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©Sylvain Chamberland
A Closer Look at the Stability of Surgically-Assisted Rapid Palatal
ExpansionJOMS 66 : 1895-1900, 2008
109th Annual SessionAmerican Association of Orthodontists
Boston2009
Dr Sylvain Chamberland, DMD, Cert. Ortho., M.Sc.
Diplomate of ABOFellow of RCDC(c)Member of EHASO
©Dr Sylvain Chamberland
The Research ProblemIs 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
“ 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
The Research Problem
©Dr Sylvain Chamberland
Goal of this Research
©Dr Sylvain Chamberland
Goal of this Research
• Provide data from the maximum expansion point to the end of the orthodontic treatment for short term relapse and stability
©Dr Sylvain Chamberland
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
©Dr Sylvain Chamberland
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
• Provide data 2 years into retention for long term stability
Literature Review
©Dr Sylvain Chamberland
Hierarchy of Stability
Proffit WR, Fields HW, Sarver DM, Contemporary Orthodontics, 4e ed, St-Louis : Mosby Elsevier, 2007, p. 715
©Dr Sylvain Chamberland
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
©Dr Sylvain Chamberland
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
©Dr Sylvain Chamberland
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
n=39
Mean expansion = 4,29± 2,55 mm
Mean relapse= 1,97± 1,5 mm
©Dr Sylvain Chamberland
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
©Dr Sylvain Chamberland
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
©Dr Sylvain Chamberland
Le Fort 1 Morbidity
• Pulpal necrosis
• Periodontal defectsB
A
©Dr Sylvain Chamberland
• Aseptic necrosis
! Most likely to occur with Le Fort 1 osteotomies done in multiple segments in conjonction with superior repositioning and transverse expansion
Le Fort 1 Morbidity
Lanigan et al, J Oral Maxillofac Surg 48: 142-156, 1990
Courtesy of Dr Brian Alpert
©Dr Sylvain Chamberland
• Nasopalatal cyst
• Fibrous healing
SARPE MorbidityA B
A B
©Dr Sylvain Chamberland
• Asymmetric fracture of interdental septum + gingival defect
• 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
Cureton SL, Cuenin M, AJODO, 1999
SARPE Morbidity
©Dr Sylvain Chamberland
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
©Dr Sylvain Chamberland
Non-surgical RPE
• Post pubertal patients! 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
Bacetti et al, AO 2001
Lagravere et al JADA 2006; AO 2005
Spilane & McNamara SO,1995
Zimring & Isaacson, AO 1965
Krebs, EOS 1964
©Dr Sylvain Chamberland
Byloff & Mossaz, 2004 (n=14)
Koudstal et al, 2009; T-B (n = 19)
Koudstal et al, 2009; B-B (n =23)
Berger et al, 1998 (n=28)
Pogrel et al, 1992 (n=12)
Stromberg & Holms, 1995 (n=20)
Bays & Greco, 1992 (n=19)
Nortway & Meade, 1997 (n=16)
-4,50 -2,25 0 2,25 4,50 6,75 9,00
7,50
5,78
5,20
6,80
8,70
5,50
5,78
8,30
6,62
4,77
4,60
6,30
5,54
-0,88
-1,01
-0,60
-0,50
-3,16
-0,22
-0,45
-1,20
Comparative study-1
mm
Stu
dy
