Surgically Assisted Maxillary Expansion

Norman J. Betts, DDS, MS a,b,c,*

KEYWORDS
 Transverse maxillomandibular discrepancy  Stability  Surgically assisted maxillary expansion  SAME

KEY POINTS
 The transverse dimension of the maxillomandibular complex must be evaluated, diagnosed, and addressed to achieve
stability after orthognathic correction.
 Orthopedic maxillary expansion (nonsurgical) is effective and stable in the young population before sutural closure and is
not effective or stable in patients after sutural closure in the maxillofacial complex. Treatment with orthopedic expansion
in this group leads to uncontrolled relapse and periodontal and occlusal complications of the teeth after the removal of
orthodontic appliances.
 To achieve the desired expansion and stability, transverse maxillary expansion should be accomplished by sutural ad-
justments in the craniofacial complex, not by alveolar bending and dental tipping. The SAME (surgically assisted maxillary
expansion) procedure is a combination of distraction osteogenesis and controlled soft tissue expansion.
 After the surgical procedure, the maxilla should remain stationary for at least 5 days before initiation of expansion at a rate
of 0.5 mm/d.
 Surgical transverse changes are unstable for a longer period than are most other surgical or orthodontic movements. It
takes approximately 6 months to achieve bony continuity in the midpalatal osteotomy site. Therefore, some form of
skeletal retention is recommended for at least 6 to 12 months after expansion.

Introduction: nature of the problem age limitation. The SAME procedure is a combination of
distraction osteogenesis and controlled soft tissue expansion.
Complete and accurate evaluation of a patient with a dentofacial Discussion of SAME is often confusing because various combi-
deformity must include assessment of the transverse dimension. nations of maxillary, pterygopalatine lateral nasal, septal, and
Few practitioners adequately evaluate the transverse dimension, palatine osteotomies have been used, based on the surgeon’s
often resulting in undiagnosed transverse maxillomandibular theory of where resistance to expansion is located. The pur-
discrepancy. When a transverse maxillomandibular discrepancy pose of this article is to describe the clinical and radiographic
exists, adult patients have traditionally been treated with or- evaluation of the transverse dimension in patients with den-
thodontic expansion or a segmental maxillary osteotomy, tofacial deformity and to present the indications for SAME and
frequently leading to transverse maxillary instability and relapse an anatomically based SAME technique.
after orthodontic appliance removal.
Orthopedic or rapid maxillary expansion (ORME) is also a
technique used to treat transverse maxillomandibular Surgical technique
discrepancy. If used in the correct patient population, this
technique is predicable and stable for the correction of Preoperative planning
transverse maxillomandibular discrepancy. It is of limited
benefit in mature teenage and adult patients, because the Accurate diagnosis and treatment of transverse maxillary
maxillary articulations become increasingly resistant to deficiency are essential to the long-term stability after
expansion with aging. Techniques of surgically assisted maxil- correction of any dentofacial deformity that includes a trans-
lary expansion (SAME) have been developed to overcome this verse discrepancy. However, diagnosis of transverse maxillary
deficiency may be difficult, because minimal facial soft tissue
changes are associated with isolated transverse maxillary hy-
a
Private Practice, Chelsea Oral and Facial Surgery, 1303 South Main poplasia. In contrast, isolated anteroposterior or vertical
Street, Suite B, Chelsea, MI 48118, USA skeletal deformities are easier to diagnose, because they often
b
Private Practice, Ann Arbor Oral and Facial Surgery, 3055 Plymouth have obvious associated facial soft tissue findings. Conse-
Road, Suite 202, Ann Arbor, MI 48105, USA
c quently, the transverse deformity is often not diagnosed when
Department of Oral and Maxillofacial Surgery, University of Michi-
gan School of Dentistry, 3055 Plymouth Road, Suite 202, Ann Arbor, MI sagittal and vertical deformities exist concomitantly. There-
48105, USA fore, it is not surprising that clinical inspection for transverse
* Chelsea Oral and Facial Surgery, 1303 South Main Street, Suite B, maxillary deficiency has been shown to be of poor diagnostic
Chelsea, MI 48118. value. Complete diagnosis of this deformity must include both
E-mail address: [email protected] clinical and radiographic evaluation.

