Mandibular Symphyseal Distraction Osteogenesis and SARPE aao 2018 Washington DC ©sylvain chamberland

Treatment of Severe
Maxillary and Mandibular
Constriction
SARPE & MSDO
AAO 118th Annual Session
©sylvainchamberland.com
Biography
Sylvain Chamberland
•D.M.D. (Docteur en Médecine Dentaire), University Laval, 1983
•Private practice, general dentistry 1983-1988
•Certificate in Orthodontics, University of Montreal, 1990
•M.Sc. in Dental Science, University Laval, 2008
•Private practice in orthodontics since 1990
•Publications
✦ Closer look at SARPE, JOMS 2008
✦ Short-term and long-term stability of SARPE revisited, AJODO 2011
✦ Long-term dental and skeletal changes following SARPE, letter to editor, OOOO 2013
✦ Functional genioplasty in growing patients, AO 2015,
✦ Response to : Functional geniolasty in growing patients by Chamberland et al, AO 2015,;85, 6: p1083
•Lecturer in several graduate program and scientific meeting in USA, Canada, Europe
Conflict of Interest Declaration
•I declare that neither I nor any member of my family have a financial
arrangement or affiliation with any corporate organization offering financial
support or grant monies for this continuing education presentation, nor do I
have a financial interest in any commercial product(s) or services I will discuss
in this presentation
All that is missing is You!
•Introduced in 2009, the DOS program provides access to care for children in need. Access to quality
orthodontic care is missing in many children’s lives. The AAO DOS program mission is to serve indigent
children without insurance coverage or that do not qualify for other assistance in their state of residence.
•The program has expanded and offers care to children nationwide in addition to the recognized state
programs in Illinois, Indiana, Kansas, Michigan, New Jersey, North Carolina, Rhode Island, Tennessee,
Texas and Virginia.
•In order to expand further, we need you to help us by volunteering to serve as a provider orthodontist or
help identify orthodontists willing to lead efforts to establish a DOS chapter in your state.
•Stop by the DOS booth here in San Diego to learn more about the program or contact Ann Sebaugh at
asebaugh@aaortho.org with questions.
AAO Donated Orthodontic Services
(DOS) Program

Treatment of Severe Maxillary and
Mandibular Constriction
•Review of the technique of SARPE and MSDO
•Case reports of combined treatment
•New approach to maxillary expansion
•Conclusion
=
FrDeMa020412
NiBo040614
Case Report
Mandibular Constriction
Not so constricted Constricted Very constricted
•Skeletal Expansion
★ Mx & Nasal cavity (p < 0.0001)
★ STABLE: NS ∆ (p=0,1166)
•Dental Expansion (7,6± 1,6mm)
★Sig.Relapse: 24% (1,8±1,8mm) at 15
months post SARPE
★Follow up 24m: Relapse 1.1 mm 
➔ 38% of total expansion
•46% Sk/Dt at 6 m
•65% Sk/Dt at 23,6 m
Changes in the Dental and Skeletal
Dimensions Over Time after SARPE

