Aao 109th annual_session_boston_2009_closer look at the stability of sarpe 2009_sarpe_sylvain_chamberland_orthodontiste_quebec

A Closer Look at the Stability of
Surgically-Assisted Rapid Palatal
Expansion
JOMS 66 : 1895-1900, 2008

109th Annual Session
American Association of Orthodontists
Boston
2009
Dr Sylvain Chamberland, DMD, Cert. Ortho., M.Sc.
Diplomate of ABO
Fellow of RCDC(c)
Member of EHASO

©Sylvain Chamberland

The Research Problem
Is the expansion obtained with SARPE more
stable than the expansion obtained with a
multi-segmented Le Fort 1?

Cases most likely treated with a multi-
segmented Le Fort 1 osteotomy
©Dr Sylvain Chamberland

The Research Problem

“ How much of the expansion that we put
in the screw is transferred to the bone? ”

Dr.Vanarsdall, personal communication
AE meeting, 2003
Lino et al, J Cranio Surg, 2008


Goal of this Research


• Provide data from the maximum expansion
point to the end of the orthodontic
treatment for short term relapse and stability


• Document post-surgical changes with
SARPE, differentiating dental and skeletal
outcomes


• Document post-surgical changes with
SARPE, differentiating dental and skeletal
outcomes
• Provide data 2 years into retention for long
term stability

Hierarchy of Stability

Profﬁt WR, Fields HW, Sarver DM, Contemporary Orthodontics, 4e ed, St-Louis :
Mosby Elsevier, 2007, p. 715

Hierarchy of Stability
• Multi-segmented Le Fort 1
! The least stable of orthognathic surgery

Profﬁt WR, Fields HW, Sarver DM, Contemporary Orthodontics, 4e ed, St-Louis :
Mosby Elsevier, 2007, p. 715

Multi-segmented
Le Fort 1 &
Expansion
• Average 50% loss of surgical expansion
• Relapse > 2 mm in 66% of the patients
• 28% had > 3 mm relapse
• Concurrent mandibular surgery
! Greater relapse at 2nd, 1st molar and 2nd premolars
(p< .02)
Int J Adult Ortho Orthognath Surg
1992; 7: 139-146

Multi-segmented
Le Fort 1 & m
Expansion m
9 9± 2 m ,55 m
=3 surgical expansion
• Average 50% loss of= 4,2 ± 1,5
n
• on 1 of
Relapse > 2 mm in 66%,97the patients
si =
an se
p p
x> 3 mm relapse
• 28%nhad rela
e
ea an mandibular surgery
•M Me
Concurrent
! Greater relapse at 2nd, 1st molar and 2nd premolars
(p< .02)
Int J Adult Ortho Orthognath Surg
1992; 7: 139-146

Early papers on SARPE stability used
those data to recommend SARPE as a 1st
stage of treatment when repositionning of
the maxilla in all 3 dimensions is planned


Relevance
• SARPE + 1 piece Le Fort 1
! Easier than segmental Le Fort 1
! Silverstern & Quinn, JOMS 1997

! Reduce the need of extraction

! Less morbidity
! (Le Fort 1) Lanigan et al 1990, (SARPE) Lanigan & Mintz, 2002

! But 2 general anesthetics


Le Fort 1 Morbidity
A

• Pulpal necrosis

B

• Periodontal defects


Le Fort 1 Morbidity
• Aseptic necrosis
! Most likely to occur with Le
Fort 1 osteotomies done in
multiple segments in
conjonction with superior
repositioning and transverse Courtesy of Dr Brian Alpert
expansion

Lanigan et al, J Oral Maxillofac Surg 48: 142-156, 1990


SARPE Morbidity
•
A B

Nasopalatal cyst

A B

• Fibrous healing


SARPE Morbidity
• Asymmetric fracture of interdental septum + gingival
defect

Cureton SL, Cuenin M, AJODO, 1999

• Non-separation of the pterygoid junction or
attempting too much expansion (3mm)
intraoperatively may lead to aberrant fracture that can
run to the base of the skull, orbit and pterygopalatine
fossa
Lanigan DT, Mintz SM, J Oral Maxillofac Surg 60: 104-110, 2002


Relevance
• Stability
! No good scientiﬁc evidence; No consensus
!Koudstaal et al, Int J Oral Maxillofac Surg, 2005
!Lagravere et al, Int J Oral Maxillofac Surg, 2006

• Morbidity, surgical risk, cost

• Impact of 1 vs 2 stages surgical procedures

• "If additional Mx surgery is required after transverse
expansion, there is little reason to perform it twice."
!Bailey et al, JOMS 1997