Atlas Oral Maxillofacial Surg Clin N Am 24 (2016) 67–77

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68 Betts

Clinical evaluation useful in determining the total discrepancy and showing

whether there is a greater deficiency or excess on 1 side or the
The existence and extent of a transverse discrepancy must be other. However, this differential does not elucidate in which
determined and the skeletal and dental components of the jaw the discrepancy exists and may be misinterpreted when
deformity must be differentiated before contemplating surgery mandibular asymmetry is present. The maxillomandibular
(Box 1, Fig. 1). transverse differential index is the age-specific expected
maxillomandibular difference minus the actual measured
maxillomandibular difference. The expected max-
Radiographic evaluation illomandibular difference is the age-appropriate expected
AG-GA distance minus the age-appropriate expected JR-JL
A standard posteroanterior (PA) cephalogram is the radiograph distance. The actual maxillomandibular difference is the
of choice for identification and evaluation of a transverse actual AG-GA measurement minus the actual JR-JL measure-
discrepancy. Ricketts developed the Rocky Mountain analysis ment. In an adult patient, a maxillomandibular transverse
and established relative norms using specific radiographic differential index greater than 5 mm suggests a need for sur-
landmarks and measurements to analyze transverse discrep- gical expansion. As well as quantifying the total discrepancy,
ancies between the maxilla and mandible (Box 2, Fig. 2). this method allows for the identification of which jaw is defi-
Using these landmarks, it is possible to determine the cient or excessive, because actual values can be compared
effective maxillary width, effective mandibular width, and with normal values. Normal values have been suggested only
frontolateral facial lines. The effective maxillary width is the for Caucasian, and these values should not be considered
width of the maxilla between the points JL (jugale left) and JR normal values for other races.
(jugale right). The effective mandibular width is the width of
the mandible between AG and GA. The frontolateral facial Treatment of transverse maxillomandibular
lines are the lateral lines constructed from OR (orbitale right) discrepancy
and OL (orbitale left) to the points AG and GA, respectively.
Using these cephalometric landmarks, it is possible to SAME combines an orthopedic appliance and osteotomies to
determine the maxillomandibular width differential and the achieve maxillary skeletal expansion in 1 to 2 weeks (Box 3).
maxillomandibular transverse differential index for quantifi- The technique chosen to correct the transverse discrepancy is
cation of the transverse maxillary discrepancy (Fig. 3). The dependent on many factors, but most important is the skeletal
maxillomandibular width differential is the distance (in milli- maturity of the patient (Box 4). Additional factors include the
meters) measured from the frontolateral facial line to JL and magnitude of the transverse discrepancy and whether gingival
JR, respectively, along a line from the frontolateral facial lines dehiscence or bony fenestration is already present on the
through JR and JL. This measurement is calculated indepen- maxillary canine and bicuspid teeth. Generally, patients in the
dently for each side and compared with a normal value of primary dentition and the mixed dentition stage are treated by
10  1.5 mm. If this value is greater than 10 mm, a transverse ORME. Transverse maxillary growth ceases and the maxillofa-
discrepancy between the maxilla and mandible exists. The cial sutures close at skeletal age 14 to 15 years in females and
values greater than 10 mm on each side are summed to 15 to 16 years in males. Adults are best treated by SAME or
quantify the total transverse deficiency. This technique is segmental Le Fort osteotomy.
After sutural closure, ORME is unsuccessful, because the
expansion is composed primarily of alveolar or dental tipping,
Box 1. Clinical indicators of transverse with little or no skeletal expansion. This situation can lead to
many problems in adults, including an inability to activate the
maxillary deficiency appliance, pain on activation, pressure necrosis of the palatal
tissue under the appliance, tipping and extrusion of the
1. Facial soft tissue changes including paranasal hollow-
maxillary teeth, bending of the alveolar bone, uncontrolled
ing, a narrowed alar base, and deepening of the
relapse after orthodontic appliance removal, and periodontal
nasolabial folds
complications. These periodontal complications result from
2. Negative space (distance between the corner of the
the tipping of the maxillary teeth out through the buccal
mouth and the buccal surfaces of the posterior maxil-
cortical bone, resulting in cortical thinning, dehiscence, or
lary teeth during full smile)
fenestration of the maxillary teeth. If gingival inflammation is
3. Unilateral or bilateral posterior crossbite (a distinction
present, the patient is predisposed to gingival recession and
must be made between dental and skeletal crossbite)
dental instability (Fig. 4). In contrast, if the transverse maxil-
4. Crowded, rotated, and palatally or buccally displaced
lary deficiency is less than 5 mm of the total maxillomandibular
teeth
discrepancy, sufficient buccal bone is generally present to
5. Narrow and tapering maxillary arch form, described as
allow for some dental tipping. In this case, ORME may be
hourglass shaped
considered if there are no periodontal defects or gingival
6. High, narrow palatal arch
recession already present in the posterior maxillary quadrants.
7. Associated skeletal deformities include maxillary ver-
tical and anteroposterior hypoplasia and zygomatic
hypoplasia (as a result of growth issues) Preparation and patient positioning
8. Other associated dentofacial deformities include ver-
tical maxillary excess, mandibular prognathism or Before the procedure, an expansion device must be placed.
mandibular sagittal deficiency, apertognathia, and The best results are achieved when one of the several varia-
repaired cleft palate tions of the jackscrew appliance is used. To achieve expansion,
a palatally positioned jackscrew is placed within a framework

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Surgically Assisted Maxillary Expansion 69

Fig. 1 (A) Intraoral view of severe transverse maxillary hypoplasia. There is a bilateral palatal crossbite and rotated, crowded, and
displaced teeth. (B) Palatal view of a patient with transverse maxillary hypoplasia. Note the narrow, tapering, hourglass-shaped arch form
in addition to the narrow and high palatal vault. (From Betts NJ, Vanarsdall RL, Barber HD, et al. Diagnosis and treatment of transverse
maxillary deficiency. Int J Adult Orthodon Orthognath Surg 1995;10:77, 91; with permission.)

