Although these varia-
tions in corticotomy may affect expansion, no studies have
evaluated this. In this study, we tested whether vomer posi-
tion affected expansion and the occurrence of dehiscence.
Defining whether the vomer affects the amount and quality
of expansion should be useful to guide dentists in subsequent
orthodontic treatments. In fact, this study found different
results for teeth, maxilla and nasal cavity according to vomer
position after SARPE.
Some patients had dehiscences before an orthodontic
treatment [17–19], but procedures to achieve expansion may
increase existing dehiscences or create new ones [13, 26].
SARPE usually results in an increase of the palatal alveo-
lar bone and a decrease of buccal bone thickness [11, 13].
In this study, we determined the number of dehiscences in
the first molars, first premolars and canines before (T0) and
immediately after (T1) expansion and analysed the asso-
ciation between expansion and dehiscence. Dehiscences
increased significantly in this interval, with a greater preva-
lence in the first molars and first premolars. These results are
in agreement with those reported by other studies [17–19].
Our findings may be explained by the fact that the teeth
under evaluation were those that support the Hyrax expander
and that receive the force and stress during the activation
of the expander screw. At the same time, the comparison
of number of dehiscences and vomer position according to
side did not reveal any statistically significant differences.
Although the vomer affects the expansion pattern, SARPE
always produces buccal tipping of the crowns and increases
the risk of alveolar defects, such as dehiscences [17, 18].
This study also found a correlation between dehiscence
and expansion, not previously reported, and which may be
of interest in these cases. Our results indicate that there may
be a limit for expansion when SARPE is used. A greater
number of dehiscences were found in the region of teeth
that underwent expansions greater than 3.20 mm. Therefore,
clinical dentists should pay special attention to cases that
require greater expansions to correct posterior crossbites or
maxillary transverse deficiency. In such cases, expansion
should be followed up closely, and the patient should be
aware that dehiscences might increase after SARPE. Follow-
up should include periodontal evaluations during clinical
examinations and should make use of imaging methods,
mainly CBCT, to identify previous conditions and avoid the
side effects of SARPE [13]. Long-term follow-up studies
will be needed to determine whether the resulting dehis-
cences improve, remain the same or deteriorate.
The cusp tips of first molars, first premolars and canines
were the landmarks used to evaluate expansion (Table 1 and
Fig. 5). These teeth, particularly the premolar and the first
molar, were chosen because they receive the tooth-borne
appliance (Hyrax). There was greater displacement (buc-
cal tipping) of teeth to the same side to which the vomer
moved after the separation of the maxillary bone. This
result confirms the occurrence of asymmetric expansions
after SARPE. Asymmetric differences smaller than 1 mm
do not usually indicate a major problem and may be cor-
rected rather easily by simply coordinating archwires. How-
ever, some patients in our study had a difference of 2.0 mm
between sides, particularly in the molar and canine regions.
In other patients, the difference was 1.5 mm. This might
have resulted from the fact that skeletal resistance of the
vomer hindered tooth movement and led to greater tooth
tipping.
The clinical effect of this increased tipping is that it may
lead to a greater expansion relapse in the side where the
vomer is. This would require another expansion or an adjust-
ment of the orthodontic treatment using expansion archwires
to achieve symmetry of the two sides and satisfactory inter-
cuspation at the completion of treatment.
The maxillary bone walls, whose landmark was the
CRM in this study, had a greater displacement to the side
opposite the vomer from T0 to T1. Clinical studies dem-
onstrated that SARPE promotes segmental tipping, but
not movement, which lead to a greater expansion of teeth
than of bone [5, 7]. The same effects were found in our
study, but asymmetric maxillary expansion was assigned
to the presence of the vomer. In the side without a vomer,
there was less expansion and greater inclination, probably
because of the greater resistance to expansion resulting
13

from greater bone support in that side. This study did not
have the objectives to evaluate the stability of results of
the expansion. However, it is worth mentioning that at
the end of retention time, the same positions of bony and
teeth were found.
Some studies using linear measurements found an
increase of the nasal cavity in patients that underwent
SARPE [3, 5, 12]. However, the effect of vomer position
on the nasal cavity after SARPE has not been investigated.
This study used the landmark N in both sides to determine
the width of the nasal cavity after SARPE. A greater dis-
tance between N in the right and in the left was evidence of
an increase in the width of the nasal cavity. This increase
was assigned to the greater displacement of N in the side
opposite the vomer, which confirmed that changes were
affected by the position of this bone. This significant dis-
placement indicated that the vomer is the cause of an asym-
metric increase of the nasal cavity, which may be explained
by the fact that this area is close to the midpalatal suture.
An asymmetric expansion of the nasal cavity might result in
an asymmetric increase of nasal soft tissue and affect facial
aesthetics. However, this has not been confirmed in the lit-
erature [27].
This study had some limitations, such as the relatively
small number of patients, the lack of long-term results, the
age differences between patients and the different occlusal
patterns in the groups of patients before SARPE. However,
this was a retrospective study using a convenience sample,
and, therefore, it was not possible to exclude all confounding
factors. At the same time, the number of participants is simi-
lar to that of other studies in the literature, and our results
showed a statistically significant difference in the number of
dehiscences and in the amount of expansion according to the
position of the vomer. In addition, all patients were treated
using the same surgical technique, same type of expander,
and results were analysed using 3D superimposition of
images on the anterior cranial base. These treatment pro-
tocols ensure that our findings are reproducible and clearly
demonstrate the changes resulting from the use of SARPE.
Conclusions
The null hypotheses were rejected.
1. Tooth tipping was greater in the side where the vomer
was, and the maxilla had greater expansion in the side
opposite the vomer.
2. Teeth expanded asymmetrically, but this asymmetry was
not associated with more dehiscences.
3. Greater expansions produced more dehiscences.
13
Oral and Maxillofacial Surgery
Authors’ contributions 1) Fábio Lourenço Romano: conception or
design of the study; acquisition, analysis or interpretation of data and
statistics; drafting and writing the manuscript; critical revision of the
manuscript; final approval of the manuscript; overall responsibility.
2) Cássio Edward Sverzut: acquisition, analysis or interpretation of
data and statistics; final approval of the manuscript; obtaining funding.
4) Alexandre Elias Trivellato: acquisition, analysis or interpreta-
tion of data and statistics; final approval of the manuscript; obtaining
funding.
5) Maria Conceição Pereira Saraiva: acquisition, analysis or inter-
pretation of data and statistics; final approval of the manuscript.
6) Tung Tahan Nguyen: conception or design of the study; acquisi-
tion, analysis or interpretation of data and statistics; drafting and writ-
ing the manuscript; critical revision of the manuscript; final approval
of the manuscript; overall responsibility.
Data availability Not applicable.
Code availability Not applicable.
Declarations
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