Non-surgical RPE
• Post pubertal patients Krebs, EOS 1964

! 18% Skeletal expansion

! 0,9 mm skeletal in adult

! vs 3 mm in adolescents

! Expansion is more
dentoalveolar in nature than
skeletal in older patients
Handelman et al AO 2000
Spilane & McNamara SO,1995
Bacetti et al, AO 2001
Zimring & Isaacson, AO 1965
Lagravere et al JADA 2006; AO 2005

Comparative study-1

-3,16
Byloff & Mossaz, 2004 (n=14) 5,54
8,70

-0,50
Koudstal et al, 2009; T-B (n = 19) 6,30
6,80

-0,60
Koudstal et al, 2009; B-B (n =23) 4,60
5,20

-1,01
Berger et al, 1998 (n=28) 4,77
Study

5,78

-0,88
Pogrel et al, 1992 (n=12) 6,62
7,50

-1,20
Stromberg & Holms, 1995 (n=20) 8,30

-0,45
Bays & Greco, 1992 (n=19) 5,78

-0,22
Nortway & Meade, 1997 (n=16) 5,50

-4,50 -2,25 0 2,25 4,50 6,75 9,00
mm

Long term relapse Short term relapse
Net expansion Maximum expansion

Comparative study-1

-3,16
Byloff & Mossaz, 2004 (n=14)
36% 5,54
8,70

Koudstal et al, 2009; T-B (n = 19) 5,5% -0,50
6,30
6,80

Koudstal et al, 2009; B-B (n =23) 11% -0,60
4,60
5,20

-1,01
Berger et al, 1998 (n=28) 17.5% 4,77
Study

5,78

12% -0,88
Pogrel et al, 1992 (n=12) 6,62
7,50

8.3% -1,20

7% -0,45
Bays & Greco, 1992 (n=19) 5,78

6% -0,22
Nortway & Meade, 1997 (n=16) 5,50

-4,50 -2,25 0 2,25 4,50 6,75 9,00
mm


Comparative study-1

-3,16
36% 5,54
8,70

6,30
6,80

4,60
5,20

-1,01
Berger et al, 1998 (n=28) 17.5% 4,77
Study

5,78

12% -0,88
Pogrel et al, 1992 (n=12) 6,62
7,50

8.3% -1,20

7% -0,45
Bays & Greco, 1992 (n=19) Not taken from the 5,78

Nortway & Meade, 1997 (n=16)
6% -0,22
maximum expansion point 5,50

-4,50 -2,25 0 2,25 4,50 6,75 9,00
mm


Comparative study-1

-3,16
36% 5,54
8,70

6,30
6,80

4,60
5,20

-1,01
Berger et al, 1998 (n=28) 17.5% 4,77
Study

5,78

12% -0,88
Pogrel et al, 1992 (n=12) 6,62
7,50

8.3% -1,20
Bias!: Selected cases. Observation:End of ortho 8 to 102 m

7% -0,45

6% -0,22

-4,50 -2,25 0 2,25 4,50 6,75 9,00
mm


Comparative study-1

-3,16
36% 5,54
8,70

6,30

ent d
6,80

reatm erio
to t udy p
4,60
5,20
n
Berger et al, 1998 (n=28) 17.5% -1,01
S till i hs st
ont
4,77
Study

5,78

Pogrel et al, 1992 (n=12)
12% -0,88 12 m 6,62
7,50

8.3% -1,20

7% -0,45

6% -0,22

-4,50 -2,25 0 2,25 4,50 6,75 9,00
mm


Comparative study-1

-3,16
36% 5,54
8,70

6,30

ent d
6,80

reatm erio
to t udy p
4,60
5,20
n
Berger et al, 1998 (n=28) 17.5% -1,01
S till i hs st
ont
4,77
Study

5,78

Pogrel et al, 1992 (n=12)
12% -0,88 12 m 6,62
7,50

8.3% -1,20

7% -0,45

6% -0,22

-4,50 -2,25 0 2,25 4,50 6,75 9,00
mm
Small sample

SARPE!: Skeletal Expansion


• Kuo & Will, DCNA 1992
! N = 15
! Ratio Skeletal / dental expansion = 84!% (range 50!%
to 100 %)


• Kuo & Will, DCNA 1992
! N = 15
! Ratio Skeletal / dental expansion = 84!% (range 50!%
to 100 %)

