Microsoft Word - Carlini 37 10-8.docx   Vol  3,  No  1  (2015)   ISSN  2167-­‐8677  (online)   DOI  10.5195/d3000.2015.37           http://dentistry3000.pitt.edu     New  articles  in  this  journal  are  licensed  under  a  Creative  Commons  Attribution  4.0  United  States  License.     This  journal  is  published  by  the  University  Library  System,  University  of  Pittsburgh  as  part  of  its  D-­‐Scribe  Digital  Publishing  Program  and  is  cosponored   by  the  University  of  Pittsburgh  Press.   Modification  of  the  technique  of  osteotomy  for  surgical  maxillary   expansion   João  Luis  Carlini1,  Cris%na  Rieth2,  Danielle  Del  Santo  Severo2,  Kesia  Keiko  Asami2     1Oral  and  Maxillofacial  Surgery,  Chief  of  Stomatology  Departament,  Professor  at  Federal  University  of  Paraná,  Staff  of  CAIF  –  Center  for  Integral  Assistance  of  Cle1  Lip   and  Palate  Pa)ents,  Curi#ba,  Paraná,  Brazil   2Dental  Surgeon,  School  of  Dental  Medicine  at  Federal  University  of  Paraná,  Curi*ba,  Paraná,  Brazil     Abstract   Surgically  assisted  maxillary  expansion   is  a   technique  used   to  correct   transverse  maxillary   deficiency,  which   is  a  dentofacial  anomaly  related  to  the  decrease  of   the  upper  arch  over   the  lower  arch.  It  is  applied  to  pa1ents  in  their  late  teens  and  adults  due  to  skeletal  maturi-­‐ ty,  causing  oblitera1on  of  the  intermaxillary  suture,  which  requires  orthodon1c  procedure,   associated  with  surgery.  The  purpose  of  this  study  is  to  report  the  clinical  case  of  a  pa6ent   admi%ed  for  surgical  maxillary  expansion  through  the  modified  technique  and  point  out  the   possible   advantages,   such   as   aesthe3cs  maintenence,   long-­‐term   stability,   faster   return   to   orthodon'c   treatment,  and   improved  bone  healing.  However,   there  are   some  contraindi-­‐ ca#ons  when  the  pa#ent  presents  severe  crowding,  roots  of  the  canine  and  lateral   incisor   are  converging  and  in  pa-ents  who  will  undergo  to  protrac-on  with  facial  mask.   Cita%on:   Carlini   J,   Rieth   C,   Severo   D,   Asami   K.   (2015)  Modifica(on  of   the   technique  of  osteot-­‐ omy   for   surgical   maxillary   expansion.   Den$stry   3000.  1:a001  doi:10.5195/d3000.2015.37   Received:  July  29,  2015   Accepted:    September  17,  2015   Published:    October  23,  2015   Copyright:  ©2015   Carlini   J,   Severo   D,  Asami   K.   This   is   an   open   access   ar!cle   licensed   under   a   Crea%ve  Commons  A"ribu%on  Work  4.0  United   States  License.   Email:  kka12@pi(.edu   Introduction     The  transverse  maxillary   deficiency  has  a  multifactorial  etiol-­‐ ogy,  and  it  is  associated  with  func-­‐ tional  and  aesthetic  commitment.   The  diagnosis  is  established   through  clinical  exams,  X-­‐rays,  and   model  study  [1].     The  patients  who  need  or-­‐ thodontic  and/or  surgical  maxillary   expansion  frequently  present  a  typ-­‐ ical  vertical  pattern:  long  facial   height  anterior  inferior,  high  palate,   low  tongue  posture,  incompetent   lips,  and  mouth  breathing  [2],  uni-­‐ lateral  or  bilateral  cross  bite,  and   anterior  crowding  [3-­‐6].     The  maturity  of  the  patient’s   skeleton  and  the  amount  of  expan-­‐ sion  expected  are  crucial  to  choose   the  technique  to  be  performed  to   correct  the  transverse  discrepancy   jaw  [3,  7,  8].  Another  relevant  as-­‐ pect  to  be  assessed  is  the  magnitude   of  the  transverse  jaw  discrepancy   [4-­‐6].     