Guided by-

Dr.(Mrs.) P. V. Hazarey

HOD ,Guide & Prof.

Surgically assisted rapid maxillary expansion combined with maxillary protraction in an adult : a patient report

Susana M. Deon Rizzatto , Marcel M. Farret, Michel A.Lanes

World Journal of Orthodontics 2009;10

Presented by- Kumar Niwlikar (P.G. student)

Introduction

The treatment of skeletal class III relationship in a young (growing) patient can consist of rapid maxillary expansion and maxillary protraction with a face mask because RME disarticulates the sutures and allows orthopedic changes.

So this approach is not promising in adults , camouflage or orthognathic surgery are the options ,depending on the severity of the anteroposterior discrepancy and the patients preference.

Many adult patients transverse maxillary deficiency with class III skeletal relationship,in this condition a surgically assisted rapid maxillary expansion with total Lefort I osteotomy is the therapy of choice.

This case report describes a 20 year women who sought orthodontic treatment at the school of dentistry at the Pontifical Catholic University of Rio Grande do Sul,Brazil.

Patient’s chief complait was the unesthetic position of her maxillary right canine and facial esthetics

Findings

Facial analysis showed a mandibular deviation to right and an increased lower facial third.

profile was concave with retrusive lips.

6.5 mm crowding in the maxillary arch, a deviation of the maxillary midline to the right.

maxillary transeverse deficiency & posterior crossbite.

3mm crowding in lower arch Class III molar relationship an edge-

to-edge incisor relationship & an open bite between the lateral incisors and premolars on both sides.

OPG shows 3rd molars were partially with cystic extensions of their pericoronal space

Fourth molar was detected on max.left side

Treatment objectives

to aling all teeth establish a normal overbite & overjet

attain a stable occlusion correct the posterior crossbite match the dental midlines to each

other and facial midline and improve the patient’s facial and dental appearance

Treatment options 3 treatment options were considered

1. Extraction of all second premolars with the intent of eliminating the crowding without much retrusion of the incisors,avoid flattening of the facial profile .

Disadvantage : As the pt.having straight to concave

profile this option would have compromised her facial esthetics even further and was consequently rejected

2. slow expansion of the maxilla and interproximal enamel reduction (IPR) to align all the teeth in both arches.

Disadvantage: Because of the pts chief complaint

of facial esthetics and the risk of increasing the maxillary posterior teeth recession via expansion

3. SARME followed by maxillary protraction with facemask and IPR of the mandibular posterior teeth as well as protrusion of the maxillary and mandibular incisors was the optimal option

Treatment initiation

Treatment started in mandibular arch with IPR ,levelling and aligning with a slight protrusion of the incisors & uprighting the lingually tipped posterior teeth to allow a larger expansion of the maxillary arch

Hyrax appliance was cemented to the 1st premolars & 1st molars and the pt.underwent surgery

One week later , the first effects of the orthopedic expansion were observed & face mask protraction was initiated .elastic producing force of 35o cN per side running at 15 degree angle downword to the palatal plane were applied 14 hours per day.

Hyrax appliance was activated for 3 weeks until there was transverse overcorrection.

Treatment progress

After 3.5 months of maxillary protraction the facial esthetics had improved considerably due to an increased convexity in the facial profile.

Intraorally ,the diastema was reduced and sagittal relation between the two arches improved

After 6 months of retention a transpalatal arch replaced the Hyrax expander and brackets were bonded to max.teeth.

The molars and left canine presented a class I relationship with a good intercuspation of the most posterior teeth

Midlines coincided & their was adequate overjet and overbite .

Results

Profile convexity was improved Intraorally there was good transverse

relationship between the arches ,a normal overbite and overjet and class I molar & canine relationship

Final OPG shows no root resorption but good root parallelism

Normal pretreatment

postexpansion

posttreatment

SNA 82 76 75 75

SNB 80 76 76 75

ANB 2 0 -1 0

SN-GoGn 32 39 40 40

U1-NA 22 18 22 26

U1-NA 4 7 9 9

L1-NB 25 22 32 23

L1-NB 4 4 6 6

U1-L1 131 140 128 134

IMPA 93 85 92 87

FMA 25 29 28 27

FMIA 62 66 60 66

CONCLUSION

In patients with mild skeletal class III discrepancy , camouflage treatment with only maxillary osteotomy and protraction is feasible.

The accomplished results are esthetically and functionally satisfying and also help to prevent extractions and orthognathic surgery.

Thank you

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