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Southwestern Medical School, Children's Medical Center, and Parkland Memorial Hospital are th e principal institutions in this building complex. Parkland Memorial Hospital, the major teachin g unit of the medical school, has 902 beds and admits approximately 39,000 patients annually. It offers a variety of services ranging from outpatient clinics to an active emergency service that provide s an abundance of clinical material for teaching purposes . From its inception, the oral surgery program at Parkland Memorial Hospital has bee n affiliated with the University of Texas Southwestern Medical School . It has since become affiliate d with John Peter Smith Hospital, Forth Worth ; Dallas Veterans Administration Hospital; Presbyterian Hospital; and Children's Medical Center . Four full-time board-certified oral surgeons, one orthodontist, and one maxillofacial prosthodontist supervise the oral surgery residents in training . In addition to the five residents accepted each year, selected appointments are made to individuals for an additional year in research relating to correction of dentofacial and maxillofacial deformities , anesthesia, and other electives in oral surgery . Dr. Robert V. Walker, chief of the division of oral surgery, has served as the program directo r since 1956 .

Surgical-orthodontic correction of horizontal maxillary deficiency

n William H. Bell, DDS, and Joe D. Jacobs, DMD, MSD, Dalla s
The treatment of adults with dentofacial deformities is frequently complicated by horizontal (trans verse) maxillary deficiency . This clinical problem i s typical in individuals with repaired cleft palates , mandibular prognathism, mandibular deficiency, an d anterior open bite deformities . Bilateral or unilatera l palatal crossbites ; crowded, rotated, and buccall y tipped teeth ; and a narrowed and tapering arch for m are the hallmarks of horizontal maxillary deficiency .

Selected maxillary osteotomies in concert with rapi d maxillary expansion appliances are dependabl e adjuncts to treatment of the various clinical manifestations of horizontal maxillary deficiency and th e accompanying crossbite . This report reviews th e important diagnostic, treatment planning, and technical considerations necessary for successful surgical orthodontic correction of horizontal maxillary deficiency .

By proper planning and execution, selecte d maxillary osteotomies can be used with appliances fo r rapid maxillary expansion to achieve correction of th e various clinical manifestations of horizontal maxillar y deficiency and. the accompanying crossbite . Mos t clinical failures with rapid maxillary expansion b y orthodontic appliances have occurred in adults . Inability to expand the maxilla, tipping of the teeth , bending of alveolar bone, and relapse are all well documented consequences of such therapy .` ' Variou s types of maxillary osteotomies have been empiricall y proposed to facilitate lateral movement of the maxill a by palatal expansion appliances . Virtually all of th e maxillary bone articulations have been sectioned to prevent the problems commonly associated with rapi d maxillary expansion in adults . ' Rapid palatal expansion after lateral maxillar y osteotomies in the postpubescent patient may greatl y enhance the potential for successful treatment for bot h orthodontic and ultimate surgical procedures . However, there are certain subtle considerations that must b e understood to adequately diagnose and plan treatment of this nature . Much of this has been discussed i n previous publications . s 10 This report reviews these concepts and adds certain modifications that hav e since been made .
n Diagnosis and Treatment Plannin g

The obvious determination that must initially be made when considering anticipated treatment induced positional changes in dental or skeletal units , or both, needed to achieve the aesthetic and function al needs of the patient is the existence and extent o f deficiency in the transverse (horizontal) dimension . The diagnosis of horizontal maxillary deficienc y is made by positioning the mandibular model into a n approximate Class I canine relationship with th e maxillary model . In many Class II malocclusions, th e same effect can be achieved by having the patien t position the mandible in simulated corrected Class I dental relationship . When this determination ha s been made, and the need for expansion of the maxillary arch does exist, other factors must be considere d to determine whether such expansion should b e achieved through lateral maxillary osteotomies an d rapid maxillary expansion as an integral part of th e presurgical orthodontic therapy, or by segmenting th e maxilla at the time of surgery to achieve transvers e correction concomitantly with ultimate vertical or sagittal, or both, treatment objectives . The first of these factors relates to the amount o f discrepancy in arch length that exists . In cases o f moderate to minimal space deficiency, rapid maxillary expansion will probably increase the circumfer-