Covariables
•Low correlation between skeletal and dental changes: r = .36; r2 = 0.13
•Low correlation between screw changes and skeletal change: r = 0.41; r2 = 0.17
✦ Hemimaxillae do not expand in parallel
✓ Lateral rotation & alveolar bending
•It explains why skeletal expansion is 47% of maximal dental expansion (T3)r T3 r T5
Diastema changes / 1st Molar 0.69 0.22
Screw changes / 1st Molar 0.93 0.38
Screw changes / Skeletal changes 0.41 0.47
Skeletal changes / Dental changes 0.36 0.03
Expansion / relapse 0.01 ©sylvainchamberland.com
•No parallel expansion of hemimaxillae in coronal view
•Rotation of hemimaxillae
✦ Inward movement of alveolar border under the osteotomy cut (C, A)
✦ Palatal depth decrease (B)
Before Expansion After Expansion
A
B
C
C
Chamberland S, Proffit WR, Short-term and long-term stability of surgically assisted rapid palatal expansion revisited AJODO 2011; 139:815-22
Koudstaal MJ, Smeets JB, Kleinrensink GJ, Schulten AJ, van der Wal KG. Relapse and stability of surgically assisted rapid maxillary expansion: an anatomic biomechanical study. J Oral Maxillofac Surg 2009;67:10-4.
Chamberland S, Proffit WR. Closer look at the stability of surgically assisted rapid palatal expansion. J Oral Maxillofac Surg 2008;66: 1895-900.
Landes CA, Laudemann K, Schubel F, Petruchin O, Mack M, Kopp S, et al. Comparison of tooth- and bone-borne devices in surgically assisted rapid maxillary expansion by three-dimensional computedtomography
monitoring: transverse dental and skeletal maxillary expansion, segmental inclination, dental tipping, and vestibular bone resorption. J Craniofac Surg 2009;20:1132-41.
Zemann W, Schanbacher M, Feichtinger M, Linecker A, Karcher H. Dentoalveolar changes after surgically assisted maxillary expansion: a three-dimensional evaluation. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
2009;107:36-42.
•No escape when hemimaxillae are expanded if the cut is not
widened at the zygoma
•Obvious inward displacement upon appliance activation per op.  
This has been proven by Chamberland& Proffit AJODO2011
•As bone contact, resistance may be similar to non-cut bone
How Much Wide?
•3-4 mm wide

MSDO. Early reports
•Tooth anchor expansion device
✦ Force is applied above C/R of Md
•Activation 1 mm /days
•Concerns:
✦ Disproportional widening of the dento-osseous
segments (alveolar bone was expanded more
than basal bone)
✦ Lower incisor proclination
Santo M., Guerrreo C., Bushang P.H., et al. Long-term skeletal and dental effects of mandibular symphyseal distraction osteogenesis AJODO 2000;118:485-93
Santo M., English Jd, Wolford L et al, Midsymphyseal distraction osteogenesis for correcting transverse mandibular discrepancies AJODO 2002; 121: 629-638
Tooth-borne Versus Hybrid Devices for
MSDO
•Greater skeletal expansion was achieved  
with a hybrid distractor.
•Greater dental expansion was achieved  
with a tooth-borne distractor
•During distraction, the hybrid distractor effected
more parallel expansion of basal and alveolar
bone than did the tooth-borne distractor
Skeletal and dental effects of tooth-borne versus hybrid devices for mandibular
symphyseal distraction osteogenesis, Niculescu, Julia A, John W King, and Steven J
Lindauer. Angle Orthod. 2014;84:68–75 doi:10.2319/022213-154.1
Long-Term Skeletal & Dental Stability
•Follow-up 6-7 years post distraction
✦ T5-T4 Skeletal change: Stable
✦ T5-T4 Dental change:
✓ NS slight increase 1st molar
King JW, Wallace JC, Winter DL, Niculescu JA. Long-term skeletal and dental stability of mandibular symphyseal distraction
osteogenesis with a hybrid distractor. Am J Orthod Dentofacial Orthop 2012;141:60-70.
Durham JN, King JW, Robinson QC, Trojan TM. Long-term skeletodental stability of mandibular symphyseal distraction
osteogenesis: Tooth-borne vs hybrid distraction appliances. Angle Orthod 2017;87:246-253.
3e rang Est 
St-Gervais

Lessons from the Past
• Constricted maxilla
• Signiﬁcant ALD
• Crossbite #22, #15
• Slight CO/CR discrepancy
• Gingival recession
•Bimax dentoalveolar protrusion
•Retrognathic proﬁle
•No anterior guidance in protrusion
✦ Interferences on balancing side
✦ Bilateral TMJ clicking on opening
✦ Pain on palpation of both lateral pterygoïd
Tx Option
• Non-surgical, extraction of 4 premolars (5’s)
• SARPE + MSDO
Tx Plan
• SARPE and MSDO
May-2001
Mei-Ra May-2001