attached to the first molars and other teeth as available osteotomies that have been empirically proposed to facilitate
(usually the first bicuspid teeth). The most common jackscrew lateral maxillary expansion reflect the controversy regarding
appliances used today are the Haas and Hyrax. The Haas the primary area of resistance to expansion in the craniofacial
appliance (Fig. 5) has acrylic palatal flanges incorporated into skeleton. Most recently, investigators have recommended
the appliance, which have been shown to decrease buccal sectioning of virtually all the maxillary bony articulations, that
tipping of the dentition and produce greater skeletal expan- is, zygomaticomaxillary buttresses, midpalatal suture, and
sion. However, because of the acrylic palatal pads, there is a pterygomaxillary junction. An investigation by Shetty and co-
slightly increased risk of palatal tissue impingement, and food workers attempted to give a biomechanical rational for the
can become entrapped beneath the flanges. The Hyrax appli- choice of osteotomies by analyzing the internal stress response
ance (Fig. 6) is similar in design to the Haas appliance, with the after SAME in a photoelastic model fabricated from a human
exception that it does not have the acrylic palatal pads. Its use skull. A Hyrax appliance was placed and activated, and
theoretically results in more dental tipping and less skeletal sequential cuts were performed on the model. The alterations
expansion. The occlusal coverage Haas appliance (Fig. 7) is a in the internal stresses of the skull were recorded after each
hybrid of the Haas appliance with a flat plane occlusal cut. All the bony buttresses of the maxilla contributed resis-
coverage splint. This appliance must be physically bonded to tance to expansion, but the midpalatal suture followed by the
the maxillary teeth. Its use is recommended in patients with pterygomaxillary articulations were the primary areas of
periodontally compromised dentition, because the appliance resistance. These investigators also reported that forces
incorporates more of the teeth in the device (not just the first caused by appliance activation have deep anatomic effects,
bicuspid and first molar teeth). Therefore, the transverse with stresses present at sites distant from the force applica-
forces are distributed among more teeth. It may also be useful tion. Even although this study has significant validity and reli-
in patients with temporomandibular joint (TMJ) symptoms, ability problems, it provides important information concerning
because the appliance can be equilibrated like an occlusal
coverage splint during expansion to minimize the premature
dental interferences common during the transverse expansion.
Like the Haas appliance, it use may result in less dental tipping
and more skeletal expansion. However, because of problems
with oral hygiene, it must be removed 3 to 4 months after
placement and an immediate palatal coverage retainer placed
to minimize transverse relapse (Box 4).
The 3 principal areas of vertical and horizontal maxillary
support are the nasomaxillary, zygomaticomaxillary, and
pterygomaxillary buttresses (Fig. 8). The many maxillary

Box 2. Skeletal landmarks used in the evalu-

ation of maxillomandibular transverse
discrepancy
1. JR (jugale right) and JL (jugale left) (the intersection
of the maxillary tuberosity and the zygomatic buttress)
2. AG (antegonion right) and GA (antegonion left) (the
inferior margin of the antegonial protuberance, below Fig. 2 The elements of the PA cephalometric analysis. These
the antegonial trihedral area) landmarks can be used to calculate the effective maxillary width
3. OR (orbitale right) and OL (orbitale left) (representing and effective mandibular width, and the frontolateral lines can be
the intersection of the orbits with the middle cranial constructed. (From Betts NJ, Vanarsdall RL, Barber HD, et al.
fossa) Diagnosis and treatment of transverse maxillary deficiency. Int J
Adult Orthodon Orthognath Surg 1995;10:78; with permission.)

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70 Betts

practice should be limited to younger patients, because they

require less extensive surgery to accomplish adequate maxil-
lary expansion. Patient positioning in the operating room
should be similar to that described for the Le Fort I osteotomy.
Nasal intubation is preferred. However, because max-
illomandibular fixation is not necessary for this surgical pro-
cedure, oral intubation can be used.

Surgical approach

Based on the knowledge that the areas of resistance to trans-

verse expansion include all the bony buttresses of the maxilla,
the technique advocated is a subtotal Le Fort I maxillary
osteotomy (Box 5, Fig. 9). The mandibular dentition should be
decompensated before surgery to allow assessment of the
amount of transverse expansion necessary and to assist in
preventing postexpansion relapse with dental interdigitation.
In addition, the maxillary expansion appliance must be placed
preoperatively and the appliance key must be present in the
operating suite to allow intraoperative activation.

Surgical caveats

During this procedure, the appliance is widened 3 to 4 mm and

then turned back to a final opening of 1 to 1.5 mm. The
perpendicular plate of the palatine bone is thick and offers
significant resistance posteriorly. During maximal expansion,
the surgeon should check that both maxillae are adequately
mobile. If they are not, the osteotomies should be checked or
more surgery performed.
Sectioning of the posterior portions of the thin lateral nasal
wall is unnecessary because it offers little resistance to
transverse expansion. Release of the pterygoid plates is
Fig. 3 Worksheet used to determine the radiographic magnitude necessary because they are part of the sphenoid, which is a
and location of the maxillomandibular transverse discrepancy. single bone without a midline suture. Therefore, orthopedic
(From Betts NJ, Vanarsdall RL, Barber HD, et al. Diagnosis and forces cannot widen the pterygoid plates, and they should be
treatment of transverse maxillary deficiency. Int J Adult Orthodon separated from the maxillae. SAME can also be used in cases of
Orthognath Surg 1995;10:79; with permission.) unilateral or asymmetric maxillary deformities. In this situa-
tion, the osteotomies outlined earlier are created on only 1
side, thus allowing a differential anchorage situation with more
the areas of resistance to transverse expansion in the adult
expansion on one side. As would be expected, on the non-
human skull.
operated side, buccal bone bending and dental tipping occur.
Typically, this procedure is performed in a hospital setting
After appliance removal, almost complete relapse occurs on
as an outpatient or 24-hour stay procedure. Although SAME has
the nonoperated side.
been successfully performed in the outpatient setting, this