ence of the arch sufficiently to permit alignment of the crowded anterior teeth without extraction of premolars or excessive forward tipping of incisors . This ma y be particularly beneficial in cases in which there is a good pretreatment relationship of the incisors to th e maxilla and minimal changes in the sagittal dimension are warranted because of possible changes in th e nasolabial angle . Planning treatment for such individuals in this manner obviates the need for a secondary maxillary surgical procedure . Second, the morphology of the arch is of ke y importance . In most cases in which a transvers e deficiency exists, a narrow, tapering arch form will b e seen . The discrepancy will, therefore, be distinct in th e region of the canines . To ultimately achieve function al occlusion in such patients, the width betwee n canines must be increased and the anterior segmen t flattened (but not retracted significantly) to th e normal elliptical arch morphology . If orthodonti c therapy without tooth extraction is desired, latera l maxillary osteotomies and rapid maxillary expansio n is the preferred treatment . With such treatment, th e width between canines may be increased and anterio r teeth repositioned to achieve proper arch morpholog y through the use of the excess space created an d evidenced by the resultant midline diastema . Treatment of transverse maxillary deficienc y associated with crowded and malaligned teeth i n individuals who have already had orthodontic treatment and extractions is also possible (additional extractions are contraindicated) . The alternative four piece segmental maxillary surgical procedure may b e less than ideal in many cases because of occlusa l compromise requiring additional orthodontic correction . If the transverse discrepancy is minimal an d extraction of first premolars is necessary or desired, a three-piece or a four-piece segmental maxillary surgical procedure may suffice after moving the canines distally by orthodontic means has provided a sufficient increase in width . However, this approac h carries an inherent potential for relapse if any significant buccal tipping of the canines has been acco m plished through orthodontic therapy . This type o f surgical approach may also be indicated if there is n o transverse deficiency in the width between canines bu t significant deficiency in the premolar-molar regio n only . The magnitude of the horizontal deficiency i s another key consideration in planning surgical-orth r dontic treatment of transverse maxillary deficiency . i f for example, a 12-mm horizontal deficiency is presen t in the inter-molar area, the physiologic limits of the L e Fort I technique or combined anterior and posterior


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maxillary osteotomies to correct the problem may b e exceeded . A dual palatal and labial-buccal approac h will facilitate surgical expansion and obviate possibl e problems associated with stretching the palatal vascular pedicle when surgery is accomplished through a circumvestibular incision only . In such cases, th e possibility of vascular impairment can also be minimized by rapid maxillary expansion with latera l maxillary osteotomies and subsequent orthodonti c treatment . Another alternative is a two-piece maxillar y procedure with a midline osteotomy . The resultan t diastema between the maxillary central incisors i s closed postsurgically by orthodontic treatment, there by eliminating the increased horizontal overjet that , obviously, would have to exist . However, there ar e several reasons why such an approach is less tha n ideal . The predictability of ultimate changes in sof t tissue is more difficult . The maxillary incisors ma y move posteriorly during closure of the diastema an d induce posterior sagittal repositioning of the upper lip , which may or may not be aesthetically acceptable t o the patient . Additionally, there is a chance of movin g the posterior maxillary dental units forward durin g closure of the diastema . This would necessitate eithe r extraoral traction for prevention, or Class II elasti c therapy to concomitantly move the mandibular arc h forward to maintain a Class I occlusion . In either case , the chances for compromising both dental and skeleta l stability greatly increase . This is particularly true i n cases in which both the maxilla and the mandibl e have been repositioned by surgery . Additionally , immediate excessive surgical expansion of the maxill a may create periodontal problems by detaching th e gingival cuff from the contiguous teeth and by strip ping the gingiva away from the crestal alveola r bone . The following technique is presented as a significant adjunct to the combined surgical-orthodonti c correction of dentofacial deformities that result i n horizontal maxillary deficiency . The technique i s based on previous research implicating the zygomaticomaxillary and pterygomaxillary articulations as th e primary anatomic sites of resistance to lateral movement of the maxilla by rapid maxillary expansio n appliances . S - 1 0 n A rigid, fixed, tooth-borne appliance with th e capability of producing orthopedic forces is designe d to produce a minimum of tooth movement and a maximum of bone repositioning. Proper design of such devices eliminates the possibility of vascula r ischemia secondary to pressure against the palatal