Following  Hass  (1980),  in   order  to  correct  the  atresia  skeletal   jaw,  it  is  necessary  a  treatment  that   does  not  only  move  teeth,  but   changes  the  position  of  the  alveolar   bone  processes,  teeth,  and  conse-­‐ quently  the  jaw  segments.     The  rapid  maxillary  expan-­‐ sion  (RME),  using  breakers  only,  is   one  of  the  techniques  indicated  to   treat  transversal  maxillary  deficien-­‐ cy  orthopedic  and  it  has  a  history   over  145  years.  Introduced  by  An-­‐ gell  [10,  11],  it  allows  the  treatment   of  transversal  discrepancy  in  skele-­‐ tally  immature  patients  [3-­‐6,  12,  13]   trough  the  power  emitted  by  the   expander,  opening  the  palatal  su-­‐ ture  and  making  the  jaw  expand   [12].     In  adult  patients,  who  have   transverse  maxillary  hypoplasia   unilateral  or  bilateral,  the  effective   form  of  treatment  is  the  surgically   assisted  rapid  maxillary  expansion   (SARME),  a  combination  of  ortho-­‐ dontics  and  surgery.  Because  of   skeletal  maturity,  there  is  an  in-­‐ crease  in  secondary  bone  interdigi-­‐ tation,  and  fusion  of  palatal  suture   [4-­‐8,  13,  14].  This  procedure  releas-­‐ es  the  resistance  sites  [4-­‐8,  10,  12,   15,  16].      Modifica(on  of  the  technique  of  osteotomy  for  surgical  maxillary  expansion   Vol  3,  No  1  (2015)        DOI  10.5195/d3000.2015.37    http://dentistry3000.pitt.edu   2     The  purpose  of  this  paper  is   to  assess  the  efficiency  of  the  surgi-­‐ cal  technique  modification,  demon-­‐ strated  with  a  case  report,  in  which   the  osteotomy  is  performed  be-­‐ tween  the  lateral  incisors  and  ca-­‐ nines,  Fig.  5.  Performing  the  modi-­‐ fied  technique,  it  was  possible  to   analyze  several  positive  aspects,   such  as:  increased  stability  of  the   correction  in  long  term,  optimized   bone  healing  due  to  the  increased   production  of  calluses,  faster  return   to  orthodontics  treatment,  mini-­‐ mum  periodontal  hazard,  it  pre-­‐ vents  the  shift  of  the  midline,  and   the  aesthetic  is  maintained  by  split-­‐ ting  the  diastema  generated  in  two   points,  as  you  can  see  in  Fig.  9  Dif-­‐ ferent  from  the  conventional  tech-­‐ nique,  where  the  diastema  is  single   and  between  central  incisors,  as  it  is   shown  in  Fig.  9.       Case  Report       Female  patient,  23  years   old,  was  referred  by  her  orthodon-­‐ tist  with  transverse  maxillary  defi-­‐ ciency,  illustrated  in  Fig.  1.  The  di-­‐ agnosis  was  based  on  X-­‐  rays,  Fig.  8,   clinical  exam  and  evaluation  of  plas-­‐ ter  models.  A  Hyrax  expander  was   used  for  one  week  to  try  to  open  the   palatal  bone  suture  without  sur-­‐ gery,  but  it  failed  (Fig.  2).     The  patient  was  submitted   to  pre-­‐operative  routine  laboratory   tests;  blood  tests,  electrocardio-­‐ gram,  chest  X-­‐ray,  and  also  a  pre   anesthetic  consultation,  then  she   was  released.  She  was  admitted  on   the  day  of  surgery,  under  general   anesthesia  and  nasotracheal  intuba-­‐ tion.  The  surgery  went  as  follows:  in   the  back  of  the  vestibule,  it  was  in-­‐ cised  with  15  scalpel  blades,  ex-­‐ tending  from  the  second  pre  molar   until  the  second  pre  molar  contrala-­‐ teral.  After  detached  the  perioste-­‐ um,  the  pyriform  aperture  and  the   zygomatic  pillar  were  exposed.   Then  the  nasal  mucous  membrane   was  detached  and  tunneled  to  the   posterior  region  until  the  maxillary   tuberosity,  where  the  reverse  re-­‐ tractor  Langenbeck  was  adapted.   