Postoperative care, rehabilitation, and recovery

Box 3. Benefits of the SAME procedure Routine follow-up care should be similar to that of the Le Fort I
osteotomy, with the exception that liquid diet is followed for
1. Improved dental and skeletal stability only the first week and the diet is advanced from that time
2. Nonextraction orthodontic alignment of the dentition forward.
3. Improved aesthetics by the elimination of negative After the surgical procedure, the maxilla should remain
space (distance between the corner of the mouth and stationary for at least 5 days before initiation of expansion at a
the buccal surfaces of the posterior maxillary teeth rate of 0.5 mm/d (2 activations of the jack screw appliance a
during full smile) and a decrease in the buccal hol- day). This strategy is based on Ilizarov’s work in the extrem-
lowing of the lateral maxilla ities, which showed that a healing period of 5 days allows for
4. Improved long-term periodontal health capillary healing across the bony gap. Reestablishment of this
5. Improved nasal respiration as a result of widening of blood supply leads to faster and more complete ossification of
the nasal cavity and internal nasal valve (this widening the expanded defect. Ilizarov showed that an expansion rate of
results from the lateral repositioning of the lateral 0.5 to 1 mm/d does not outstrip this critical blood supply.
nasal walls during maxillary expansion) However, in the maxilla, a rate of 0.5 mm/d is recommended.
Expansion rates greater than this may cause gingival recession

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Surgically Assisted Maxillary Expansion 71

Fig. 4 Palatal (A) and lateral (B, C) views of an adult patient who had previously undergone unsuccessful orthopedic rapid maxillary
expansion. The expansion has relapsed and has also resulted in significant buccal gingival recession bilaterally in the canine and premolar
regions. (From Betts NJ, Vanarsdall RL, Barber HD, et al. Diagnosis and treatment of transverse maxillary deficiency. Int J Adult Orthodon
Orthognath Surg 1995;10:84; with permission.)

on the mesial side of the central incisors, especially if bone and symmetric. If gingival recession or gapping occurs between the
attachment loss is already present. gingiva and the root surface, the expansion rate should be
During expansion, the patient should feel little discomfort. decreased. In contrast to ORME, overcorrection is not recom-
If pain is experienced, there is bony interference or inadequate mended for SAME.
mobilization or the appliance is not functioning properly. Surgical transverse changes are unstable for a longer period
However, symptoms of tightness and minor discomfort in the than are most other surgical or orthodontic movements. It
nasal root/glabellar area and posterior orbit can and do occur, takes approximately 6 months to achieve bony continuity in the
with anatomic basis. Pain in the nasal root area can be midpalatal osteotomy site. Therefore, some form of skeletal
attributed to an outward rotation of the maxillary halves retention is recommended for at least 6 to 12 months after
around an axis of rotation located near the frontonasal suture expansion. The expansion device can be retained for this
(because the lateral nasal walls are not osteotomized purpose or a palatal coverage retainer can be placed (Fig. 11).
completely during the surgical procedure) (Fig. 10). The pres-
sure felt in the posterior orbit is caused by the small articu-
lation of the palatine bone, which is not sectioned during the Potential complications
surgical procedure.
Palatal expansion must occur within 4 weeks of surgery or Intraoperative complications of SAME are similar to those that
the osteotomies may heal before the required transverse occur with Le Fort I maxillary osteotomy. Intraoperative
dimension has been achieved. During the period of expansion, hemorrhage can be limited by respecting the relevant anat-
immature attached gingival tissue should be seen medial to omy, carefully elevating nasal mucosa, limiting the lateral
each central incisor tooth. This immature attached gingival nasal wall osteotomies to the first 1.5 mm, and appropriately
tissue arises when skeletal or dental expansion exceeds the placing and orienting the pterygoid osteotome. By maintaining
ability of the attached gingiva to remodel. It is a sign of suc- the horizontal osteotomy 5 mm above the dental apices, risk of
cessful expansion and should appear bilaterally and be devitalizing the teeth is diminished. The vertical osteotomy

Fig. 5 Clinical example of a Haas palatal expansion device. Fig. 6 Hyrax expansion device. (From Betts NJ, Vanarsdall RL,
(From Betts NJ, Vanarsdall RL, Barber HD, et al. Diagnosis and Barber HD, et al. Diagnosis and treatment of transverse maxillary
treatment of transverse maxillary deficiency. Int J Adult Orthodon deficiency. Int J Adult Orthodon Orthognath Surg 1995;10:83; with
Orthognath Surg 1995;10:83; with permission.) permission.)

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72 Betts

Fig. 7 Occlusal coverage Haas-type appliance. (From Betts NJ,

Vanarsdall RL, Barber HD, et al. Diagnosis and treatment of Fig. 8 The maxillary buttresses: nasomaxillary, zygomatico-
transverse maxillary deficiency. Int J Adult Orthodon Orthognath maxillary, and pterygomaxillary. Resistance to palatal expansion
Surg 1995;10:83; with permission.) also arises from the midpalatal suture. (From Betts NJ, Vanarsdall
RL, Barber HD, et al. Diagnosis and treatment of transverse
maxillary deficiency. Int J Adult Orthodon Orthognath Surg
between the central incisors should be performed with a 1995;10:85; with permission.)
spatula osteotome to preserve bony coverage of the medial
surface of the central incisor roots. Preoperative orthodontics
may be useful in splaying the roots in preparation for surgery. expansion, the surgeon must perform more extensive surgery
Postoperative complications can be divided into those in older patients. Older patients often require rechecking of
caused by inadequate release of the maxillae (Box 6) and those the osteotomies and scoring of the posterior wall of the sinus to
caused by problems with the expansion device (Box 7, Figs. 12 achieve adequate mobilization.
and 13). Palatal tori can be a significant barrier to palatal expansion,
because they are composed of dense cortical bone. The pres-
ence of a palatal torus in this situation can be approached in 2
Other caveats (modification of the surgically assisted different ways. The ideal treatment is to surgically remove the
maxillary expansion procedure) torus 4 to 6 months before the SAME procedure. However,
concomitant removal of the torus can be performed if the
There is increased resistance to expansion with increasing surgeon is willing to place the expansion appliance intra-
skeletal maturity and age. To achieve stable and adequate operatively. The appliance must be fabricated on a model from