Follow Up
• Mx: .33 mm/day
• Md: 0,5 mm/day • 3 days into expansion
✓ Sequestra between 31-41
✓ Granulation tissue B #11
May 28
✓ 7 days post surgery
May 25 June 6
✓ 21 days post surgery
End of Distraction
• Expansion is slightly larger at the dental level than the mandibular border
June 11
At 4 months
• Mx: .016 CNT
• Md: segment .016 CNT 
 
 
 
• At 5 months
✦ Removal of both expander, bond molars
✦ Lower arch aligned in 3 segments
At 10 Months
•Mx & Md: .016 X .022 cnt
★Elastomeric chain 42 to 32
★2nd molars were not engaged
March 02

Parodontal Assessment
• Root surfacing was
required
April 2002
Outcome
• Class I occlusion was achieved
• Slight anterior guidance
• Slight curve of Spee maintained
• Gingival recession B 31-41
Dental
Changes
•At 1st molars
✦ Mx: + 4,06
✦ Md: + 6,58
43.48
50.06
+6.58
38.15
42.21
+4.06
Tx time: 22 months
• No TMJ symptoms
• Maximum interincisor
opening 46 mm

Superposition
• Md forward??
• /1-MP = maintained
• 1/-FH increased
RM 24
• Parodontal status maintained or improved
• Root parallelism improved, except 21 & 22
Follow up at 31 months
Epilogue
•I said that I will never do that again…
•But…
✦ Bone anchor device:
✓ Malkoç et al Sem. Ortho. 2012; 18:152-161 et AJODO 2007;
132:769-75
✓ Conley RS., Legan HL AJODO 2006; 129:283-92

Missed Opportunity
3e rang Est 
St-Gervais
Bologna Midline Distractor (KLS Martin)
• 1 activation 90° = 0,25 mm
• Screw parallel to occlusal plane
• Relief 2 mm buccal
• Upper connector 2-3 mm apical  
to gingival margin
•Fissure bur
•Osteotomy cut deviated to the right where there is more
room between roots of 42-43.

•q
Inferior plates of the distractor are bent
and adjusted to the form of the mandible
Distractor seated on abutment teeth
to figure out plates adjustment
Stepped parasagittal cut to
widest interradicular site
Bologna Distractor
Precise plates positioning to
ensure stress-free fixation ©sylvainchamberland.com
Osteotomy site
Precise plates positioning to
ensure stress-free fixation
Precise adaptation & fixation Mobility check of bone fragment
Precise adaptation & fixation Mobility check of bone fragment
Mucosa margin sutured2 mm expansion perop
©Dr Sylvain Chamberland
• EMRAC movie

Distraction Protocol
•Latency period of 7-8 days
✦ Critical to allow time for a callus of good quality to form
•Rate of distraction: 1 mm per day
✦ Too fast: can lead to poor bone quality, partial union, ﬁbrous union
✦ Too slow: premature consolidation, inability to obtain the planned
amount of expansion
•Rhythm of distraction: 0,25 mm qid or 0,50 mm bid
Conley R., Legan H., Mandibular Symphyseal Distraction Osteogenesis:Diagnosis and Treatment Planning Considerations,
Angle Orthod 2003;73:3–11 ©sylvainchamberland.com
Distraction protocol
•Postdistraction orthodontic movement
✦ Should not begin until radiographic evidence of consolidation is
observed
✦ Typically 2-3 months
•Removal of the distractor
✦ 6 months after the end of distraction
Conley R., Legan H., Mandibular Symphyseal Distraction Osteogenesis:Diagnosis and Treatment Planning Considerations,
Angle Orthod 2003;73:3–11
Complications
•Irritation to labial mucosa 
•Gingival inﬂammation
✦ Careful cleaning is mandatory 
•Loss of interdental septum
✦ Mesial to 31
Garreau É, Wojcik T, Rakotomalala H, Raoul G, Ferri J. Symphyseal distraction in the context of orthodontic treatment: A series of
35 cases, Int Orthod. 2015 Mar;13(1):81-95. ©sylvainchamberland.com
Complications
•Cellulitis
✦ 1 patient required antibiotic therapy + marsupialisation
•Hardware problems:
✦ If the surgeon break the thread of the screw or if you forget to
ligate, your are screwed…
Garreau É, Wojcik T, Rakotomalala H, Raoul G, Ferri J. Symphyseal distraction in the context of orthodontic treatment: A series of
35 cases, Int Orthod. 2015 Mar;13(1):81-95.
1 m post distraction 5 days later