mucosa, which is the principal source of blood to th e maxilla . The appliance is fabricated from workin g models made of stone and consists of four orthodonti c hands connected by heavily reinforced, soldere d 0.045- to 0 .060-in stainless steel wires and an expansion screw (Fig IF, 2, top right) . The appliance i s cemented to the maxillary first premolars and firs t molars before surgery . The operation is usually done with the patien t under general anesthesia . In selected cooperative individuals, however, lateral maxillary and palatal osteotomies can often be done in the office, and both can b e done using local anesthesia and sedation with relative ly little postoperative morbidity . Antibiotics are. routinely used preoperatively and postoperatively t o protect against infection ; steroids are used to reduc e swelling of soft tissue . Local anesthetic with a vasocon strictor is infiltrated into the labiobuccal vestibule fo r hemostasis . A horizontal incision is made through th e mucoperiosteum above the mucogingival junction i n the depth of the buccal vestibule extending from th e canine region to the second molar (Fig 1B) . A horizontal osteotomy is made through the lateral wall of th e maxilla 4 to 5 mm superior to the apexes of th e anterior and posterior teeth (Fig IA), extending fro m the inferolateral aspect of the piriform rim posteriorl y to the inferior aspect of the junction of the tuberosit y and pterygoid plate . Posteriorly, the bony incision i s angled inferiorly to terminate at the inferior junctio n of the maxillary tuberosity and pterygoid plate . Whe n properly planned and executed in this manner , sectioning of the pterygomaxillary suture is frequentl y unnecessary . In individuals who have excess maxillar y height, the lateral maxillary osteotomies will frequently be positioned more than 5 mm above the apexes o f the teeth, depending on the distance between the roo t apexes and the nasal floor . A small curved osteotom e is used next to separate the tuberosity and pterygoi d plate . The opposite side is operated similarly (Fig IC) . No effort is made to actually mobilize and repositio n the right and left maxillas . A vertical incision is made through the attache d gingiva and mucosa opposite the planned site of th e interincisor osteotomy . Immediate expansion of th e anterior part of the maxillas is usually accomplishe d by careful malleting of a thin osteotome between th e central incisors as illustrated in Figure 1D . Th e forefinger is positioned on the incisive papilla to fee l the osteotome as it transects the palatal bone . Th e osteotome is then malleted posteriorly . If the maxilla s do not separate spontaneously, a fine osteotome i s malleted between the central incisors to fracture th e interseptal bone . Finally, an osteotome is positioned i n the interradicular space and carefully manipulated