Long term relapse Short term relapseNet expansion Maximum expansion
©Dr Sylvain Chamberland
Byloff & Mossaz, 2004 (n=14)
Koudstal et al, 2009; T-B (n = 19)
Koudstal et al, 2009; B-B (n =23)
Berger et al, 1998 (n=28)
Pogrel et al, 1992 (n=12)
Stromberg & Holms, 1995 (n=20)
Bays & Greco, 1992 (n=19)
Nortway & Meade, 1997 (n=16)
-4,50 -2,25 0 2,25 4,50 6,75 9,00
7,50
5,78
5,20
6,80
8,70
5,50
5,78
8,30
6,62
4,77
4,60
6,30
5,54
-0,88
-1,01
-0,60
-0,50
-3,16
-0,22
-0,45
-1,20
Comparative study-1
mm
Stu
dy
Long term relapse Short term relapseNet expansion Maximum expansion
12%
7%
6%
8.3%
17.5%
36%
5,5%
11%
©Dr Sylvain Chamberland
Byloff & Mossaz, 2004 (n=14)
Koudstal et al, 2009; T-B (n = 19)
Koudstal et al, 2009; B-B (n =23)
Berger et al, 1998 (n=28)
Pogrel et al, 1992 (n=12)
Stromberg & Holms, 1995 (n=20)
Bays & Greco, 1992 (n=19)
Nortway & Meade, 1997 (n=16)
-4,50 -2,25 0 2,25 4,50 6,75 9,00
7,50
5,78
5,20
6,80
8,70
5,50
5,78
8,30
6,62
4,77
4,60
6,30
5,54
-0,88
-1,01
-0,60
-0,50
-3,16
-0,22
-0,45
-1,20
Comparative study-1
mm
Stu
dy
Not taken from the maximum expansion point
Long term relapse Short term relapseNet expansion Maximum expansion
12%
7%
6%
8.3%
17.5%
36%
5,5%
11%
©Dr Sylvain Chamberland
Byloff & Mossaz, 2004 (n=14)
Koudstal et al, 2009; T-B (n = 19)
Koudstal et al, 2009; B-B (n =23)
Berger et al, 1998 (n=28)
Pogrel et al, 1992 (n=12)
Stromberg & Holms, 1995 (n=20)
Bays & Greco, 1992 (n=19)
Nortway & Meade, 1997 (n=16)
-4,50 -2,25 0 2,25 4,50 6,75 9,00
7,50
5,78
5,20
6,80
8,70
5,50
5,78
8,30
6,62
4,77
4,60
6,30
5,54
-0,88
-1,01
-0,60
-0,50
-3,16
-0,22
-0,45
-1,20
Comparative study-1
mm
Stu
dy
Not taken from the maximum expansion point
Bias!: Selected cases. Observation:End of ortho 8 to 102 m
Long term relapse Short term relapseNet expansion Maximum expansion
12%
7%
6%
8.3%
17.5%
36%
5,5%
11%
©Dr Sylvain Chamberland
Byloff & Mossaz, 2004 (n=14)
Koudstal et al, 2009; T-B (n = 19)
Koudstal et al, 2009; B-B (n =23)
Berger et al, 1998 (n=28)
Pogrel et al, 1992 (n=12)
Stromberg & Holms, 1995 (n=20)
Bays & Greco, 1992 (n=19)
Nortway & Meade, 1997 (n=16)
-4,50 -2,25 0 2,25 4,50 6,75 9,00
7,50
5,78
5,20
6,80
8,70
5,50
5,78
8,30
6,62
4,77
4,60
6,30
5,54
-0,88
-1,01
-0,60
-0,50
-3,16
-0,22
-0,45
-1,20
Comparative study-1
mm
Stu
dy
Not taken from the maximum expansion point
Still into treatment
12 months study period
Bias!: Selected cases. Observation:End of ortho 8 to 102 m
Long term relapse Short term relapseNet expansion Maximum expansion
12%
7%
6%
8.3%
17.5%
36%
5,5%
11%
©Dr Sylvain Chamberland
Byloff & Mossaz, 2004 (n=14)
Koudstal et al, 2009; T-B (n = 19)
Koudstal et al, 2009; B-B (n =23)
Berger et al, 1998 (n=28)
Pogrel et al, 1992 (n=12)
Stromberg & Holms, 1995 (n=20)
Bays & Greco, 1992 (n=19)
Nortway & Meade, 1997 (n=16)
-4,50 -2,25 0 2,25 4,50 6,75 9,00
7,50
5,78
5,20
6,80
8,70
5,50
5,78
8,30
6,62
4,77
4,60
6,30
5,54
-0,88
-1,01
-0,60
-0,50
-3,16
-0,22
-0,45
-1,20
Comparative study-1
mm
Stu
dy
Not taken from the maximum expansion point
Still into treatment