Rte 279 intersection 3e rang
Est, St-Gervais-St Lazare ©sylvainchamberland.com
Case 2
•Class I
•Constricted dental arches
•Moderate ALD
FrDeMa020412
•Orthognathic proﬁle
•But slight retrusion of Mx & Md
•Mouth breather
FrDeMa020412
End of distraction
•Mx: 0,25 mm bid
✦ mx diastema: 8,6 mm
•Md: 0,5 mm bid (2 activations bid or 2 activations morning 1 activation evening)
✦ 0,75 to 1 mm per day
✦ ∆ intercanine= 5,4 mm, diastema ~ 6 mm
De-Ma, Fri 23-05-2013

1 m Postdistraction
• Latency period was 7 days.
Expansion monitored every
week
• Activation period: 14 days
• Note the parallelism of md
segment
De-Ma, Fri 23-05-2013
•Bonding at 1 month post distraction
✦ Mx: .016 Supercable™ 15 to 25
✦ Md: .016 Supercable™ 42 to 33
•Careful cleaning and root surfacing at each visit
De-Ma, Fri 20-06-2013 De-Ma, Fri 05-08-2013
•At 20 weeks
✦ Mx: .016 x .022 CNT
✦ Md: .016 CNT
De-Ma, Fri 16-09-2013
•At 32 weeks
✦ Mx expansion device is removed
✦ Mx and Md arch are coordinated; .020x .020CNT / .016 X .
022CNT
✦ Class I relationship is maintained
✦ Crowding is resolved
De-Ma, Fri 09-12-2013

•Transverse dimension improved
•1st, 2nd & 3rd order movement needed for lower and upper
anteriors
FrDeMa020412 De-MaFr09-12-2013FrDeMa200613 De-MaFr06-03-2014De-MaFr27-05-2014
At 76 weeks
•Finishing stages
De-MaFr16-10-2014
Final outcome
•Tx time 85 weeks
•Class I fonctionnal occlusion
FrDeMa161214 ©sylvainchamberland.com
•Improvement of interincisal
relationship
✦ 1/ retroclined 10°, /1 maintained 93°
•Proﬁl maintained or improved

• Osteogenesis of distraction site
• Root surfacing was done mesial of #43 during tx.
• Root parallelism obtained (except 34)
FDM_Jan-28-2014
Dental Changes
33,77
25,47
30,43
24,51
24,34
42,44
32,99
+7,52
+8,67
+8,72
+10,02
+2,24
39,15
34,53
26,58
+23,62+21,56
Follow up at 2 years
De-MaFr12-01-2017
3e rang Est 
St-Gervais

Risk and Complication
• Case from a netsurfer who lives
in France
•Oronasal communication
•Open communication mesial to #31
•This case is…POORLY manage
Risk and Complication
•Follow up ~ 1 year
•Lack of bone between central
incisors
•Hyperplasia right concha
©sylvainchamberland.com ©sylvainchamberland.com
Mx & Md Constriction
End of SARPE End of MSDO
Midline osteotomy cut is where
there is space available
Courtesy of Dr Dany Morais & Dr Claude Gariepy

Outcome
•Final occlusion
Prior phase 2 surgery
Courtesy of Dr Dany Morais & Dr Claude Gariepy
•Class I
•Severe bimax constriction
Courtesy of Dr Sandra Labbé
JeDu Aprl 2017
JeDu Aprl 2017
JeDu Aprl 2017
JeDu January 2018
End of Distraction
•Inward rotation of hemimaxilla
•Parallel md expansion
✦ Expansion device || occlusal plane
JeDu 23 octobre 2017