Box 5. Summary of the surgical procedure

(see Fig. 9)
Box 4. Indications for SAME 1. Vestibular incision 5 mm above the mucogingival
junction bilaterally from the first molar area to the
1. Skeletal maxillomandibular transverse discrepancy midline
greater than 5 mm (Caucasian patients) 2. Bilateral maxillary osteotomy from the pyriform rim to
2. Significant transverse maxillary deficiency associated the pterygomaxillary fissure; this osteotomy is created
with a narrow maxilla and wide mandible parallel to the maxillary occlusal plane with a step at
3. Failed orthodontic or orthopedic expansion the buttress and ostectomy performed the buttress to
4. Necessity for a large amount (>7 mm) of expansion, or allow expansion
preference to avoid the potential increased risk of 3. Release of the nasal septum (to prevent septal devia-
segmental osteotomies tion during expansion)
5. Extremely thin, delicate gingival tissue or presence of 4. Midline palatal osteotomy extended interdentally be-
significant buccal gingival recession in the canine- tween the maxillary incisors and from the anterior
bicuspid region of the maxilla nasal spine through the posterior nasal spine
6. Significant nasal stenosis 5. Osteotomy of the anterior 1.5 mm of the lateral nasal
7. Need for widening of the maxillary arch when no other wall
skeletal deformity is present 6. Bilateral release of the pterygoid plates
8. Widening of the arch to provide space for dental 7. Activation of the appliance with a total widening of 1
alignment without requiring maxillary extractions to to 1.5 mm, with evaluation for symmetric expansion
create space 8. Soft tissue closure, including alar base cinch with
9. Widening of the arch after collapse associated with the nonresorbable suture and V-Y closure to control the
cleft palate deformity soft tissues of the nasal base and upper lip

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Surgically Assisted Maxillary Expansion 73

Fig. 9 Individual steps in the technique of SAME (A) Preoperative state. (B) The Haas palatal expansion device in place before surgery. The
appliance has not been activated. (C) Clinical photograph of the surgical incision identical to the one used for the LeFort I osteotomy,
above the mucogingival junction. (D) The maxillary osteotomy extending from the pyriform rim to the pterygomaxillary fissure. This
osteotomy is parallel to the occlusal plane, with a step and bone removed at the buttress to allow for expansion. (E) Clinical photograph
showing the maxillary osteotomies. (F) Release of the nasal septum from anterior nasal spine to the posterior nasal spine. (G) The nasal
septal release. (H) The midline palatal osteotomy. The osteotome is first directed inferiorly to split the alveolar bone between the
maxillary central incisors and then posteriorly to split the hard palate. (I) Osteotome placement being used to split the alveolar bone
between the maxillary central incisors. (J) Separation of the hard palate, with the osteotome directed posteriorly along the palate. (K) The
lateral nasal wall osteotomy, which is carried posteriorly for 1.5 mm. (L) Release of the pterygoid plates from the tuberosity of the
posterior maxilla. Note that a curved osteotome of less than 10 mm is being positioned in an inferior, anterior, and medial direction. (M)
Clinical view of the placement of the curved osteotome to separate the pterygoid plates. (N) Expansion device key used for appliance
activation. The key should be attached to floss or string to prevent accidental swallowing or aspiration. (O) Clinical view showing activation
of the appliance with the key. (P) Frontal diagram of the completed SAME.

which the torus has been removed. Because a midpalatal maxilla preferentially moves inferiorly at the first molar during
incision is necessary to remove the torus, thus compromising expansion (Fig. 14A). This movement can cause worsening of an
palatal blood supply, the lateral, nasal, horizontal maxillary, open bite or conversion of an open-bite tendency to a skeletal
pterygomaxillary, and anterior midpalatal osteotomies should open bite, therefore mandating a secondary maxillary osteot-
be performed through vertical incisions in the buccal mucosa omy. Prevention of this problem requires modification of the
combined with subperiosteal tunneling. The torus is then SAME technique to ensure that all osteotomies of the anterior
removed by the conventional technique, and parasagittal and lateral maxillary walls are parallel to the maxillary occlusal
palatal osteotomies are completed directly through this inci- plane. A vertical step is created at the maxillary buttress so that
sion. The expansion appliance is then tested to ensure that it transverse expansion can occur without bony interference in the
has no direct contact with the palatal tissues. buttress region. Bone removal of just less than half the desired
When performing SAME on patients with a skeletal open bite amount of transverse expansion is completed at each buttress
or open-bite tendency, care must be taken to prevent worsening (see Fig. 14B). If a secondary Le Fort I maxillary osteotomy is
of the open bite with this procedure. If a ramped or angled cut is planned because of the existence of other dentofacial de-
made from the pyriform rims to the maxillary buttress, the formities, the osteotomies for SAME should be placed in the