12 months study period
Bias!: Selected cases. Observation:End of ortho 8 to 102 m
Long term relapse Short term relapseNet expansion Maximum expansion
12%
7%
6%
8.3%
17.5%
36%
5,5%
11%
Small sample
©Dr Sylvain Chamberland
SARPE!: Skeletal Expansion
©Dr Sylvain Chamberland
• Kuo & Will, DCNA 1992! N = 15
! Ratio Skeletal / dental expansion = 84!% (range 50!% to 100 %)
SARPE!: Skeletal Expansion
©Dr Sylvain Chamberland
• 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
SARPE!: Skeletal Expansion
©Dr Sylvain Chamberland
SARPE!: Skeletal Expansion
©Dr Sylvain Chamberland
•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
SARPE!: Skeletal Expansion
©Dr Sylvain Chamberland
•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
• 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)
SARPE!: Skeletal Expansion
©Dr Sylvain Chamberland
•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
• 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)
SARPE!: Skeletal Expansion
• They advocate : separation of
pterygoid junction + a rigid
appliance
©Dr Sylvain Chamberland
Tipping of Buccal Segments
©Dr Sylvain Chamberland
• 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
©Dr Sylvain Chamberland
• 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
©Dr Sylvain Chamberland
Tipping of Buccal Segments
©Dr Sylvain Chamberland
• 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
©Dr Sylvain Chamberland
• 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)
Tipping of Buccal Segments
©Dr Sylvain Chamberland
Tipping of Buccal 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
" Sk / Dental expansion : 111!%– 7,15 ± 2,3!mm / 6,44 ± 1,92!mm
V-shape opening AP & vertically
! Pterygoïd jct
Tausche et al, AJODO 2007
©Dr Sylvain Chamberland
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
©Dr Sylvain Chamberland
• 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
Systematic review-2
©Dr Sylvain Chamberland
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
©Dr Sylvain Chamberland
Research Hypothesis
©Dr Sylvain Chamberland
Research Hypothesis
• The relapse obtained after SARPE and osseous distraction is less than 40% mm in 2/3 of the patients
©Dr Sylvain Chamberland
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)
©Dr Sylvain Chamberland
Sub-hypothesis
©Dr Sylvain Chamberland
Sub-hypothesis
• The diastema measured at the end of the distraction
©Dr Sylvain Chamberland
Sub-hypothesis
• The diastema measured at the end of the distraction
• The screw change is a predictor of skeletal changes
©Sylvain Chamberland
Materials & Methods
Prospective clinical studyConsecutively treated cases
©Dr Sylvain Chamberland
Sample Size Estimation between 2 Groups
• Power 80!%
• 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
N Relapse ^m S-D
Pogrel
Byloff
Philips
Subsample
12 0,88 0,48
14 2,6 1,8
1,364
39 1,97 1,5
12 3,06 1,31
n =2(z1!" /2 + z1!# )
2 sp2
(X1-X2 )2
©Dr Sylvain Chamberland
Sample
• Le Fort 1 subjects > 5 mm! Control subsample !