• Berger et al, AJODO 1998
! N = 28; Ratio Sk / D = 52%
! Mean skeletal expansion Mx-Mx = 3 mm
! Mean relapse 0,51 mm (~17!%). Net skeletal
expansion = 2,49!mm

• Byloff & Mossaz, EJO 2004
! N =14; Ratio Sk / D = 17 %
! Mean expansion!: 1,31 mm
! Mean relapse!: 0,35!mm (27!%); Net Sk Expansion =
0,96!mm


! N =14; Ratio Sk / D = 17 %
0,96!mm

• Hino C.T., Pereira M.D. et al, J Craniofac Surg, 2008
! Haas group : N =19; Hyrax group : N =19
! Skeletal expansion : Haas = 6,9!mm; Hyrax = 6,3!mm
! Ratio Sk / D = 71!%
" " " " (minor errors in the Tables. Position of the landmark Mx seem low)

! N =14; Ratio Sk / D = 17 %
0,96!mm

• Hino C.T., Pereira M.D. et al, J Craniofac Surg, 2008
ration
of
! Haas group : N =19;ocat : sepa a =19
e group+: N rigid
a dv Hyrax tion
They oid junc
• pteryg
! Skeletal expansion : Haas = 6,9!mm; Hyrax = 6,3!mm
e
plianc
! Ratio Sk /ap = 71!%
D
" " " " (minor errors in the Tables. Position of the landmark Mx seem low)

Tipping of Buccal
Segments


Tipping of Buccal
Segments
• Chun & Goldman, EJO 2003 (HAAS 4 bd)
! Mesiobuccal rotation of Pm et M
! Vestibular tipping of the molars = 7,04° ± 4,58°


Tipping of Buccal
Segments
• Chun & Goldman, EJO 2003 (HAAS 4 bd)
! Mesiobuccal rotation of Pm et M
! Vestibular tipping of the molars = 7,04° ± 4,58°

• Byloff & Mossaz, EJO 2004 (Hyrax 4 bd)
! Tipping of 9,6°; relapse 0,3° à T4
! Dental tipping
! Lateral rotation of the hemimaxillae

Tipping of Buccal
Segments

• Hino C.T.et al, J Craniofac Surg, May 2008
! Buccal tipping occurs : Haas ~ 3,5° to 4,5°; Hyrax~ 2°
! Conﬁrm : Lateral rotation of hemimaxillae occurs


Tipping of Buccal
Segments

• Hino C.T.et al, J Craniofac Surg, May 2008
! Buccal tipping occurs : Haas ~ 3,5° to 4,5°; Hyrax~ 2°
! Conﬁrm : Lateral rotation of hemimaxillae occurs

•Conclusion ! overexpansion is needed
!Agreement!: 2 mm (Byloff); 1,5!mm / 30!% (Racey, Chung)


V-shape opening AP &
Tipping of Buccal vertically
! Pterygoïd jct

Segments
• Bone-borne implant RPE (Dresden distractor)
! Alveolar tipping = 11°
! Dental tipping = 3,5°

• Observation
! T2 : bone scan 9 ± 4 months
after the end of distraction
! Enough time for teeth to relapse
Tausche et al, AJODO 2007

" Sk / Dental expansion : 111!%
– 7,15 ± 2,3!mm / 6,44 ± 1,92!mm

Systematic Review-1
• Lagravere et al, Int. J. Oral Maxillofac.
Surg. 2006 : 35
! Secondary level of evidence found

! Recommendation :
! Randomized controlled clinical trial

" Evaluate dental & skeletal changes immediately
after SARME and continue follow-up for possible
relapse


Systematic review-2
• Koudstaal et al, Int. J. Oral Maxillofac.
Surg. 2005 : 34
! No consensus regarding the surgical technique,
type of distractor, existence, cause and amount of
relapse, whether or not overcorrection is needed
! Recommendation!:
! Prospective randomized clinical study


Koudstaal et al, Int. J. oral
Maxillofac. Surgery, 2009
• N= 46 : 25 bone-borne; 21 tooth-borne

• 12 months study period

• No difference between B-B and T-B
# Same efﬁcacy in expansion
# Same relapse

• Expansion is stable at 12 months


Research Hypothesis


Research Hypothesis

• The relapse obtained after SARPE and
osseous distraction is less than 40%
mm in 2/3 of the patients


Research Hypothesis

• The relapse obtained after SARPE and
osseous distraction is less than 40%
mm in 2/3 of the patients
• The skeletal expansion of the maxilla
( Mx) is 50% of the dental expansion
( M)