Rang St-Joseph,
Armagh, Bellechasse ©sylvainchamberland.com
•Class I
•Missing 42, 41
•Maxillary and mandibular constriction
•ENT specialist referred for snoring and apnea
NiBo040614
•Mx et Md Retrusion
•Class I skeletal relationship
•Proclined 1/ (121°)
•Retroclined /1 (79°)
•Similar case published by Conley et Legan
Conley RS., Legan HL., Correction of severe obstructive sleep apnea
with bimaxillary transverse distraction osteogenesis and
maxillomandibular advancement. AJODO 2006;129:283-92

•Osteotomy on the midline turning to the right between diverging roots of
43 - 31.
•Problems
✦ Complete separation should not be done before ﬁxation of the distractor
✦ Distraction device should be more parallel to the occlusal plane
✦ Fitting of the plates could be improved
•Distraction starts 7 days post op
•Mx: activation ⅓ mm bid
•Md: 2 activations morning (0,5 mm) et 1 activation evening (0,25 mm)
NiBo230914
End of Distraction at 30 days post op
NiBo161014
• Distractor
canted to the left
NiBo021014
Oct. 2 (+10 days)
c-c = 15 mm
NiBo091014
Oct. 9 (+7 days)
c-c = 16,7 mm
NiBo141014
Oct.14 (+5 days)
c-c = 20,5 mm
NiBo161014
Oct 16 (+2 days)
c-c = 22,5 mm
Latérodéviation mandibulaire gauche.

Complication
Oct. 16 Nov. 12 Nov. 17 
Patient noted that the
screw seems to unscrew
Nov. 24: reactivation completed + ligature Dec.17: Bond Mx teeth
11,5 mm
10,4 mm
10,8 mm
•Note
✦ Chances are that thread of the screw were stripped when the surgeon adapted the plates of the device on the
symphysis and it may explain the loss of expansion at 1 month post distraction, because there was some slack of
the screw when activating.
✦ Or it is because the screw was not ligate and immobilized at the end of distraction.
✦Advice: Always lock the screw with a ligature with such device.
17,5 mm
39,62 mm
•I accepted the loss of 1 to 2 mm expansion
•Because I had to reactivate 1 month after we had stopped
distraction I was nervous to reactivate .
NiBo161014
NiBo171214
End of Distraction. October End of Distraction. December
What Happens if You Don’t Ligate the
Screw?
•You will likely learn the
hard way that you should
have ligate…
•Complete relapse in 2
months
•Call
JeDu January15 2018
JeDu 23 octobre 2017
JeDu March 12, 2018

19 weeks
•Osteogenesis at
distraction site
•Bonding md teeth
NiBo260115 ©sylvainchamberland.com
At 5½ months
•Wide BL width of the
distraction site
NiBo090315
At 7 Months
•Removal Mx distractor Superscrew™
NiBo220415
At 8 Months
•Removal of the
Bologna Distractor 
 
 
 
•Possible sequela of
reactivation at 1
months
NiBo280515

Bone Grafting
•Follow up 2 months post grafting
NiBo241115
•Baseline June 2014 on left 
 
 
 
 
 
 
•Progress January 2016→12,42
17,66
33,69
40,17
24,83
25,2
33,54
34,84
48,22
42
32,78
24,32
10,52
+8,34
+10,01
+8,05
+8,31
+15,12
+11,9
69 weeks
NiBo12012016
Mx width 59,6 Mx width 65,5+5,9 mm

82 weeks
•Implant placement with a surgical guide
94 weeks
NiBo07072016
94 weeks
Follow up 61 weeks into retention
NiBo05092017

Follow up 61 weeks into retention
•Good osteogenesis
•Increase oropharynx airway
NiBo05092017NiBo05092017
Airways
•Oropharynx
widened
•Hyoïd bone moved
up
•Epiglottis opened
Orthodontic Pearls Controversies
•Such outcome CAN NOT be compare to bone augmentation
completed with corticotomy and grafted freeze-dried bone allograft
material
•SARPE or MARPE and MSDO is by far better IMHO
Corticotomy & Grafted Freeze Dried
Bone
• Mx dentoalveolar expansion
• Md dentoalveolar expansion 
into grafted bone
• Increase airway (?????)
✦ Buccal proclination
✦ Md forward position
• NO BASAL WIDTH CHANGE
Evans M. et al, 3D guided comprehensive approach to mucogingival problems in orthodontics , Semin Orthod 2016;22:52– 63.