Experimental
! Conclusion can be inferred
! t : p = 0.6487
! Wilcoxon : p = 0.4777
> 5 mm ^X S-D N
Le Fort 1 Selected subsample
SARPE Consecutive cases
7,36 1,59 12
7,60 1,57 38
• Historical Le Fort 1
! Phillips et al. study (1992)
! Selected Subsample : N =12
! Follow up at postorthodontics (at least 7,5 m post surgery)
Power 80%P < .05
©Dr Sylvain Chamberland
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
©Dr Sylvain Chamberland
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
©Dr Sylvain Chamberland
SARPE Patient Characteristics
• N = 38! 19!, 19"
! Age ^m : 24.9 ± 9,7(range 15,1: 53,7)
• Expander type
! 17 bonded
! 21 banded
# cas
0
2
5
7
9
-,17] (17, 20] (20,25] (25,30] (30,35] (35, +
6
5
2
9
7
9
Distribution
# o
f p
atie
nts
Âge
©Dr Sylvain Chamberland
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 2nd surgery
• T5= At debonding
• T6= At 2 years into retention
©Dr Sylvain Chamberland
SARPE Patient Characteristics
Treatment time (months) N Mean S-D S-E Min Max
©Dr Sylvain Chamberland
SARPE Patient Characteristics
T1-T2 (Distraction completed) 38 0,68 0,22 0,04 0,46 1,81
Treatment time (months) N Mean S-D S-E Min Max
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
©Dr Sylvain Chamberland
Outcome Measures
©Dr Sylvain Chamberland
• 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.
Outcome Measures
©Dr Sylvain Chamberland
• 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
©Dr Sylvain Chamberland
• 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
Appliance Designs
Screw in line with 1st molarsToo forward
©Dr Sylvain Chamberland
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
Aida TI, IJOMS 2003; 32: 54-62
Proffit, Contemporary Tx of dentofacial deformity; 358-361
Racey, JOMS 1992; 50: 114-115
Paccione et al, J Cran Surg 2001;12 (2); 175-181
©Dr Sylvain Chamberland
Treatment Modality
• Brackets bonded in maxillary arch 2 months after expansion
• Expander removal : 6 months after expansion is stopped
• No other retention except the main arch wire
©Dr Sylvain Chamberland
Our SARPE Technique
• Done by the same surgeon(DM)
• Subtotal Le Fort 1 osteotomy Piriform rim
Zygomaticomaxillary buttres
Pterygomaxillary junction
Midpalatal suture
©Dr Sylvain Chamberland
Our SARPE Technique
• Done by the same surgeon(DM)
• Subtotal Le Fort 1 osteotomy Piriform rim
Zygomaticomaxillary buttres
Pterygomaxillary junction
Midpalatal suture
Zygomatic buttress Piriform aperture
Widening of the osteotomy cut : lateral rotation hemimaxillae
©Dr Sylvain Chamberland
• Subtotal Le Fort 1 osteotomy
Our SARPE Technique
©Dr Sylvain Chamberland
• Subtotal Le Fort 1 osteotomy
Separation of the pterygoïd junction Separation with osteotome
of the midpalatal suture
Per-op diastema of 1 to 1,5 mm
Our SARPE Technique
©Dr Sylvain Chamberland
Results of the Study
Error method• Coefficient of fidelity!:
! 99,94!% on dental cast
! 99,90!% on PA Ceph
©Dr Sylvain Chamberland
• All significant : p < .0001
! Expansion
! Relapse
! Net expansion
• Md 1st molar! Expansion : p = .0005
! Relapse : p = .5321
! Net expansion : p = .0129
