Non-surgical palatal expansion in adult patient: a clinicalcase reportM.M. Pithon
Southwest Bahia University UESB, Bahia, Brazil; Doctor of Orthodontics at the School of Dentistry, Federal University of Rio de Janeiro – UFRJ, Brazil
Abstract
Aim: The objective of the present study was to report a case of non-surgicalpalatal expansion in an adult patient.Report of case: A Hyrax-type expander was mounted onto the six upperteeth of the patient who was instructed to activate the orthodontic appli-ance twice a day at 12 h intervals.Results: After 15 days, suture separation was observed, which was con-firmed by the presence of midline diastema and widening of the radiolucentimage of the suture on occlusal radiograph. Based on this observation, theappliance was further activated for 7 days, thus totalising 21 days of activa-tion and expander screw opening of 10.5 mm.Conclusion: One can conclude that in specific cases, it is possible to obtainan opening of the midpalatal suture in adult patients, thus avoiding surgicalprocedures.
Posterior crossbite is one of the most frequent maloc-clusions in orthodontics1. Possible aetiologies includeprolonged retention or premature loss of deciduousteeth, crowding, palatal cleft, genetic factors, archdeficiencies, abnormalities in tooth anatomy or erup-tion sequence, orodigital habits, mouth breathingduring critical growth periods and a dysfunction of thetemporomandibular joint2,3.
To determine the treatment plan for cases involvingposterior crossbite, it must be decided whether theposterior crossbite is attributed to a true skeletal originor dentoalveolar in origin. Betts et al.4 stated that theposterior crossbite does not confine itself to dentaldysplasias but is more often related to an underlyingskeletal problem.
The correction of transverse maxillary deficienciesproceeds through opening of the midpalatal suture.Maxillary expansion was described by Angell5 and theclinical protocol was established by Haas in 19616.
Rapid maxillary expansion is extremely advanta-geous for the treatment of class III cases of real and
relative maxillary deficiency and of cases of inadequatenasal capacity exhibiting chronic nasal respiratoryproblems7–9.
The procedure has been used effectively in childrenand adolescents to obtain more stability related to theamount of bone expansion and avoidance of toothtipping. In adults, it is frequently associated withfailure. This may be attributed in part to the anatomy ofthe maturing face; the midpalatal suture and adjacentcircummaxillary articulations become more rigid andbegin to calcify in the mid-20s. In order to overcomethe resistance of the adult sutures to expansion, ‘surgi-cally assisted’ rapid maxillary expansion has beenadvocated10,11.
Therefore, the objective of this article was to describea clinical case of palatal expansion in adult patient inwhich the opening of the midpalatal suture was per-formed without needing surgical intervention.
Clinical case
A Caucasian female patient aged 28 years old soughtorthodontic treatment complaining of ‘narrow archand tilted teeth’. The patient’s medical history waschecked. With regard to her general heath status, theHome Page: http://www.matheuspithon.com.br
patient presented with no reported pathology or sys-temic disorder.
The patient presented with a class III malocclusionon a skeletal III base (ANB -2°C) with bilateral poste-rior crossbites and missing teeth lost to caries (16 and26) (Figs 1 and 2).
Initially, the treatment planning was to achieve apalatal expansion surgically in association with con-ventional orthodontic treatment for balancing theocclusal relationship. First, the patient was referred toan oral maxillofacial surgeon so that she could beinformed about the surgical procedure to be per-formed. On the return visit, the patient reported thatshe would be inclined to accept the surgery. However,the patient was told that initially a non-surgical inter-vention would be tried in order to expand her arch, andin the case of unbearable discomfort during the firstweek and enhanced horizontal movement of the teeth,appliance activation would be stopped and then shereferred to surgery soon after.
A modified Hyrax-type expander was used for such aprocedure. These modifications were obtained by using
teeth 17 and 27 instead of teeth 16 and 26 (missingones) and inclusion of teeth 15 and 25 in conjunctionwith teeth 14 and 24.