What is New About
Maxillary Expansion?
New Hybrid Superscrew Device
MARPE
3e rang Est 
St-Gervais ©sylvainchamberland.com
What is New About Maxillary
Expansion?
•Hy
Tooth-Borne device 
+ Le Fort 1 osteotomy
Hybrid device 
+ Le Fort 1 osteotomy
Bicortical TAD
Non Surgical 
Maxillary Skeletal Expansion
•Parallel expansion of buccal segment
✦ Note the step out at the osteotomy cut
•Mx width gain 8,6 mm
•Nasal cavity width gain 6,6 mm
Lar-Lav Ste-10-12-15
Lar-Lav Ste-10-12-15
•Larger
skeletal
expansion

Hybrid Hyrax
•Early cases
✦ TADs too short (8 mm)
✦ 10-12 mm recommended
to engage both palatal &
nasal cortex
•TADs should be place in the
horizontal part of the palate
•Expansion device in line or
posterior to 1st molars
DubPe30-09-15
Tomas pin EP 12 mm
Miniscrew Assisted Rapid Palatal
Expansion (MARPE)
•4 mini-screw de 1,8mm X 11 mm
•MSE position: posterior palatal vault  
between 1st-2nd molars
•Rate of activation MSE II
✦ Early teens: 6x/week (0,8 mm/Wk)
✦ Teens: 2x/day (0,27 mm/ day)
✦ Early to mid 20s: 4-6x/day (0,53-0,8 mm)
✦ Adult (>25-30): 4-6X/day minimum
•After diastema: 2x/day (0,27 mm/day)
•Non rigid connector
•Dégagement 2 mm
MARPE
•Disengagement of pterygoïd plate /
pyramidal process
✦ 53% (16 sutures/30)
•Skeletal expansion
✦ 71% et 63% of the screw changes
✓ (SARPE: 46%)
71%
63%
A:Rupture bilatérale. B: Rupture unilatérale
• Cantarella D, Dominguez-Mompell R, Mallya SM, Moschik C, Pan HC, Miller J et al. Changes in the
midpalatal and pterygopalatine sutures induced by micro-implant-supported skeletal expander,
analyzed with a novel 3D method based on CBCT imaging. Prog Orthod 2017;18:34. ©sylvainchamberland.com
MARPE Skeletal Changes vs SARPE
•MARPE Center of Rotation higher than SARPE
•MARPE
✦ Maxilla move laterally
✓ Downward
✓ Forward
✦ Hemimaxillae: quasi parallel expansion
✓ Posterior part bend medially
• Cantarella D, Dominguez-Mompell R, Mallya SM, Moschik C, Pan HC, Miller J et al. Changes
in the midpalatal and pterygopalatine sutures induced by micro-implant-supported skeletal
expander, analyzed with a novel 3D method based on CBCT imaging. Prog Orthod
2017;18:34.
as a consequence 
of the rotation}
After Expansion
B
CR CR
SARPE
Blue picture
Courtesy Dr Won Moon

MARPE Skeletal Changes vs SARPE
•MARPE Center of Rotation higher than SARPE
•MARPE
✦ Maxilla move laterally
✓ Downward
✓ Forward
✦ Hemimaxillae: quasi parallel expansion
✓ Posterior part bend medially
2017;18:34.
as a consequence 
of the rotation}
After Expansion
B
CR CR
SARPE
MARPE Skelettal Changes
•Disengagement of palatal bones
✓ Bending of vertical process (sphenoïd)
•Hemimaxillae: quasi parallel expansion
✦ Posterior part bend medially
•Maxilla move laterally
✦ Downward
✦ Forward
Plan horizontal
Plan coronal
2017;18:34.
as a consequence of the rotation
}
•Center of rotation frontal and occlusal
From Dr Moon lecture ©sylvainchamberland.com
•Disengagement of palatal bones
✓ Bending of vertical process
(sphenoïd)
•Hemimaxillae: quasi parallel expansion
✦ Posterior part bend medially Plan horizontal
Plan coronal
2017;18:34.