Dental Changes: Total/Net/Relapse
Closer look at the stability of Surgically-Assisted Rapid Palatal Expansion
JOMS 66: 1895-1900, 2008
Canine
1st premolar
2nd premolar
1st molar
2nd molar
Lower 1st molar
-6,75 -4,50 -2,25 0 2,25 4,50 6,75 9,00
1,39
7,36
7,60
7,86
7,61
5,69
1,59
3,28
5,56
6,04
5,49
2,80
0,25
-4,15
-1,92
-1,75
-1,84
-2,74
Mean changes (mm)
Relapse T5-T3Net expansion T5-T1Maximal expansion T3-T1
©Dr Sylvain Chamberland
Dental Changes
• Canine! Expand less
! Not include into RPE
! Relapse more!Finishing and arch coordination
• 2nd molar
! No ! bonded vs banded
! Relapse due to arch form coordination
Closer look at the stability of Surgically-Assisted Rapid Palatal Expansion
JOMS 66: 1895-1900, 2008
Canine
1st premolar
2nd premolar
1st molar
2nd molar
Lower 1st molar
-6,75 -4,50 -2,25 0 2,25 4,50 6,75 9,00
1,39
7,36
7,60
7,86
7,61
5,69
1,59
3,28
5,56
6,04
5,49
2,80
0,25
-4,15
-1,92
-1,75
-1,84
-2,74
Mean changes (mm)
Relapse T5-T3Net expansion T5-T1Maximal expansion T3-T1
©Dr Sylvain Chamberland
•Expansion at 1st Pm vs 2nd M! SARPE at T3
! Posterior expansion = anterior expansion
! In contrary to previous litterature and non-surgical RPE
! Supported by recent CT scan study (Loddi et al, J Cranio Surg 2008)
! SARPE at T5 : Greater relapse 2nd M may be explained by arch form coordination
! Le Fort 1 : Posterior expansion > anterior expansion
SARPE T3-T1 SARPE T5-T1 Le Fo ort 1
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 66
Expansion Pattern
May be explained by the separation of the pterygoïd junction
©Dr Sylvain Chamberland
•Expansion at 1st Pm vs 2nd M! SARPE at T3
! Posterior expansion = anterior expansion
! In contrary to previous litterature and non-surgical RPE
! Supported by recent CT scan study (Loddi et al, J Cranio Surg 2008)
! SARPE at T5 : Greater relapse 2nd M may be explained by arch form coordination
! Le Fort 1 : Posterior expansion > anterior expansion
SARPE T3-T1 SARPE T5-T1 Le Fo ort 1
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 66
Expansion Pattern
May be explained by the separation of the pterygoïd junction
©Dr Sylvain Chamberland
• Significant skeletal expansion!
! 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
Skeletal e expansion
" Mx T2-T1 " Mx T5-T1
X 3,44 3,63
S-d 1,39 1,54
N 36 23
Paired T p < .0001 p < .0001
Skeletal Changes
©Dr Sylvain Chamberland
• Significant skeletal expansion!
! 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
Skeletal e expansion
" Mx T2-T1 " Mx T5-T1
X 3,44 3,63
S-d 1,39 1,54
N 36 23
Paired T p < .0001 p < .0001
Skeletal Changes
©Dr Sylvain Chamberland
• Skeletal expansion! Mx & Nas. Cav.
! Stable
• Most of the relapse! Dental
• % Sk/Dental! Increased from 45!% to 65!%
! Consistent with other studies
Changes F(time)
0
2,00
4,00
6,00
8,00
0,68 6,65 15,49 23,110
18
35
53
70
45 47
58
65
Ex
pan
sio
n (
mm
)
Time post SARPE (months)
% S
ke
leta
l e
xp
an
sio
n
" 1st Molar" Nasal cavity" Mx% "Mx / " 1st Molar
Changes post SARPE at 1st molar / at Mx / at Nasal cavity
©Dr Sylvain Chamberland
Relapse F(type of surgery)
• One way Anova