Sub-hypothesis


Sub-hypothesis

• The diastema measured at the end of the
distraction


Sub-hypothesis

• The diastema measured at the end of the
distraction

• The screw change is a predictor of
skeletal changes


Materials & Methods

Prospective clinical study
Consecutively treated cases

©Sylvain Chamberland

Sample Size Estimation
between 2 Groups
2(z1! " /2 + z1! # )2 s 2 N Relapse ^m S-D
n=
p

(X1 -X 2 )2
Pogrel 12 0,88 0,48
• Power 80!% Byloff 14 2,6 1,8
1,364
Philips 39 1,97 1,5
Subsample 12 3,06 1,31

• To find a difference of 1 mm # n = 29
• To find a difference of 1.25 mm #n = 19
• To find a difference of 1.5 mm # n = 13

> 5 mm ^X S-D N

Sample Le Fort 1 Selected
7,36 1,59 12
subsample
Power 80%
SARPE Consecutive
P < .05 cases
7,60 1,57 38

• Historical Le Fort 1 • Le Fort 1 subjects > 5 mm
! Phillips et al. study (1992) ! Control subsample !
Experimental
! Selected Subsample : N =12
! Conclusion can be inferred
! Follow up at ! t : p = 0.6487
postorthodontics (at least
! Wilcoxon : p = 0.4777
7,5 m post surgery)

Type 1 Error

• To avoid type 1 error, since there was
multiple T test : canine, 1st Pm, 2nd Pm,
1st M, 2nd M
• Level of signiﬁcance is divided by 5
• Bonferonni correction
# P < .05 $ P < .01


Experimental Sample

• Inclusion criteria
! Transverse deﬁciency > 5 mm

! Skeletal growth completed

• Research protocol approuved by the
Ethical Comitee (CERUL 2005-101)
! All participants signed an informed consent


SARPE Patient Characteristics

•
Distribution

N = 38 9
9 9

! 19!, 19" 7 7

# of patients
# cas 6
! Age ^m : 24.9 ± 9,7 5 5
(range 15,1: 53,7)
•
2
Expander type 2

0
! 17 bonded -,17] (17, 20] (20,25] (25,30] (30,35] (35, +
Âge
! 21 banded


Observation
• D1= Tx intiated in mandibular arch
• T1= Prior to SARPE
• T2= At the end of distraction
• T3= At the removal of the expander (~6 m)
• T4= Prior to 2 surgery
nd

• T5= At debonding
• T6= At 2 years into retention

Treatment time (months) N Mean S-D S-E Min Max


Treatment time (months) N Mean S-D S-E Min Max

T1-T2 (Distraction completed) 38 0,68 0,22 0,04 0,46 1,81

T2-T3 (Expander retention) 38 5,95 0,68 0,11 4,21 7,12

T1-T4 (Start to 2nd surgery) 28 15,49 3,90 0,74 10,38 24,28

T2-T5 (End expansion to deband) 28 21,15 5,36 1,01 12,88 41,69

T3-T5 (Expander out to deband) 28 15,15 5,11 0,96 8,67 35,19

D1-T5 (Total treatment time) 28 23,12 5,31 1,00 15,80 43,07

T5-T6 (Post ortho treatment) 19 24,70 3,05 0,69 20,96 35,05


Outcome Measures


Outcome Measures
• Study cast
• Screw width
! Before & after expansion
! In situ + on PA ceph
" Enlargment factor = 4%

• Diastema
! End of distraction (T2)

• Standardized PA Ceph
! Mx : JR-JL

! Nas. Cav.

Appliance Designs
• Superscrew™ (16 mm) (Klapper, JCO 1995)

! 2 bands + 2 occlusal rests

! Bonded

• Maximal rigidity required
(Braun et al, AJODO 2000; Isaacson et al, AO 1964 )


Appliance Designs
• Screw placed close to C res
! (Braun et al, AJODO 2000)

! Screw in line with the 1st molars

! Relief of 3-4 mm from the palatal vault

Too forward
Screw in line with 1st molars


Treatment Modality
• Tx initiated in the mandibular arch
• Appliance cementation 1 day to 1 week
prior to surgery
• Latency period : 7 days
• Distraction period : 0,3 mm bid,
! 14 to 21 days; monitored twice a week
Legan HL, AJODO 2002; 121 (2): 15A
Racey, JOMS 1992; 50: 114-115
Aida TI, IJOMS 2003; 32: 54-62
Paccione et al, J Cran Surg 2001;12 (2);
Profﬁt, Contemporary Tx of dentofacial 175-181
deformity; 358-361