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74 Betts

Fig. 9 (continued) (Q) Palatal view of a Haas expansion device in place, with the vectors of expansion shown (R) An alar cinch suture and V-Y
closure are used to close the incision to control the soft tissues of the upper lip and nasal base. Clinical photograph of a Boley gauge checking
the width of the alar base of the nose after an alar cinch suture has been placed to reposition the tissues to the preoperative value. (S) Clinical
photograph showing the use of a Boley gauge set at 10 mm to correctly close the vertical leg of the V-Y closure. (T) Completed V-Y closure. (U)
Palatal view of the maxilla with the Haas appliance in place after 2 weeks of expansion. (V) Maxillary occlusal film showing the palatal
expansion after 2 weeks. (W) Clinical palatal view of same patient 3 months after expansion with Haas appliance used as a retention device.
(X) Haas appliance removed. (Y) Occlusal coverage transpalatal retainer which will be used for the next 3 months to prevent transverse
relapse. This patient had preexisting TMJ problems, hence the occlusal coverage. (From Betts NJ, Vanarsdall RL, Barber HD, et al. Diagnosis
and treatment of transverse maxillary deficiency. Int J Adult Orthodon Orthognath Surg 1995;10:86e9; with permission.)

location of the planned osteotomy cut of the future Le Fort 1 year after SAME (still in orthodontic appliances) and found an
procedure. This strategy is because the osteotomies in the 11.8% relapse at the maxillary first molar. Bays and Greco
anterior and lateral maxillary walls seldom completely heal studied 19 patients who had undergone SAME who had
after SAME, and this may compromise future osteotomies or the completed orthodontic therapy more than 6 months previously
ability to apply rigid fixation. and found an 8.8% relapse at the canines, 1% at the first bicuspid,
and 7.7% at the first maxillary molar. The reported relapse in the
Surgically assisted maxillary expansion versus transverse component of segmental maxillary osteotomies has
segmental maxillary osteotomy and clinical results in been considerably higher. Stephens found a 30% and 23% relapse
the literature at the canine and molar regions, respectively, in 15 patients who
had undergone segmental maxillary osteotomies with an
When a patient requires surgical correction of a transverse average follow-up of 47.5 months after debanding. Phillips and
discrepancy, a decision must be made regarding which surgical colleagues compared the transverse stability in 39 patients who
technique (SAME or segmental maxillary osteotomy) will be underwent either a 2-piece Le Fort osteotomy (n Z 26) or a 3-
used. Certainly, for a patient who requires a maxillary osteot- piece Le Fort osteotomy (n Z 13). The postorthodontic follow-
omy to correct vertical or anteroposterior deformities, consid- up was 14 to 47 months (mean Z 24.4 months). Significant
eration should be given to the segmental maxillary osteotomy. transverse relapse in both groups was observed, ranging from
There are some difference (other than SAME requiring a second 11% at the canines to 47% at the second molar in the 2-piece
surgical procedure) that merit discussion. The first is post- group and from 30% at the first premolar to 51% at the first molar
operative stability. Pogrel and associates studied 12 patients in the 3-piece group.

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Surgically Assisted Maxillary Expansion 75

segmental maxillary osteotomy often include extraction of

teeth with partial orthodontic space closure to allow for safe
performance of interdental osteotomies. In nonextraction
segmental osteotomies, the dentition requires buccal expan-
sion before surgery, which is unstable and prone to post-
operative relapse.
The major disadvantage of a treatment plan that includes
SAME followed by a 1-piece Le Fort maxillary osteotomy is
that 2 surgical procedures are required. If a patient who has
had a SAME procedure requires a Le Fort osteotomy for
correction of concomitant dentofacial deformity, a second
procedure must occur after orthodontic decompensation of
the maxillary and mandibular dentition. In contrast, a
segmental maxillary osteotomy attempts to correct the de-
formities in all planes of space during 1 surgical procedure.
The segmental maxillary osteotomy is a more difficult, more
technically sensitive, and potentially more morbid procedure
than a 1-piece maxillary osteotomy. Complications such as
Fig. 10 The outward rotation of the maxillary halves around the
tooth root injuries, periodontal defects, and vascular
axis of rotation located near the frontonasal suture. This situation
compromise are more common in segmental than in 1-piece
results from incomplete lateral nasal wall osteotomies, which are
maxillary osteotomies. The total cumulative time under
not sectioned during surgery and articulate with the skull high in
general anesthesia is approximately the same for SAME fol-
the nasal cavity. (From Betts NJ, Vanarsdall RL, Barber HD, et al.
lowed by a 1-piece Le Fort I as for a segmental Le Fort
Diagnosis and treatment of transverse maxillary deficiency. Int J
osteotomy. The potential postoperative morbidity is reduced
Adult Orthodon Orthognath Surg 1995;10:90; with permission.)
when SAME followed by a 1-piece Le Fort maxillary osteotomy
is performed. Surgical and operating costs are less for the
segmental maxillary osteotomy when performed in the hos-
pital, but costs could be less if the SAME were performed in an
The pattern of transverse expansion is different for SAME ambulatory or office setting.
than for maxillary segmental osteotomies. More expansion
occurs at the canines and less at the molars after SAME. In
contrast, during segmental Le Fort maxillary osteotomy, more
expansion is achieved at the maxillary molars than at the ca-
Summary and suggestions regarding the
nines. In the SAME procedure, all the maxillary articulations correction of transverse discrepancies in adult
are not osteotomized superiorly and posteriorly (lateral nasal patients
wall and palatine bone); therefore, the greater resistance to
expansion in the posterior maxilla accounts for less posterior  For patients who require less than 5 mm of transverse
expansion. The inelasticity of the palatal mucosa is a major expansion with adequate buccal bone present and no
limiting factor for segmental Le Fort osteotomy. Widening of gingival recession on the posterior maxillary dentition,
more than 6 mm is not stable or feasible. Therefore, transverse orthodontic/orthopedic expansion should be attempted.
expansion greater than 7 mm would be an indication for SAME.  If the transverse discrepancy is greater than 5 mm, SAME
SAME is generally performed early in the treatment should be performed early in the treatment sequence,
sequence. Early expansion of the maxilla allows orthodontic after dental decompensation of the mandibular dentition.
alignment in the severely crowded maxillary arch without the  In a patient requiring a maxillary osteotomy for correction
need to extract teeth. Treatment plans that include a of concomitant dentofacial deformities with a transverse