Fig 1Soft tissue and bone incisions for surgical orthodontic expansion of maxilla to correct bilateral horizontal maxillary deficiency . A, bilateral horizontal maxillary deficiency is associated with crossbite; horizontal osteotomy of lateral maxilla is made 4 to 5 mm above roo t apexes . B, horizontal incision is made through mucoperiosteum in maxillary vestibule above mucogingival reflection from canine region t o second molar region. Superior margins of incision are raised and retracted to visualize lateral wall of maxilla and inferolateral part of piriform aperture . After distal part of tuberosity has been exposed by tunneling beneath mucoperiosteum, retractor is positioned in area of pterygornaxillary suture to facilitate visualization of lateral maxilla. Periosteal elevator is positioned between nasal mucosa and lateral wal l nasal cavity to protect nasal mucosa when anterolateral portion of maxilla is sectioned with reciprocating saw or bur . Horizontal osteotom y of lateral maxilla is made under constant irrigation with saline solution 4 to 5 mm superior to apexes of anterior and posterior teeth , extending from inferolateral part of pir form rim posteriorly to pterygomaxillary fissure. Posteriorly, horizontal bone incision is angled inferiorh . to terminate at inferior junction of tuberosity and pterygoid plate . C, when cut is not extended inferiorly, maxilla is separated from pterygoi d palate with osteotome malleted medioanteriorly. D, maxillas are separated by malleting thin osteotome between central incisors. Forefinger i s positioned on incisive papilla to feel redirected osteotome as it transsects deeper portion of midpalatal suture . E, osteotome is positioned i n central incisor interradicular space and manipulated to achieve mobilization of anterior maxillas . ., maxillary expansion appliance is activate d to gain space between central incisors and bodily movement of maxilla . G, maxillas are overcorrected so that lingual cusps of mandibula r buccal segments ride up on buccal cusps of mandibular buccal segments.'


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until movement of the right and left maxillas is fel t (Fig 1E) . After the incisions in the bone have bee n completed, the soft tissue wounds are closed wit h continuous resorbable sutures . The appliance for palatal expansion is immediately activated four quarte r turns (1 mm) . Spacing between the central incisor s and midpalatal separation is seen immediately afte r the appliance is activated (Fig IF) . Normally, th e expansion mechanism is activated two quarter turn s twice a day (0 .5 to 1 mm) until the desired amount o f expansion is achieved (Fig 1G) . The patient i s observed every two or three days to monitor th e transverse changes in the maxilla . With such a n expansion, midpalatal separation is achieved wit h minimal pain or sensation of pressure at the maxillar y articular sites . The width of the maxillary arch i s maintained by stabilizing the appliance either b y passing a piece of wire through the hole in th e expansion screw and looping it around the anterio r guide rod, or by adding cold-curing acrylic resin to th e central portion of the expansion appliance ." Th e repositioned segments are retained for two or thre e months with either the maxillary expansion device, a heavy transpalatal wire, or removable appliance . Other orthodontic procedures can be initiated afte r the appliance is stabilized . The rapidity with which such skeletal movements are elicited does not allo w the stretching of the periodontal ligament fibers an d intra-alveolar fibers to concurrently close the resultan t midline diastema as in conventional techniques o f maxillary expansion . As a result, active orthodontic

force will probably be necessary to move the centra l incisors into juxtaposition . Figure 2 illustrates a case o f rapid maxillary expansion using the described technique . When there is clinical evidence of a palata l exostosis, then, in addition to lateral osteotomies an d sectioning of the midpalatal suture, parasagittal palatal osteotomies may be indicated . When extraction o f impacted or partially erupted maxillary third molar s is indicated, they can be concomitantly removed b y slight modification in the design of the horizonta l mucosal incision or through separate soft tissue incisions . The extraction of four impacted third molar s and selected maxillary osteotomies to facilitate expansion of the maxilla is a practical, timely, and usefu l combination of surgical techniques in many adolescents and adults undergoing orthodontic treatment .
n Discussio n

Obviously, there are indications for the treatmen t described in this paper as well as viable alternative s that must be given consideration in treatment planning . This is particularly true when vertical or sagittal, or both, repositioning of the maxilla is necessar y to achieve the desired results . Treatment may b e programmed to achieve the desired horizontal, vertical, and anteroposterior maxillomandibular relation ship by a secondary Le Fort I osteotomy . Additionally , premolars may be extracted after maxillary expansio n to facilitate alignment by a one-, two-, three-, o r four-piece Le Fort I osteotomy . The prime indication for lateral maxillary osteot -