! No significant effect
• Any combination of surgical variables
! (Md, Mx, Bimax, No 2nd phase)
! No significant effect
! p = 0.0670 to 0.4525
N F value p
Bimax
Md
Mx
Nil
Total
6
7 F (3, 26) = 0 8125
5
( ) 0.32
0.8125
9
27
©Dr Sylvain Chamberland
Relapse F(time T3-T4-T5)
1st M T3 1st M T4 1st M T5 1st M T6
1st M width
N
p value
Mean
%
50,22 49,13 48,24 47,22
38 30 27 19
p = .0 0008
p = .0 0118
p < .0001
T4-T3 T5-T4 T5-T3
-1,09 -0,89 -1,98
55!% 45!% 100!%
• 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
! 55!% relapse entre T4-T3
! 45!% relapse entre T5-T4
©Dr Sylvain Chamberland
Relapse F(type of appliance)
• Banded expander has the same efficacy of bonded expander
! Similar dental expansion
! Similar skeletal expansion
! Similar relapse
N Bonded N 2 Bd Hx p value
Exp. 1st M T3-T1
Sk Exp Mx
Relapse 1st M T5-T3
17 7,91 21 7,34 .2727
15 3,85 12 3,04 .7090
16 -1,70 11 -2,23 .4410
©Dr Sylvain Chamberland
Relapse F(extraction pattern)
• 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
"1st M M T5-T3
N Mean S-D Paired T
Extraction
Non-Extraction
6 -2,97 ± 1,40p = 0 1366
17 -1,68 ± 1,85p = 0.1366
©Dr Sylvain Chamberland
•" 1st M T3-T1 / Diastema T2 = 91%! 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
Diastema F(" 1st molar)
! Expansion rate too slow (.3 mm / jrs)
! Callus ossification ! bone consolidation
©Dr Sylvain Chamberland
• A-Telescoping zygomatic arch
• B-Minimal palatal separation
• C-Impinging of the screw into the palate
• Appliance = totally inadequate
C
A A
B
©Dr Sylvain Chamberland
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
©Dr Sylvain Chamberland
Before expansion
After expansionA
B
Lateral Rotation• A- Inward Mvt
• B- Palatal impingement
• Therefore!: place the screw 3- 4 mm away from palatal mucosa
• Supported Koodstaal et al, 2009
! Increase in palatal width results in decrease in depth... explained by tipping of the maxillary segments
©Dr Sylvain Chamberland
• A-moderate separation
• B-Impingement
• C-Inward Mvt
Alveolar bendingBefore
expansion
After expansionC
A
B
©Dr Sylvain Chamberland
• A-moderate separation
• B-Impingement
• C-Inward Mvt
Alveolar bendingBefore
expansion
After expansionC
A
B
©Dr Sylvain Chamberland
©Dr Sylvain Chamberland
" Skeletal" / " Screw
©Dr Sylvain Chamberland
" 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
©Dr Sylvain Chamberland
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
©Dr Sylvain Chamberland
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
©Dr Sylvain Chamberland
Comparison to non-surgical RPE
•Our data! 3,58!mm skelettal!: 65!% of the mean net dental
expansion (5,56!mm)
©Dr Sylvain Chamberland
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
©Dr Sylvain Chamberland
SARPEE Le Fort 1
N Mean S-D N Mean S-D p value
Canine
1st premolar
2nd premolar
1st molar
2nd molar
26 -2,74 1,75 12 -0,74 1,85 .0026
22 -1,84 2,11 9 -1,31 1,67 .5130
27 -1,75 2,55 11 -2,05 1,45 .7099
27 -1,92 1,74 12 -3,06 1,31 .0491
24 -4,15 1,89 8 -3,69 1,08 .5193
Stability Compared to Segmental Osteotomy
• No significant difference! 1st Pm, 2nd Pm, 1st M, 2nd M