Fig. 11 (A) Haas expansion device maintained as a retention device after expansion. Note the immature red granulation tissue present
bilaterally on the medial surfaces of the maxillary central incisors. (B) Palatal coverage retainer used as a retention device. The acrylic
base plate should not touch the anterior teeth and allows for orthodontic movement and closure of the midline diastema. (From Betts NJ,
Vanarsdall RL, Barber HD, et al. Diagnosis and treatment of transverse maxillary deficiency. Int J Adult Orthodon Orthognath Surg
1995;10:91; with permission.)

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 Box 6. Complications associated with inade- Box 7. Complication caused by the expansion
quate surgery (activation of an appliance device
against mature, intact sutures)
1. Lack of appliance expansion
1. Pain and pressure 2. Deformation of the appliance caused by processing
2. Dental tipping errors (see Fig. 12)
3. Periodontal breakdown (as teeth are pushed through 3. Stripping or loosening of the midpalatal screw (see
the buccal plate) Fig. 13)
4. Palatal tissue impingement by the expansion device
(possibly with tissue necrosis)
5. Postorthodontic relapse

Fig. 12 (A) Example of an appliance that was overheated during fabrication, leading to deformation of the metal frame rather than
expansion. The patient experienced pain from the palate with each activation of the expansion key. Note the absence of a midline
diastema, indicating lack of maxillary expansion. (B) Palatal view after removal of the expansion appliance, showing a large ulcer on the
plate extending to the alveolar ridge. (From Betts NJ, Vanarsdall RL, Barber HD, et al. Diagnosis and treatment of transverse maxillary
deficiency. Int J Adult Orthodon Orthognath Surg 1995;10:91; with permission.)

Fig. 13 Occlusal view showing unequal expansion of a Haas appliance that had a malfunctioning jackscrew, although adequate expansion
was achieved. (From Betts NJ, Vanarsdall RL, Barber HD, et al. Diagnosis and treatment of transverse maxillary deficiency. Int J Adult
Orthodon Orthognath Surg 1995;10:92; with permission.)

Fig. 14 (A) The result of performing SAME using a ramped cut. As the expansion is performed, the maxilla moves inferiorly at the first
molar, worsening an open bite or converting an open-bite tendency into a true open bite. (B) This problem of inferior movement of the
maxilla during expansion can be overcome by performing the osteotomies parallel to the maxillary plane and creating a vertical cut at the
buttress, with excision of bone in the amount of the planned movement. This allows the maxillary expansion to occur without any bony
interference. (From Betts NJ, Vanarsdall RL, Barber HD, et al. Diagnosis and treatment of transverse maxillary deficiency. Int J Adult
Orthodon Orthognath Surg 1995;10:92; with permission.)

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Surgically Assisted Maxillary Expansion 77