Treatment Modality
• Bracketsafter expansion arch 2
months
bonded in maxillary

• Expander removal : 6 months after
expansion is stopped
• No other retention except the main arch
wire


Our SARPE Technique
• Done by the same surgeon(DM) Midpalatal suture

Zygomaticomaxillary buttres

• Subtotal Le Fort 1 osteotomy Piriform rim Pterygomaxillary
junction


Our SARPE Technique
• Done by the same surgeon(DM) Midpalatal suture

Zygomaticomaxillary buttres

• Subtotal Le Fort 1 osteotomy Piriform rim Pterygomaxillary
junction

Widening of the
osteotomy cut : lateral
rotation hemimaxillae

Piriform aperture
Zygomatic buttress

Our SARPE Technique
• Subtotal Le Fort 1 osteotomy


Our SARPE Technique
• Subtotal Le Fort 1 osteotomy

Separation of the Per-op diastema of 1 to
pterygoïd junction Separation with osteotome 1,5 mm
of the midpalatal suture


Results of the Study

Error method
• Coefﬁcient of ﬁdelity!:
! 99,94!% on dental cast

! 99,90!% on PA Ceph


Dental Changes: Total/Net/Relapse
Relapse T5-T3
Net expansion T5-T1
Maximal expansion T3-T1
• All signiﬁcant : p < .0001 Canine
-2,74
2,80
5,69

! Expansion -1,84
1st premolar 5,49
7,61

! Relapse -1,75
2nd premolar 6,04
7,86

! Net expansion -1,92
1st molar 5,56
7,60

• Md 1st molar 2nd molar
-4,15
3,28
7,36

! Expansion : p = .0005 0,25
Lower 1st molar 1,59
1,39

! Relapse : p = .5321 -6,75 -4,50 -2,25 0 2,25 4,50 6,75 9,00

! Net expansion : p = .0129 Mean changes (mm)
Closer look at the stability of Surgically-
Assisted Rapid Palatal Expansion
©Dr Sylvain Chamberland JOMS 66: 1895-1900, 2008

Dental Changes
Relapse T5-T3
Net expansion T5-T1
Maximal expansion T3-T1
• Canine Canine
-2,74
2,80
5,69

! Expand less 1st premolar
-1,84
5,49
7,61
! Not include into RPE -1,75
2nd premolar 6,04
7,86
! Relapse more -1,92
1st molar 5,56
!Finishing and arch coordination
7,60

-4,15

•
2nd molar 3,28
2nd molar 7,36

0,25
Lower 1st molar 1,59
! No ! bonded vs banded 1,39

-6,75 -4,50 -2,25 0 2,25 4,50 6,75 9,00
! Relapse due to arch form Mean changes (mm)
coordination Closer look at the stability of Surgically-
Assisted Rapid Palatal Expansion
©Dr Sylvain Chamberland JOMS 66: 1895-1900, 2008

Expansion Pattern
SARPE T3-T1 SARPE T5-T1 Le Fo 1
ort
1st PM 2nd M 1st PM 2nd M 1st PM 2nd M
X 7,61 7,36 5,52 3,06 4,06 9,67
S-D ± 1,87 ± 1,85 ± 3,13 ± 1,42 ±0,75 ± 2,82
p = 0.
.1168 p = 0.
.0040 p = 0.
.0022
N 29 19 6

• Expansion at 1st Pm vs 2nd M
! SARPE at T3
! Posterior expansion anterior expansion

! In contrary to previous litterature and non-surgical RPE May be explained by
the separation of the
! Supported by recent CT scan study (Loddi et al, J Cranio Surg 2008) pterygoïd junction
! SARPE at T5 : Greater relapse 2nd M may be explained by arch form coordination
!
©Dr Sylvain Chamberland Le Fort 1 : Posterior expansion > anterior expansion

Skeletal e
expansion

Skeletal Changes X
" Mx T2-T1 " Mx T5-T1

3,44 3,63

S-d 1,39 1,54

•
N 36 23
Signiﬁcant skeletal expansion! Paired T p < .0001 p < .0001

! 3,44 ±1,39!mm
! Less than Hino et al, 2008 (Mean sk. = 6,6 mm)

• Skeletal relapseT5- T3 = - 0,03 mm
! 21,15 ± 5,36 months post surgery
! Non signiﬁcant