• Canine : relapse more because of arch coordination
©Dr Sylvain Chamberland
• 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
Stability Compared to Segmental Osteotomy
1st molar 27 -1,92 (25%) ±1,74 12 -3,06 (42%) ±1,31 .0491
©Dr Sylvain Chamberland
• 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 treatmentMeasured from the maximum expansion point
Stability Compared to Segmental Osteotomy
1st molar 27 -1,92 (25%) ±1,74 12 -3,06 (42%) ±1,31 .0491
©Dr Sylvain Chamberland
Experimentals (n=38; 27;19)
Controls (n=12)
Controls (n=39)
Byloff & Mossaz, 2004 (n=14)
Koudstal et al, 2009 (n = 19) T-B
Koudstal et al, 2009 (n =23) B-B
Berger et al, 1998 (n=28)
Pogrel et al, 1992 (n=12)
Stromberg & Holms, 1995 (n=20)
Bays & Greco, 1992 (n=19)
Nortway & Meade, 1997 (n=16)
-4,50 -2,25 0 2,25 4,50 6,75 9,00
4,6
7,50
5,78
5,20
6,80
8,70
4,28
7,36
7,59
5,50
5,78
8,30
6,62
4,77
4,60
6,30
5,54
2,31
4,30
5,56
-0,88
-1,01
-0,60
-0,50
-3,16
-1,97
-3,06
-1,91
-0,22
-0,45
-1,20
-1,01
mm
Comparison to Other Studies
Long Term Relapse Short Term RelapseNet expansion Maximum expansionLong term exp
©Dr Sylvain Chamberland
Experimentals (n=38; 27;19)
Controls (n=12)
Controls (n=39)
Byloff & Mossaz, 2004 (n=14)
Koudstal et al, 2009 (n = 19) T-B
Koudstal et al, 2009 (n =23) B-B
Berger et al, 1998 (n=28)
Pogrel et al, 1992 (n=12)
Stromberg & Holms, 1995 (n=20)
Bays & Greco, 1992 (n=19)
Nortway & Meade, 1997 (n=16)
-4,50 -2,25 0 2,25 4,50 6,75 9,00
4,6
7,50
5,78
5,20
6,80
8,70
4,28
7,36
7,59
5,50
5,78
8,30
6,62
4,77
4,60
6,30
5,54
2,31
4,30
5,56
-0,88
-1,01
-0,60
-0,50
-3,16
-1,97
-3,06
-1,91
-0,22
-0,45
-1,20
-1,01
mm
Comparison to Other Studies
Long Term Relapse Short Term RelapseNet expansion Maximum expansionLong term exp
Relapse>>
>>
©Dr Sylvain Chamberland
Experimentals (n=38; 27;19)
Controls (n=12)
Controls (n=39)
Byloff & Mossaz, 2004 (n=14)
Koudstal et al, 2009 (n = 19) T-B
Koudstal et al, 2009 (n =23) B-B
Berger et al, 1998 (n=28)
Pogrel et al, 1992 (n=12)
Stromberg & Holms, 1995 (n=20)
Bays & Greco, 1992 (n=19)
Nortway & Meade, 1997 (n=16)
-4,50 -2,25 0 2,25 4,50 6,75 9,00
4,6
7,50
5,78
5,20
6,80
8,70
4,28
7,36
7,59
5,50
5,78
8,30
6,62
4,77
4,60
6,30
5,54
2,31
4,30
5,56
-0,88
-1,01
-0,60
-0,50
-3,16
-1,97
-3,06
-1,91
-0,22
-0,45
-1,20
-1,01
mm
Comparison to Other Studies
But ! NS
Long Term Relapse Short Term RelapseNet expansion Maximum expansionLong term exp
Relapse>>
>>
Relapse <
<
©Dr Sylvain Chamberland
Experimentals (n=38; 27;19)
Controls (n=12)
Controls (n=39)
Byloff & Mossaz, 2004 (n=14)
Koudstal et al, 2009 (n = 19) T-B
Koudstal et al, 2009 (n =23) B-B
Berger et al, 1998 (n=28)
Pogrel et al, 1992 (n=12)
Stromberg & Holms, 1995 (n=20)
Bays & Greco, 1992 (n=19)
Nortway & Meade, 1997 (n=16)
-4,50 -2,25 0 2,25 4,50 6,75 9,00
4,6
7,50
5,78
5,20
6,80
8,70
4,28
7,36
7,59
5,50
5,78
8,30
6,62
4,77
4,60
6,30
5,54
2,31
4,30
5,56
-0,88
-1,01
-0,60
-0,50
-3,16
-1,97
-3,06
-1,91
-0,22
-0,45
-1,20
-1,01
mm
Comparison to Other Studies
But ! NS
Long Term Relapse Short Term RelapseNet expansion Maximum expansionLong term exp
Relapse>>
>>
Relapse <
<
"Exp.