Fig 2Teeth of 24-year-old woman with mandibula r deficiency treated by orthodonti c and surgical techniques for 12 months. Top left, pretreatmen t Class II malocclusion with horizontal maxillary deficiency . Top right, rapid expansio n appliance widening maxilla after lateral maxillary an d pterygomaxillary osteotomies and midsagittal sectioning o f maxilla (technique shown in Figure 1) . Bottom left, centri c occlusion before mandibula r advancement; there is harmony between maxillary an d mandibular arches. Bottom right, mandible is postured int o simulated corrected Class I occlusion to demonstrate tha t arches are adequately coordinated.

omies and rapid maxillary expansion as part o f presurgical orthodontic therapy will be in cases tha t will ultimately not require vertical or sagittal repositioning of the maxilla . However, indications for suc h treatment may also exist for reasons of alleviation o f space discrepancies, presurgical coordination of arche s before mandibular surgery, and correction of abnormal arch morphology even in cases that will require subsequent maxillary surgery . Continual reassessmen t and monitoring of the transverse dimensions of th e maxilla during presurgical orthodontics is indicated t o determine the final definitive surgical plan . If th e problem is mandibular deficiency, the assessment ca n usually be made by instructing the patient to posture the mandible into a Class I occlusion . If this is no t possible, study casts must be taken and models arbitrarily positioned in a Class I canine relationship . B y increasing the width of the maxillary arch, correctio n of crowded and malaligned teeth and uprighting o f anterior teeth can be accomplished without extractions . Additionally, severe constriction of the maxilla that may not be safely corrected by maxillary surger y alone is amenable to correction . If the roots of the central incisors are very closel y apposed, an alternative method of surgery usin g corticotomy principles may be used . With such a method, all of the previously mentioned bone cuts ar e accomplished except the sectioning of interseptal bon e between the central incisors . Gradual orthopedi c forces generated by the expansion appliance during a longer period effect separation of the maxillas (one o r two turns per day) .

n Summar y Selected maxillary osteotomies in concert wit h rapid maxillary expansion appliances are dependabl e adjuncts to treatment of the various clinical manifestations of horizontal maxillary deficiency and th e accompanying crossbite . The important diagnostic , treatment planning, and technical consideration s necessary for successful surgical-orthodontic correction of horizontal maxillary deficiency wer e discussed .
Dr . Bell is associate professor, department of surgery, Center fo r Correction of Dento-Facial Deformities, The University of Texa s Health Science Center, Dallas . Dr . Jacobs is assistant professor , department of orthodontics, Baylor College of Dentistry, Dallas . Requests for reprints should be sent to Dr . Bell, Division of Ora l Surgery, 5323 Harry Hines Blvd, Dallas, 75235 . 1. Wertz, R.A. Skeletal and dental charges accompanying rapi d midpalatal suture opening . Am J Orthod 58 :41-66, 1970. 2. Moss, J .P . Rapid expansion of the maxillary arch . J Prac t Orthod 2 :165-171, 1968 . 3. Moss, J .P . Rapid expansion of the maxillary arch . J Prac t Orthod 2 :215-223, 1968 . 4. Maclntosh, R.B . Total mandibular alveolar osteotomy . J Maxillofac Surg 2(4) :210-218, 1974 . 5. Kole, H . Surgical operations on the alveolar ridge to correc t occlusal abnormalities . Oral Surg 12 :515-529, 1959 . 6. Lines, P .A . Adult rapid maxillary expansion with corticotomy . Am J Orthod 67 :44-56, 1975 . 7. Allison, M .L . Surgical palate splitting . American Society o f Oral Surgeons Audiovisual Awards Contest first prize, institutiona l category, 1974 . 8. Bell, W .H., and Epker, B .N . Surgical-orthodontic expansion o f the maxilla . Am J Orthod 79(5) :517-528, 1976 . 9. Kennedy, J ., and others . Osteotomy as an adjunct to rapi d maxillary expansion . Am J Orthod 70(2) :123-137, 1976 . 10. Bell, W .H ., and Turvey, T .A . Surgical correction of posterio r crossbite . J Oral Surg 32(11) :811-822, 1974 .