Protecting  the  nasal  mucosa,  with   shifter  Molt  the  osteotomy  with  re-­‐ ciprocating  saw  was  performed;   starting  from  the  tuberosity,  a  sec-­‐ tion  was  made  5  mm  above  the   roots  of  the  teeth.  The  osteotomy   was  performed  on  the  entire  side   wall  of  the  maxillary  sinus  and  the   region  of  the  piriform  aperture,   being  bicortical,  Fig  4.  Using  the   curved  chisel,  it  promoted  the   separation  of  the  blade  pterygoid   of  the  tuberosity  of  the  maxilla.   With  a  single  guide  chisel,  the  me-­‐ dial  wall  of  the  maxillary  sinus   was  broken  and  with  the  double   guide  chisel,  the  nasal  septum  was   separated.  Then  the  flap  was  dis-­‐ placed  in  the  region  between  the   canine  and  the  lateral  incisor  until   the  inserted  gingiva,  tunneling  until   the  cervical  of  the  teeth  was  per-­‐ formed.  Using  the  reciprocating   saw,  the  osteotomy  was  done  with  a   blade  of  0.5  mm  thick,  illustrated  in   Fig.  5,  leaving  from  the  piriform  ap-­‐ erture  toward  the  cervical  of  the   teeth,  protecting  the  palatal  mucosa   with  the  index  finger.  The  osteoto-­‐ my  extended  about  5  mm  below  the   alveolar  crest  interdental,  seen  in   Fig.  6.  For  subsequent  region,  after   detaching  the  nasal  mucosa,  the  re-­‐ ciprocating  saw  was  in  the  most   posterior  position,  then  the  osteot-­‐ omy  was  complemented  with  a   straight  chisel  to  the  posterior  edge   of  the  jaw.  Similarly,  we  use  the   chisel  to  complete  the  osteotomy   between  the  teeth,  always  protect-­‐ ing  the  palatal  mucosa  and  then  it   was  taken  into  occlusion  to  observe   the  positioning  of  the  teeth.  The   breaker  was  activated  to  observe  if   the  expansion  occurred  symmetri-­‐ cally,  as  shown  in  Fig.  7.  If  this  was   not  happening,  it  would  be  im-­‐ portant  go  over  the  chisel  in  all  os-­‐ teotomies.  The  screw  breaker  was   turned  off  and  we  sutured  the   wound  with  wire  vicryl  4-­‐0.       The  time  of  surgery  was  50   minutes,  and  the  patient  was  dis-­‐ charged  the  same  day.  The  postop-­‐ erative  care  consisted  of  ice  packs   on  the  face,  three  days  of  a  liquid   diet,  followed  by  pasty-­‐liquid,  saline   solution  for  cleaning,  and  anti-­‐    Modifica(on  of  the  technique  of  osteotomy  for  surgical  maxillary  expansion   Vol  3,  No  1  (2015)        DOI  10.5195/d3000.2015.37    http://dentistry3000.pitt.edu   3   inflammatory  and  analgesic  for   three  days.  After  seven  days  the  pa-­‐ tient  was  re-­‐evaluated  in  the  clinic   and  she  started  activating  the   breaker,  with  activation  ¼  turn  in   the  morning  and  ¼  turn  in  the  af-­‐ ternoon.  After  a  week  the  patient   was  referred  to  the  orthodontist  to   control  the  extent  of  maxillary  ex-­‐ pansion.       The  control  of  bone  healing   was  performed  by  occlusal  radio-­‐ graphs.  After  30  days,  seen  in  Fig.  8,   and  after  three  months,  which  cal-­‐ lus  formation  was  observed.  Then   the  orthodontist  removed  the   breaker  and  began  the  orthodontic   treatment,  Fig.  8  and  Fig  9.    No  se-­‐ quel  was  observed  after  surgery,   such  as  gingival  retraction,  tooth   roots  injury,  no  bone  callus  for-­‐ mation  or  recurrence  that  could   compromise  the  result.     The  measurement  was  per-­‐ formed  on  plaster  models,  preoper-­‐ atively  and  postoperatively,  using   calibrated  caliper.  