discrepancy of less than 7 mm, consideration should be Betts NJ, Thanasas AG, Lisenby CW, Mosier KM. Evaluation of racial
given to segmental maxillary osteotomy. (African-American, Caucasian) and gender differences in skeletal
 When a segmental maxillary osteotomy is used in a pa- transverse dimension. J Oral Maxillofac Surg 1997;55(Suppl 3):86e7.
tient with a transverse discrepancy of greater than 6 mm, Buamrind S, Korn EL. Transverse development of human jaws between
the ages of 8.5 and 15.5 years, studied longitudinally with the use of
complete expansion at the molars is difficult to achieve at
implants. J Dent Res 1990;69:1298e306.
the time of surgery, because of palatal tissue inelasticity, Crosby DR, Jacobs JD, Bell WH. Special adjunctive considerations:
and is difficult to retain in the posttreatment period. transverse (horizontal) maxillary deficiency. In: Bell WH, editor.
Therefore, SAME should be performed early in the treat- Modern practice in orthognathic and reconstructive surgery, vol. 3.
ment sequence, followed by a 1-piece Le Fort osteotomy. Philadelphia: WB Saunders; 1992. p. 2403e30.
 If 2 separate maxillary surgical procedures are planned, da Silva Filho OG, Boas MC, Capelozza Gilho L. Rapid maxillary
the SAME osteotomies should be performed where the 1- expansion in the primary and mixed dentitions: a cephalometric
piece maxillary osteotomies are projected to be. evaluation. Am J Orthod 1991;100:171e81.
 The diagnosis of maxillomandibular transverse discrep- Enlow DH. The facial growth process: part 1. In: Enlow DH, edi-
ancy may be difficult in adult patients when sagittal and tor. Facial growth. 3rd edition. Philadelphia: WB Saunders;
1990. p. 58e76.
vertical deformities mask the transverse maxillary
Haas AJ. Rapid expansion of the maxillary dental arch and nasal cavity
discrepancy. When appropriate clinical and radiographic by opening the midpalatal suture. Angle Orthod 1961;31:73e90.
assessments are performed, the correct diagnosis and Haas AJ. The treatment of maxillary deficiency by opening the mid-
treatment sequences can be applied, resulting in an palatal suture. Angle Orthod 1965;35:200e17.
acceptable and stable outcome. Ilizarov GA. Clinical applications of tension-stress effects for limb
lengthening. Clin Orthop Relat Res 1990;(250):8e26.
Further readings Kraut RA. Surgically assisted rapid maxillary expansion by opening the
midpalatal suture. J Oral Surg 1984;42:651e5.
Angell EH. Treatment of irregularities of the permanent or adult teeth. Krebs A. Midpalatal suture expansion studied by the implant method
Dental Cosmos 1860;1:540e4. 599-601. over a seven year period. Trans Eur Orthod Soc 1964;40:131e42.
Bailey L, White RP, Proffitt WR, Turvey TA. Segmental LeFort I Lanigan DT, Hey JH, West RA. Aseptic necrosis following maxillary
osteotomy for management of transverse maxillary deficiency. J osteotomies: report of 36 cases. J Oral Maxillofac Surg 1990;48:
Oral Maxillofac Surg 1997;55:728e31. 142e56.
Banning LM, Gerard N, Steinberg BJ, Bogdanoff E. Treatment of Melson B. A histological study of the influence of sutural morphology
transverse maxillary deficiency with emphasis on surgically assisted and skeletal maturation on rapid palatal expansion in children.
rapid maxillary expansion. Compend Cont Educ Dent 1996;17: Trans Eur Orthod Soc 1972;48:499e507.
170e8. Mossaz CF, Byloff FK, Richter M. Unilateral and bilateral corticotomies
Basdra EK, Zoller JE, Komposch G. Surgically assisted rapid palatal for correction of maxillary transverse discrepancies. Eur J Orthod
expansion. J Clin Orthod 1995;29:762e6. 1992;14:110e6.
Bays RA, Greco JM. Surgically assisted rapid palatal expansion: an Persson M, Thilander B. Palatal suture closure in man from 15-35 years
outpatient technique with long-term stability. J Oral Maxillofac Surg of age. Am J Orthod 1977;72:42e52.
1992;50:110e3. Phillips C, Medland WH, Fields HW Jr, et al. Stability of surgical
Bays RA, Greco JM, Hale RG. Stability of surgically assisted rapid maxillary expansion. Int J Adult Orthodon Orthognath Surg 1992;7:
palatal expansion. A long term study. J Dent Res 1990;69:296. 139e46.
Bell WH, Epker BN. Surgical-orthodontic expansion of the maxilla. Am J Pogrel MA, Kaban LB, Vargervik K, Baumrind S. Surgically assisted rapid
Orthod 1976;70:517e28. maxillary expansion in adults. Int J Adult Orthodon Orthognath Surg
Bell WH, Jacobs JD. Surgical-orthodontic correction of horizontal 1992;7:37e41.
maxillary deficiency. J Oral Surg 1979;37:897e902. Ricketts RM, Roth RH, Chaconas SJ, et al. Orthodontic diagnosis and
Bell RA. A review of maxillary expansion in relation to rate of expansion planning.their roles in preventative and rehabilitative dentistry.
and patient’s age. Am J Orthod 1982;81:32e7. Denver (CO): Rocky Mountain Data Systems; 1982. p. 20e5. 42,
Betts NJ, Lisenby CW. Normal adult transverse jaw values obtained 50e59, 138, 233e235.
using standardized posteroanterior cephalometrics. J Dent Res Ricketts RM. Perspectives in the clinical application of cephalometrics,
1994;73:298. the first fifty years. Angle Orthod 1981;51:115e50.
Betts NJ, Rosenberg M. Two different alar cinch suturing techniques Shetty V, Cardid JM, Caputo AA, et al. Biomechanical rationale for
following surgical maxillary expansion. J Dent Res 1995;74:96. surgical-orthodontic expansion of the adult maxilla. J Oral Max-
Betts NJ, Scully JR. Transverse maxillary distraction osteogenesis. illofac Surg 1994;52:742e9.
In: Fonseca RJ, Marciani R, Turvey TA, editors. Oral and Silverstein K, Quinn PD. Surgically-assisted rapid palatal expansion for
maxillofacial surgery. 2nd editionvol. III. St Louis (MO): Saun- management of transverse maxillary deficiency. J Oral Maxillofac
ders; 2009. p. 219e37. Surg 1997;55:725e7.
Betts NJ, Fonseca RJ, Vig P, et al. Changes in the nasal and labial soft Stephens CR. An examination of the long-term stability of surgical-or-
tissues after surgical repositioning of the maxilla. Int J Adult thodontic maxillary expansion [Master’s thesis]. Columbus (OH):
Orthodon Orthognath Surg 1993;8:7e23. Ohio State University; 1986.
Betts NJ, Vanarsdall RI, Barber HD, et al. Diagnosis and treatment of Turvey TA. Maxillary expansion: a surgical technique based on surgical-
transverse maxillary deficiency. Int J Adult Orthodon Orthognath orthodontic treatment objectives and anatomic considerations. J
Surg 1995;10:75e96. Maxillofac Surg 1985;13:51e8.

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