Skeletal Change
•More expansion anteriorly than
posteriorly
•More expansion inferiorly than
superiorly
∆ Zygomatic area
MSE
∆ Zygomatic area
Hyrax
From Dr Moon lecture
• Cantarella D, Dominguez-Mompell R, Mallya SM, Moschik C, Pan HC, Miller J et al. Changes in the
midpalatal and pterygopalatine sutures induced by micro-implant-supported skeletal expander, analyzed
with a novel 3D method based on CBCT imaging. Prog Orthod 2017;18:34.
∆ Maxilla area
Hyrax
∆ Maxilla area
MSE
Airway Changes
•Decrease nasal resistance
•Increase airflow
∆ Zygomatic area
MSE
∆ Zygomatic area
Hyrax
From Dr Moon lecture
• Hur JS, Kim HH, Choi JY, Suh SH, Baek SH. Investigation of the effects of miniscrew-assisted rapid palatal
expansion on airflow in the upper airway of an adult patient with obstructive sleep apnea syndrome using
computational fluid-structure interaction analysis. Korean J Orthod 2017;47:353-364
• Cantarella D, Dominguez-Mompell R, Mallya SM, Moschik C, Pan HC, Miller J et al. Changes in the midpalatal and pterygopalatine
sutures induced by micro-implant-supported skeletal expander, analyzed with a novel 3D method based on CBCT imaging. Prog
Orthod 2017;18:34.
Dental Expansion
38,3 45,7
+7,4 45,3+7
Skeletal Expansion
•Mx: 5,7 mm
•NC: 5,3 mm
•1stM: 7 mm 
 
 
•Sk/Dt : 81%

©sylvainchamberland.com ©sylvainchamberland.com
Conclusion
•My next case
✦ Cl II div 2
✦ Right buccal Xbite
✦ Missing LR4
Conclusion
•Mandibular symphyseal distraction osteogenesis
✦ Effective to alleviate md crowding and maintain /1 AP relationship
✦ Small advancement of the mandible could be explained by outward
rotation of the condyle in the fossa
✦ May improve airways by permitting the tongue to have room
between dental arches
•Monitoring expansion every week is mandatory. Every 3-4 days ideally
Conclusion
•SARPE:
✦ Skeletal change is stable but account for only 46% at end of distraction
•MARPE
✦ Skeletal change is about 70% of the screw change
•MSDO
✦ Skeletal change is about 80% of the screw change. Relapse is NS
•Therefore one should aim for skeletal change because it is stable

MSE & MSDO
• Correct the Mx expansion with MSE device or Hybrid device
• Mandibular Symphyseal Distraction Osteogenesis
Bicortical TAD
MARPE
De-Ma, Fri 23-05-2013
Hybrid Supercrew
Thank you
Do you have questions?
2e Rang
St-Gervais, Bellechasse
•Thanks for
you attention
Vanessa lived 10 004 days.  
It seemed like a moment.
The next 10 000 days that I,
Carole, Pier-Eric and Richard
will live will be an eternity. 
I am 558 days into eternity
Who blocks my chest
I can not breath anymore
It prevents me from singing
My dear parents, I'm leaving
I love you but I'm leaving
You’ll have no more children
Tonight
I do not run away I fly
Understand I'm flying
Without Smoke, without alcohol
I fly
lalalala
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Mandibular Symphyseal Distraction Osteogenesis and SARPE aao 2018 Washington DC ©sylvain chamberland

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Mandibular Symphyseal Distraction Osteogenesis and SARPE aao 2018 Washington DC ©sylvain chamberland