! Paired T test : p = 0,9156


Changes F(time) Changes post SARPE
at 1st molar / at Mx /
at Nasal cavity

• Skeletal expansion
8,00 70
65

58
! Mx & Nas. Cav. 6,00 53

% Skeletal expansion
47

Expansion (mm)
45
! Stable

• Most of the relapse
4,00 35

! Dental 2,00 18

• % Sk/Dental 0
0,68 6,65 15,49 23,11
0

! Increased from 45!% to 65!% Time post SARPE (months)
" 1st Molar
! Consistent with other studies " Nasal cavity
" Mx
% "Mx / " 1st Molar

Relapse F(type of surgery)
• One way Anova
N F value p
! No signiﬁcant effect Bimax 6

• Any combination of surgical Md
Mx
7
5
F ( 26) =
(3, )
0.32
0.8125
0 8125
variables
Nil 9
! (Md, Mx, Bimax, No 2nd phase)
Total 27
! No signiﬁcant effect
! p = 0.0670 to 0.4525


Relapse F(time T3-T4-T5)
• Repeated measures Anova
• Relapse is related with time elapsed after expansion
• Relapse of 1st M between T5, T4, T3
! Mean interval!: 8,7 and 7,7 m 1st M T3 1st M T4 1st M T5 1st M T6
1st M width 50,22 49,13 48,24 47,22
! 55!% relapse entre T4-T3
N 38 30 27 19
! 45!% relapse entre T5-T4
p = .0
0008
p value p = .0
0118
p < .0001
T4-T3 T5-T4 T5-T3
Mean -1,09 -0,89 -1,98
% 55!% 45!% 100!%

Relapse F(type of appliance)
N Bonded N 2 Bd Hx p value

Exp. 1st M T3-T1 17 7,91 21 7,34 .2727

Sk Exp Mx 15 3,85 12 3,04 .7090

Relapse 1st M T5-T3 16 -1,70 11 -2,23 .4410

• Banded expander has the same efﬁcacy of
bonded expander
! Similar dental expansion
! Similar skeletal expansion
! Similar relapse

Relapse F(extraction pattern)
"1st M T5-T3
N Mean S-D Paired T
Extraction 6 -2,97 ± 1,40
p = 0 1366
0.1366
Non-Extraction 17 -1,68 ± 1,85

• Non extraction group (17) / extraction group (6)
! Relapse 1st M T5-T3 ! not statiscally different (p = 0.1366)

• The trend toward more constriction of the maxillary
arch in the extraction subgroup, altough non
signiﬁcant, might be explained by the need of arch
coordination of a non extracted maxillary arch on an
extracted mandibular arch

Diastema F(" 1st molar)
•" 1 M T3-T1 / Diastema T2 = 91%
st

! r = 0.64; r2 = 0,41; p < 0,0001
! This indicates that the development of a diastema is a
predictor that adequate molar expansion is occurring
! IF NOT :
! Non-separation of Mx & tipping of the buccal segments is occurring

• " 1st M T5-T1 - Diastema T2; r2 = 0,12; p = 0,0835 (NS)
! Net dental changes can not be predicted from the diastema

! Expansion rate too slow (.3 mm / jrs)
! Callus ossiﬁcation ! bone consolidation

A
A
B

C

• A-Telescoping zygomatic arch

• B-Minimal palatal separation

• C-Impinging of the screw into the palate

• Appliance = totally inadequate


Skeletal " T3 / Dental " T3
• Low correlation between Sk " / Dt "
! r = 0,249; r2 = 0,06; p = 0.1843 , (NS)

• Hemimaxillae do not expand in parallel
! Lateral rotation & alveolar bending
! Supported by Hino et al, J Cranio Surg 2008

• It explains why skeletal expansion is 47!%
of maximum dental expansion (T3)
• T3 # T5 % Dental relapse is highly variable

Lateral Rotation
• A- Inward Mvt Before expansion

• B- Palatal impingement

• Therefore!: place
the screw 3- 4 mm away
from palatal mucosa
After expansion
• Supported Koodstaal et A
B
al, 2009
! Increase in palatal width
results in decrease in
depth... explained by
tipping of the maxillary
segments

Alveolar bending
Before
expansion

• A-moderate
separation

• B-Impingement
C
After
expansion
• C-Inward Mvt A

B


" Skeletal" / " Screw


" Skeletal" / " Screw
• Chun et al, 2005; PA ceph : Sk / Screw = 30% at J-J

• Hino et al, 2008; PA ceph : Sk / Screw = ~ 72% at Mx-Mx

• Loddi et al, 2008; CT scan : Sk / Screw = ~ 65% Midpal. sut.
! Greater skeletal efﬁcacy with Hyrax than Haas