We  analyzed  the   interdental  distances  between  cen-­‐ tral  fossae  of  the  upper  first  molars   and  the  palatal  portion  of  the  upper   canines,  Table  1.     Discussion       The  success  of  treatment   depends  on  correct  diagnosis,  ana-­‐ tomical  knowledge  and  selection  of   the  correct  technique.  To  treat  adult   patients  with  maxillary  atresia,  sur-­‐ gically  assisted  disjunction  has   demonstrated  excellent  results  as  a   complementary  method  to  ortho-­‐ dontic  treatment,  where  the  surgery   is  to  relieve  the  resistance  of  bone   structure  to  the  expansive  forces.       There  are  several  authors   who  describe  the  techniques  for   rapid  maxillary  expansion.  These   techniques  are  diversified  according   to  age,  advocated  osteotomies,  local   aspects,  etc  [12].  Age  is  a  factor  to   be  considered  before  performing   the  surgical  expansion  because  with   increasing  age,  the  probability  of   decrease  in  the  bone  support  is   higher  and  thus  the  power  emitted   by  the  expander  is  not  transmitted   to  the  intermaxillary  bone  or  other   skeletal  structure,  but  for  teeth,  that   may  cause  extrusion  of  teeth,  and   the  skeletal  expansion  is  reduced   [17].       Although  there  is  no  con-­‐ sensus  regarding  the  extension  of   the  surgery,  the  vast  majority  of  au-­‐ thors  cite  the  nasomaxillary,  pala-­‐ tine,  and  zigomaticomaxilar  osteot-­‐ omies  as  indispensable.  However,   pterygomaxillary  disjunction  is  not   always  included  [16].  Seeberger  et   al.  (2010)  concluded  in  his  work   that  even  without  the  pterygomaxil-­‐ lary  disjunction,  it  is  possible  to   achieve  an  expansion  with  stable   bite.  Laudemann  et  al.  (2009,  2010,   2011)  mentioned  that  this  maneu-­‐ ver  can  be  potentially  dangerous   and  can  lead  intra-­‐  and  extracranial   complications  such  as  severe  bleed-­‐ ing  or  injury  of  the  internal  jugular   vein  or  the  internal  carotid  artery,   caused  by  displaced  fragments  of   the  pterygoid  plate  or  by  the  chisel   during  pterygomaxillary  disjunc-­‐ tion.       Regarding  the  technique,  in   this  study  we  chose  the  modified   technique,  in  which  the  osteotomy   is  performed  between  the  lateral   incisors  and  canines,  instead  of  be-­‐ tween  the  central  incisors.  Even   though  we  performed  the  ptery-­‐ gomaxillary  disjunction,  there  were   no  complications  regarding  this   maneuver.       In  the  study  of  Landes  et  al.   (2009,  2012),  the  minimum  dis-­‐ tance  between  the  roots  of  the  lat-­‐ eral  incisors  and  canines  with  95%   reliability  to  perform  the  modified   technique  was  1.4mm,  however,  in   clinical  practice  it  has  been  ob-­‐ served  that  with  a  measure  of  1.2   mm  is  already  possible  to  perform   modified  technique  of  maxillary  ex-­‐ pansion  without  major  damage.  In   the  present  study  the  distance  of   1mm  was  considered  safe  to  per-­‐ form  the  procedure.  That  is  because   the  reciprocating  saw  blades  are   0.5mm,  and  the  visualization  of  the   root  protuberances,  especially  the   canines,  assist  in  the  location  of  the   osteotomy.      Modifica(on  of  the  technique  of  osteotomy  for  surgical  maxillary  expansion   Vol  3,  No  1  (2015)        DOI  10.5195/d3000.2015.37    http://dentistry3000.pitt.edu   4     Landes  et  al.  (2009,  2012)   used  the  piezo  device  in  their  study,   arguing  there  was  less  damage  to   the  tooth  roots,  compared  to  recip-­‐ rocating  saw  that  we  used  in  this   study.  