After cementation of the appliance (Fig. 3), thepatient’s caregiver was instructed to activate the appli-ance twice a day for 7 days at 12 h intervals. After thisperiod of time, the patient returned and complained ofno discomfort or pain, and molar and premolar teethmaintained their position as well. Because of theseresults, the appliance was kept activated for additional7 days. On the 15th day, a palatal suture opening wasobserved, which was confirmed by the presence ofmidline diastema and widening of the radiolucentimage of the suture on occlusal radiograph (Fig. 4).
Based on these observations, the appliance wasfurther activated for 7 days, thus totalising 21 days ofactivation and expander screw opening of 10.5 mm.On the 22nd day, the patient returned for stabilisationof expander appliance with Transbond light-curingcomposite (3M Unitek, Monrovia, CA) for a 6 monthperiod (Fig. 5).
During the stabilisation period, the lower fixedorthodontic appliance was mounted according tothe edgewise technique in order to accelerate thetreatment.
Discussion
In adults, the Haas expander has the ability toexpand the posterior dentition with its alveolarhousing, perhaps by bending the alveolus with boneremodeling11,12. This outcome is also expected whena Hyrax-type appliance is used. Handelman13 sug-gested that after the age of 18, it is often impossibleto open the midpalatal suture. However, increasedanchorage by bands in the second premolars favoursan increase in the orthopaedic effect10. This appliancecan increase the possibility of opening the midpalatalsuture, and by keeping this idea in mind, we havetried to open the midpalatal suture with no surgicalintervention.
Figure 3 Photographs following cementation of expander.
Ribeiro et al.10 have achieved palatal expansion withno surgical intervention by using a modified Hass-type appliance in which all premolars and first uppermolars were banded, and the second molars wereincorporated by bonding a wire segment extendingfrom the appliance’s acrylic base to their palatalsurfaces.
However, in our case, the Hyrax-type appliancewas chosen because of the possibility of surgery if nosuture opening can be achieved and ease of oralhygiene maintenance. The Hyrax-type expander isthe best option when there is a possibility of surgicalintervention.
In order to increase the support for optimal distri-bution of the screw forces, six upper teeth werebanded instead of using four teeth as usual. Thisincreased anchorage allows forces to be better dis-tributed, thus avoiding overload on these teeth andpossible fracture of the buccal bone plate and gingivalretractions.
One fundamental point regarding the use of non-surgical midpalatal expander in adult patients is thatthey should be informed that the outcome is not guar-anteed, and in the event of failure, surgical-assistedexpansion is the only option to perform the expansion.With this in mind, the patient was initially told that theonly way of achieving a successful correction would bethrough surgery. Therefore, the patient was preparedfor a surgical intervention. The patient was referred toan oral maxillofacial surgeon who explained the detailsof the procedure as well as post-operative complica-tions and side effects.
The decision for a non-surgical intervention wasbased on the fact that the supporting teeth were freeof gingival recessions and had good bony supportand free of disease. Thus, if the suture was notopened despite dental tipping, the roots would not beexposed.
This kind of procedure requires increased clinicalattention, and in our case, the patient attended theclinic every week and the orthodontist called her everyday to find out if there was any discomfort. This care isimportant to detect and prevent possible undesirableand irreversible effects from occurring.
After achieving the midpalatal suture opening,the expander screw was stabilised in order to keepits positioning. Stabilisation lasted 6 months, whichwas enough to allow bone maturation in the area ofrecently expanded midpalatal suture.
The use of a modified Hyrax appliance with increasedanchorage was thus shown to be effective for correctingmaxillary deficiency in patients with suture matura-tion. These findings suggest that some precautions
must be taken, including knowing the skeletal age andthe patient’s level of cooperation. If these factors aretaken into account, satisfactory results can likely bereached, with improved function and aesthetics and aminimal morbidity.
Conclusion
According to the findings described in this clinicalreport, one can conclude that non-surgical interven-tion in adult patients can be performed if judiciouslyindicated, thus favouring a transverse correction of themaxilla without the drawbacks of the orthognathicsurgery.
References
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