• Our Data; PA ceph : Sk / Screw = 46%
! T3 : r = 0,249; r2 = 0,062; p = 0,1843 ( NS )

• Skeletal expansion can not be predicted, nor estimated by
screw changes
! Tipping and lateral rotation occurs, do not expand in parallel

Relapse vs Expansion

• Relapse T5-T3 / Dental expansion T3
(n = 27) : 25%
! r = -0,031; r2 = 0,0009; p = 0,8787 (NS)

! No correlation between expansion & relapse

• Relapse / Skeletal Expansion
! r = -0,360; r2 = 0,130; p = 0,0707 ( NS )

! Inadequate skeletal expansion may be related
to dental relapse

SARPE Skeletal Expansion
• Skeletal expansion greater than other
studies using PA ceph except Hino et al
• At maximum : 47% skelettal, 53 % dental
• Relapse almost totallly due to lingual
movement of posterior teeth
• 2 mm overexpansion is recommended
to compensate for buccal tipping of
posterior segments

Comparison to non-
surgical RPE
•Our data
! 3,58!mm skelettal!: 65!% of the mean net dental
expansion (5,56!mm)


Comparison to non-
surgical RPE
•Our data
! 3,58!mm skelettal!: 65!% of the mean net dental
expansion (5,56!mm)

With SARPE , the skeletal
change is
greater & more stable than with
RPE in post pubertal patient

Stability Compared to
Segmental Osteotomy
SARPE
E Le Fort 1
N Mean S-D N Mean S-D p value
Canine 26 -2,74 1,75 12 -0,74 1,85 .0026

1st premolar 22 -1,84 2,11 9 -1,31 1,67 .5130

2nd premolar 27 -1,75 2,55 11 -2,05 1,45 .7099

1st molar 27 -1,92 1,74 12 -3,06 1,31 .0491

2nd molar 24 -4,15 1,89 8 -3,69 1,08 .5193

• No signiﬁcant difference
! 1st Pm, 2nd Pm, 1st M, 2nd M

•
Canine : relapse more because of arch coordination

Segmental Osteotomy
1st molar 27 -1,92 (25%) ±1,74 12 -3,06 (42%) ±1,31 .0491

• Relapse of SARPE is comparable to Le Fort 1
! T : t = -2,03, df = 37; p = 0.0491

! Wilcoxon : S = 176; p = 0.0608

• Mean T5-T3 : 15,2 ± 5,1 months
• All patients were out of ortho treatment

Segmental Osteotomy
1st molar 27 -1,92 (25%) ±1,74 12 -3,06 (42%) ±1,31 .0491

np oint
• Relapse of SARPE is comparable atosiLe Fort 1
exp
n o
! T : t = -2,03, df = 37; p = 0.0491
ximum
em a
th
! Wilcoxon : S = 176; p = 0.0608

df rom15,2 ± 5,1 months
• easu e
MeanrT5-T3 :
M patients were out of ortho treatment
• All

Comparison to Other Studies
-1,91 -1,01
Experimentals (n=38; 27;19) 5,56
7,59
4,6
-3,06
Controls (n=12) 4,30
7,36

-1,97
4,28

-3,16
Byloff & Mossaz, 2004 (n=14) 5,54
8,70

-0,50
Koudstal et al, 2009 (n = 19) T-B 6,30
6,80

-0,60
Koudstal et al, 2009 (n =23) B-B 4,60
5,20

-1,01
Berger et al, 1998 (n=28) 4,77
5,78

-0,88
Pogrel et al, 1992 (n=12) 6,62
7,50
-1,20

-0,45
Bays & Greco, 1992 (n=19) 5,78

-0,22
Nortway & Meade, 1997 (n=16) 5,50

-4,50 -2,25 0 2,25 4,50 6,75 9,00
mm
Long Term Relapse Short Term Relapse
©Dr Sylvain Chamberland Net expansion Maximum expansion
Long term exp