We  believe  it  is  a  great  option   for  the  execution  of  this  technique   because  the  piezo  is  much  less   traumatic.  However  the  time  for  the   execution  is  much  higher  when   compared  with  the  reciprocating   saw,  but  this  depends  on  the  sur-­‐ geon's  skill.    According  to  Gauthier   et  al.  (2001),  the  surgical  maxillary   expansion,  when  it  releases  the  re-­‐ sistance  between  the  intermaxillary   suture,  produces  minimum  perio-­‐ dontal  hazard.  In  the  present  study,   the  same  conclusion  was  found.  It  is   worth  remembering  that  the  pa-­‐ tients  who  underwent  surgery  had   a  healthy  periodontal  condition  and   sufficient  posterior  dental  support.   However,  Sanromán  et  al.  (2010)   mentioned  that  tailored  devices  are   an  alternative  to  a  stable  expansion   achieved  in  adult  patients  who  have   poor  periodontal  quality  and  low   posterior  dental  support.   Other  advantage  of  the  surgical   maxillary  expansion  is  that  it  pro-­‐ vides  the  patient  an  enlargement  of   the  nasal  air  passages,  due  to  lateral   repositioning  of  the  lateral  nasal   walls,  thereby  improving  nasal   breathing  [7,  8,14,18].  In  this  study   the  patient  had  significant  im-­‐ provement  in  breathing  after  being   submitted  to  maxillary  expansion   surgery.     Similar  to  the  work  of   Anttila  et  al.  (2004),  in  this  study   the  patient  succeeded  in  transverse   maxillary  expansion.  Another  im-­‐ portant  observation  of  Anttila  et  al.   (2004)  that  was  also  observed  in   this  study  is  the  fact  that  the  sup-­‐ port  bone  of  teeth  must  not  be   compromised,  this  being  so,  it  is  a   prerequisite  to  achieve  success  in   this  surgical  procedure.     Another  factor  to  be  consid-­‐ ered  is  the  type  of  breaker.  Hyrax   breaker  can  increase  the  pressure   on  the  teeth  because  the  support  is   only  on  the  teeth.  When  opting  for   Hass  breaker,  where  there  is  also  a   support  in  the  palatal  mucosa,  this   issue  is  minimized.  In  this  case  we   used  the  Hyrax  expander   for  ease  of  cleaning,  less   compression  of  the  palatal   mucosa,  and  the  fact  that   osteotomies  were  checked   to  observe  possible  points   of  resistance.     General  anesthesia,  as  cited   Alfaro  et  al.  (2010),  is  clas-­‐ sically  advocated  for  per-­‐ forming  the  SARME,  since  ptery-­‐ gomaxillary  disjunction  becomes   potentially  traumatic  to  the  patient;   it  is  performed  only  with  sedation.   For  this  reason,  in  this  study,  all   surgical  procedures  were  per-­‐ formed  with  patients  under  general   anesthesia.       It  is  important  to  note  that   comparisons  between  dimensions   achieved  through  the  expansion  of  a   study  and  another  are  irrelevant,   since  the  requirements  may  vary   from  patient  to  patient.  What  is  rel-­‐ evant  is  to  obtain  an  adequate  ex-­‐ pansion  to  correct  a  cross  bite  or   any  other  occlusal  patient's  need  in   a  specific  case  [19].     Conclusion       Surgically  Assisted  Rapid   Maxillary  Expansion  has  proven  to   be  an  effective  and  reliable  tech-­‐ nique  to  treat  maxillary  transverse   deficiency  in  adolescent  and  adult   patients.  SARME  has  shown  several   advantages,  such  as  a  stable  proce-­‐ dure,  with  minimum  periodontal   hazard;  improved  aesthetics  seen  in   the  immediate  post-­‐operative,  by   splitting  the  diastema  generated  in   two  points;  early  return  for  ortho-­‐ dontic  treatment,  and  improved  na-­‐ sal  breathing.        