©Dr Sylvain Chamberland
• 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
H1 : Relapse obtained after SARPE and osseous distraction is less than 40% mm in 2/3 of the patients
0!%
10,0!%
20,0!%
30,0!%
40,0!%
50,0!%
'-,-3] (-3 to -1] (-1 to 1] (1 to 3]
9,1!%
18,2!%
50,0!%
22,7!%
3,7!%
29,6!%
40,7!%
25,9!%
SARPE: Post-Tx changes
% o
f p
atie
nt
Relapse (mm)
First MolarFirst Premolar
0!%
14,0!%
28,0!%
42,0!%
56,0!%
70,0!%
'-,-3] (-3 to -1] (-1 to 1] (1 to 3]
11,1!%
44,4!%
33,3!%
11,1!%
0!%
8,3!%
25,0!%
66,7!%
LeFort 1:Post-Tx Changes
Relapse (mm)
First MolarFirst Premolar
©Dr Sylvain Chamberland
• 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
H1 : Relapse obtained after SARPE and osseous distraction is less than 40% mm in 2/3 of the patients
0!%
10,0!%
20,0!%
30,0!%
40,0!%
50,0!%
'-,-3] (-3 to -1] (-1 to 1] (1 to 3]
9,1!%
18,2!%
50,0!%
22,7!%
3,7!%
29,6!%
40,7!%
25,9!%
SARPE: Post-Tx changes
% o
f p
atie
nt
Relapse (mm)
First MolarFirst Premolar
0!%
14,0!%
28,0!%
42,0!%
56,0!%
70,0!%
'-,-3] (-3 to -1] (-1 to 1] (1 to 3]
11,1!%
44,4!%
33,3!%
11,1!%
0!%
8,3!%
25,0!%
66,7!%
LeFort 1:Post-Tx Changes
Relapse (mm)
First MolarFirst Premolar
66%
©Dr Sylvain Chamberland
Clinical Implications
• If only transverse changes are needed! SARPE = Choice # 1
MC; tx:18m CS; tx:~22mYP; tx:~24m
©Dr Sylvain Chamberland
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
©Dr Sylvain Chamberland
But!: SARPE still indicated
• For large transverse AP and vertical changes or periodontally compromised patients
(Personal opinion)
©Dr Sylvain Chamberland
• SARPE! Improved stability not proven from the maximum
expansion point
! 2 mm overexpansion recommended
! Tipping et rotation of hemimaxillae
• Once normal transverse relationship is achieved = new case to diagnose and Tx plan
Clinical Implications
tx:18m: 2Y ret tx:22m; 2 surg tx:27m; 2 surg
©Dr Sylvain Chamberland
Final Discussion
• SARPE
– Long term stability proven; relapse at 2 y N-S
• Le Fort 1 : No data from sequential PA ceph & no long term data
SARPE long g term relap pse 2Y SARPE lo ong term changes
N Mean S-D p value N Mean S-D p value
Canine
1st premolar
2nd premolar
1st molar
2nd molar
Low. 1st Molar
18 0,02 0,73 .9090 18 2,41 2,01 < .0001
16 -0,44 1,45 .2467 16 4,94 2,23 < .0001
19 -0,56 1,43 .1067 19 5,36 2,47 < .0001
19 -1,01 1,13 .0011 19 4,60 2,09 < .0001
17 -0,59 1,34 .0857 16 2,59 1,31 < .0001
19 -0,23 1,50 .5057 19 0,69 2,45 .2320
©Dr Sylvain Chamberland
Relapse T5-T32 y out of txNet expansion T5-T1Maximal expansion T3-T1Sans titre 1
Canine
1st premolar
2nd premolar
1st molar
2nd molar
1st lower molar
-6 -4 -2 0 2 4 6 8
0,69
2,59
4,60
5,36
4,94
2,41
1,39
7,36
7,60
7,86
7,61
5,69
1,59
3,28
5,56
6,04
5,49
2,80
0,02
-0,48
-0,56
-1,01
-0,59
-0,23
0,25
-4,15
-1,92
-1,75
-1,84
-2,74
Dental changes: Total/Net/Relapse
Mean changes (mm)
Te
eth
©Dr Sylvain Chamberland
Thank You Dr Proffit
For your precious advice and help
©Dr Sylvain Chamberland
I also want to thank my wife Carole and my children Pier-EricVanessaRichardfor their patience and their love
Thank You !