-1,91 -1,01
7,59
4,6
-3,06
7,36

-1,97
4,28

-3,16
Byloff & Mossaz, 2004 (n=14) 5,54
8,70

Koudstal et al, 2009 (n = 19) T-B > -0,50 6,30
6,80

Relapse >
-0,60
5,20

Berger et al, 1998 (n=28) > -1,01 4,77
5,78

Pogrel et al, 1992 (n=12) > -0,88 6,62
7,50
-1,20

-0,45
Bays & Greco, 1992 (n=19) 5,78

-0,22
Nortway & Meade, 1997 (n=16) 5,50

-4,50 -2,25 0 2,25 4,50 6,75 9,00
mm
Long term exp

-1,91 -1,01
But ! NSControls (n=12)
7,59
4,6

< -3,06 4,30
7,36

Relapse Controls (n=39) -1,97 2,31
4,28

Byloff & Mossaz, 2004 (n=14) < -3,16 5,54
8,70

6,80

Relapse >
-0,60
5,20

Berger et al, 1998 (n=28) > -1,01 4,77
5,78

Pogrel et al, 1992 (n=12) > -0,88 6,62
7,50
-1,20

-0,45
Bays & Greco, 1992 (n=19) 5,78

-0,22
Nortway & Meade, 1997 (n=16) 5,50

-4,50 -2,25 0 2,25 4,50 6,75 9,00
mm
Long term exp

-1,91 -1,01
But ! NSControls (n=12)
7,59
4,6

< -3,06 4,30
7,36

Relapse Controls (n=39) -1,97 2,31
4,28

Byloff & Mossaz, 2004 (n=14) < -3,16 5,54
8,70

6,80

Relapse > "Exp.
-0,60
5,20

Berger et al, 1998 (n=28) > -1,01 4,77
5,78

Pogrel et al, 1992 (n=12) > -0,88 6,62
7,50
-1,20

-0,45
Bays & Greco, 1992 (n=19) 5,78

-0,22
Nortway & Meade, 1997 (n=16) 5,50

-4,50 -2,25 0 2,25 4,50 6,75 9,00
mm
Long term exp

H1 : Relapse obtained after SARPE and osseous
distraction is less than 40% mm in 2/3 of the patients

• SARPE : 25!% of patients relapse > 3!mm (4,26 mm)

• Le Fort 1 : 67!% of patients relapse > 3!mm

• SARPE : 41!% relapse a mean 2!mm
LeFort 1:Post-Tx Changes
70,0!%
SARPE: Post-Tx changes 66,7!%
First Molar
First Premolar
50,0!% 56,0!%
50,0!% First Molar
First Premolar
40,0!% 40,7!% 42,0!% 44,4!%
% of patient

30,0!% 29,6!% 33,3!%
25,9!%
28,0!%
20,0!% 22,7!% 25,0!%
18,2!%
14,0!%
10,0!% 11,1!% 11,1!%
9,1!%
8,3!%
3,7!%
0!% 0!% 0!%
'-,-3] (-3 to -1] (-1 to 1] (1 to 3] '-,-3] (-3 to -1] (-1 to 1] (1 to 3]
Relapse (mm) Relapse (mm)

H1 : Relapse obtained after SARPE and osseous
distraction is less than 40% mm in 2/3 of the patients

• SARPE : 25!% of patients relapse > 3!mm (4,26 mm)

• Le Fort 1 : 67!% of patients relapse > 3!mm 66%

• SARPE : 41!% relapse a mean 2!mm
LeFort 1:Post-Tx Changes
70,0!%
SARPE: Post-Tx changes 66,7!%
First Molar
First Premolar
50,0!% 56,0!%
50,0!% First Molar
First Premolar
40,0!% 40,7!% 42,0!% 44,4!%
% of patient

30,0!% 29,6!% 33,3!%
25,9!%
28,0!%
20,0!% 22,7!% 25,0!%
18,2!%
14,0!%
10,0!% 11,1!% 11,1!%
9,1!%
8,3!%
3,7!%
0!% 0!% 0!%
'-,-3] (-3 to -1] (-1 to 1] (1 to 3] '-,-3] (-3 to -1] (-1 to 1] (1 to 3]
Relapse (mm) Relapse (mm)

Clinical Implications
• If only transverse changes are needed
! SARPE = Choice # 1

MC; tx:18m YP; tx:~24m CS; tx:~22m


Clinical Implications
• When maxilla need to be repositioned AP or vertically in a
2nd phase
! Stability ???

• Therefore, decision should be based on the risk & morbidity
of 2 surgery versus risk & morbidity of 1 stage segmental Le
Fort 1 for large expansion along with vertical and AP
changes
• 2 mm overexpansion is recommended as in segmental ostetomy


But!: SARPE still indicated
• For large transverse AP and vertical
changes or periodontally compromised
patients

©Dr Sylvain Chamberland (Personal opinion)

Aao 109th annual_session_boston_2009_closer look at the stability of sarpe 2009_sarpe_sylvain_chamberland_orthodontiste_quebec

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