Modifica(on  of  the  technique  of  osteotomy  for  surgical  maxillary  expansion   Vol  3,  No  1  (2015)        DOI  10.5195/d3000.2015.37    http://dentistry3000.pitt.edu   5     References   1.   Avaliação  clínica  dos  pro-­‐ cedimentos  de  expansão  cirurgi-­‐ camente  assistida  da  maxila   (ECAM).  Clinical  evaluation  of  sur-­‐ gically  assisted  maxillary  expansion   (SAME).  Paulo  Domingos  Ribeiro   Jr.I;  Eduardo  Sanches  GonçalesII;   Paulo  César  Ulson  de  SouzaIII;  Hugo   Nary  FilhoIV;  João  Gualberto   Cerqueira  LuzV  .  Rev.  Dent.  Press   Ortodon.  Ortop.  Facial  vol.11  no.1   Maringá  Jan./Feb.  2006.  Paulo  Do-­‐ mingos  Ribeiro  Jr.I;  Eduardo   Sanches  GonçalesII     2.   Nasal  cavity  size,  airway   resistance,  and  subjective  sensation   after  surgically  assisted  rapid  maxil-­‐ lary  expansion:  a  prospective  longi-­‐ tudinal  study.  Magnusson  A,  Bjerk-­‐ lin  K,  Nilsson  P,  Jönsson  F,  Mar-­‐ cusson  A.  Am  J  Orthod  Dentofacial   Orthop.  2011  Nov;140(5):641-­‐51.   doi:  10.1016/j.ajodo.2010.11.024.   PMID:  22051484   3.   Periodontal  effects  of  surgi-­‐ cally  assisted  rapid  palatal  expan-­‐ sion  evaluated  clinically  and  with   cone-­‐beam  computerized  tomogra-­‐ phy:  6-­‐month  preliminary  results.   Gauthier  C,  Voyer  R,  Paquette  M,       Rompré  P,  Papadakis  A.  Am  J  Or-­‐ thod  Dentofacial  Orthop.  2011   Apr;139(4  Suppl):S117-­‐28.  doi:   10.1016/j.ajodo.2010.06.022.   PMID:  21435529   4.   Evaluation  of  surgically  as-­‐ sisted  rapid  maxillary  expansion   with  or  without  pterygomaxillary   disjunction  based  upon  preopera-­‐ tive  and  post-­‐expansion  3D  com-­‐ puted  tomography  data.  Laude-­‐ mann  K,  Petruchin  O,  Mack  MG,   Kopp  S,  Sader  R,  Landes  CA.  Oral   Maxillofac  Surg.  2009   Sep;13(3):159-­‐69.  doi:   10.1007/s10006-­‐009-­‐0167-­‐3.   PMID:  19714376   5.   Long-­‐term  3D  cast  model   study:  bone-­‐borne  vs.  tooth-­‐borne   surgically  assisted  rapid  maxillary   expansion  due  to  secondary  varia-­‐ bles.  Laudemann  K,  Petruchin  O,   Nafzger  M,  Ballon  A,  Kopp  S,  Sader   RA,  Landes  CA.  Oral  Maxillofac  Surg.   2010  Jun;14(2):105-­‐14.  doi:   10.1007/s10006-­‐009-­‐0194-­‐0.   PMID:  20108107   6.   Assessment  of  surgically   assisted  rapid  maxillary  expansion   regarding  pterygomaxillary  disjunc     tion  using  thin  volume-­‐rendering   technique:  in  variance  analysis  and   in  reliability,  accuracy,  and  validity.   Laudemann  K,  Santo  G,  Revilla  C,   Harth  M,  Kopp  S,  Sader  RA,  Landes   CA.  J  Oral  Maxillofac  Surg.  2011   Oct;69(10):2631-­‐43.  doi:   10.1016/j.joms.2010.12.007.  Epub   2011  Apr  7.  PMID:  21474227   7.   Comparison  of  bipartite   versus  tripartite  osteotomy  for   maxillary  transversal  expansion   using  3-­‐dimensional  preoperative   and  postexpansion  computed  to-­‐ mography  data.  Landes  CA,  Laude-­‐ mann  K,  Petruchin  O,  Mack  MG,   Kopp  S,  Ludwig  B,  Sader  RA,  Seitz  O.   J  Oral  Maxillofac  Surg.  2009   Oct;67(10):2287-­‐301.  doi:   10.1016/j.joms.2009.04.069.  PMID:   19761925   8.   Advantages  and  limits  of  3-­‐ segment  (paramedian)  versus  2-­‐ segment  (median)  surgically  assist-­‐ ed  rapid  maxillary  expansion   (SARME).  Landes  CA,  Laudemann  K,   Petruchin  O,  Revilla  C,  Seitz  O,  Kopp   S,  Ludwig  B,  Sader  RA.  Oral  Surg   Oral  Med  Oral  Pathol  Oral  Radiol.   2012  Jan;113(1):29-­‐40.  doi:   10.1016/j.tripleo.2011.01.013.   Table  1.  Canine  /  Molar  Relation     Pre-operative Post-operative Canine 24 mm 29 mm Molar 25 mm 34 mm    Modifica(on  of  the  technique  of  osteotomy  for  surgical  maxillary  expansion   Vol  3,  No  1  (2015)        DOI  10.5195/d3000.2015.37    http://dentistry3000.pitt.edu   6   Epub  2011  Mar  31.  PMID:   22677689   9.   Long-­‐term  posttreatment   evaluation  of  rapid  palatal  expan-­‐ sion.  Haas  AJ.  Angle  Orthod.  1980   Jul;50(3):189-­‐217.  No  abstract   available.  PMID:  6996533   10.   Stability  in  dental  changes   in  RME  and  SARME:  a  2-­‐year  follow-­‐ up.  Sokucu  O,  Kosger  HH,  Bicakci   AA,  Babacan  H.  Angle  Orthod.  2009   Mar;79(2):207-­‐13.  doi:   10.2319/031808-­‐155.1.  PMID:   19216605   11.   Surgically  assisted  rapid   maxillary  expansion:  a  comparison   of  technique,  response,  and  stabil-­‐ ity.  Northway  WM,  Meade  JB  Jr.  An-­‐ gle  Orthod.  1997;67(4):309-­‐20.   PMID:  9267580   12.   Minimally  invasive  surgical-­‐ ly  assisted  rapid  palatal  expansion   with  limited  approach  under  seda-­‐ tion:  a  report  of  283  consecutive   cases.  Hernandez-­‐Alfaro  F,  Mareque   Bueno  J,  Diaz  A,  Pagés  CM.  J  Oral   Maxillofac  Surg.  2010   Sep;68(9):2154-­‐8.  doi:   10.1016/j.joms.2009.09.080.  Epub   2010  Jul  2.  PMID:  20584567   13.   Surgically  assisted  rapid   palatal  expansion  (SARPE).  God-­‐ dard  R,  Witherow  H.  Br  J  Oral  Maxil-­‐ lofac  Surg.  2011  Jan;49(1):65-­‐6.  doi:   10.1016/j.bjoms.2009.11.013.  Epub   2010  Feb  18.  No  abstract  available.   PMID:  20170994   14.   Transverse  maxillary  dis-­‐ traction  in  patients  with  periodon-­‐ tal  pathology  or  insufficient  tooth   anchorage  using  custom-­‐made  de-­‐ vices.  Fernández-­‐Sanromán  J,  Do-­‐ nascimento  MG,  López  AC,  Ferro   MF,  Berrondo  IA.  J  Oral  Maxillofac   Surg.  2010  Jul;68(7):1530-­‐6.  doi:   10.1016/j.joms.2009.09.074.  Epub   2010  Apr  22.  PMID:  20417007   15.   Long  term  effects  of  surgi-­‐ cally  assisted  rapid  maxillary  ex-­‐ pansion  without  performing  osteot-­‐ omy  of  the  pterygoid  plates.   Seeberger  R,  Kater  W,  Davids  R,   Thiele  OC.  J  Craniomaxillofac  Surg.   2010  Apr;38(3):175-­‐8.  doi:   10.1016/j.jcms.2009.07.003.  Epub   2009  Aug  5.  PMID:  19660962   16.   Changes  in  nasopharyngeal   airway  following  orthopedic  and   surgically  assisted  rapid  maxillary   expansion.  Kurt  G,  Altuğ-­‐Ataç  AT,   Atac  MS,  Karasu  HA.  J  Craniofac   Surg.  2010  Mar;21(2):312-­‐7.  doi:   10.1097/SCS.0b013e3181cf5f73.   PMID:  20186094   17.   Feasibility  and  long-­‐term   stability  of  surgically  assisted  rapid   maxillary  expansion  with  lateral   osteotomy.  Anttila  A,  Finne  K,  Keski-­‐ Nisula  K,  Somppi  M,  Panula  K,  Pel-­‐ tomäki  T.  Eur  J  Orthod.  2004   Aug;26(4):391-­‐5.  PMID:  15366383   18.   Changes  in  nasal  volume   after  surgically  assisted  bone-­‐borne   rapid  maxillary  expansion.  Deeb  W,   Hansen  L,  Hotan  T,  Hietschold  V,   Harzer  W,  Tausche  E.  Am  J  Orthod   Dentofacial  Orthop.  2010   Jun;137(6):782-­‐9.  doi:   10.1016/j.ajodo.2009.03.042.   PMID:  20685533   19.   Correção  das  deficiências   transversas  e  ântero-­‐posteriores  da   maxila  em  pacientes  adultos  /  Max-­‐ illary  anteroposterior  and  trans-­‐ verse  problems  correction  in  adult   patients.  Carlini,  João  Luiz;  Biron,   Cássia;  Gomes,  Kelston  Ulbricht;   Gebert,  Andréa;  Strujak,  Guilherme.   Rev.  dent.  press  ortodon.  ortopedi.   facial;  12(5):  92-­‐99,  set.-­‐out.  2007.   ilus,  tab.  Artigo  em  Português  |  LI-­‐ LACS  |  ID:  lil-­‐465909.