A Closer Look at the Stability of
  Surgically-Assisted Rapid Palatal
             Expansion
                          JOM...
The Research Problem
             Is the expansion obtained with SARPE more
               stable than the expansion obtai...
The Research Problem

                 “ How much of the expansion that we put
                 in the screw is transferre...
Goal of this Research




©Dr Sylvain Chamberland
Goal of this Research
           • Provide data from the maximum expansion
                  point to the end of the ortho...
Goal of this Research
           • Provide data from the maximum expansion
                  point to the end of the ortho...
Goal of this Research
           • Provide data from the maximum expansion
                  point to the end of the ortho...
Literature Review
Hierarchy of Stability




                          Proffit WR, Fields HW, Sarver DM, Contemporary Orthodontics, 4e ed, St...
Hierarchy of Stability
                          • Multi-segmented Le Fort 1
                           ! The least stable...
Multi-segmented
                   Le Fort 1 &
                     Expansion
               • Average 50% loss of surgica...
Multi-segmented
                   Le Fort 1 &                       m
                     Expansion                     ...
Early papers on SARPE stability used
                          those data to recommend SARPE as a 1st
                    ...
Relevance
                     • SARPE + 1 piece Le Fort 1
                          ! Easier than segmental Le Fort 1
   ...
Le Fort 1 Morbidity
                                                  A




                          • Pulpal necrosis

 ...
Le Fort 1 Morbidity
                •         Aseptic necrosis
                     !     Most likely to occur with Le
   ...
SARPE Morbidity
     •
                                    A   B

                 Nasopalatal cyst



                   ...
SARPE Morbidity
     •           Asymmetric fracture of interdental septum + gingival
                 defect


          ...
Relevance
           • Stability
                ! No good scientific evidence; No consensus
                          !Kou...
Non-surgical RPE
            • Post pubertal patients                                                         Krebs, EOS 1...
Comparative study-1


                                                        -3,16
             Byloff & Mossaz, 2004 (n=...
Comparative study-1


                                                        -3,16
             Byloff & Mossaz, 2004 (n=...
Comparative study-1


                                                        -3,16
             Byloff & Mossaz, 2004 (n=...
Comparative study-1


                                                        -3,16
             Byloff & Mossaz, 2004 (n=...
Comparative study-1


                                                        -3,16
             Byloff & Mossaz, 2004 (n=...
Comparative study-1


                                                        -3,16
             Byloff & Mossaz, 2004 (n=...
SARPE!: Skeletal Expansion




©Dr Sylvain Chamberland
SARPE!: Skeletal Expansion
                 • Kuo & Will, DCNA 1992
                          ! N = 15
                   ...
SARPE!: Skeletal Expansion
                 • Kuo & Will, DCNA 1992
                          ! N = 15
                   ...
SARPE!: Skeletal Expansion




©Dr Sylvain Chamberland
SARPE!: Skeletal Expansion
                 • Byloff & Mossaz, EJO 2004
                          ! N =14; Ratio Sk / D = ...
SARPE!: Skeletal Expansion
                 • Byloff & Mossaz, EJO 2004
                          ! N =14; Ratio Sk / D = ...
SARPE!: Skeletal Expansion
                 • Byloff & Mossaz, EJO 2004
                          ! N =14; Ratio Sk / D = ...
Tipping of Buccal
                Segments




©Dr Sylvain Chamberland
Tipping of Buccal
                Segments
                 • Chun & Goldman, EJO 2003 (HAAS 4 bd)
                       ...
Tipping of Buccal
                Segments
                 • Chun & Goldman, EJO 2003 (HAAS 4 bd)
                       ...
Tipping of Buccal
                Segments




©Dr Sylvain Chamberland
Tipping of Buccal
                Segments

                 • Hino C.T.et al, J Craniofac Surg, May 2008
                ...
Tipping of Buccal
                Segments

                 • Hino C.T.et al, J Craniofac Surg, May 2008
                ...
V-shape opening AP &
             Tipping of Buccal                                                vertically
            ...
Systematic Review-1
                     • Lagravere et al, Int. J. Oral Maxillofac.
                           Surg. 2006...
Systematic review-2
                     • Koudstaal et al, Int. J. Oral Maxillofac.
                           Surg. 2005...
Koudstaal et al, Int. J. oral
                  Maxillofac. Surgery, 2009
                     •        N= 46 : 25 bone-bo...
Research Hypothesis




©Dr Sylvain Chamberland
Research Hypothesis

                     • The relapse obtained after SARPE and
                          osseous distrac...
Research Hypothesis

                     • The relapse obtained after SARPE and
                          osseous distrac...
Sub-hypothesis




©Dr Sylvain Chamberland
Sub-hypothesis

               • The diastema measured at the end of the
                          distraction




©Dr Syl...
Sub-hypothesis

               • The diastema measured at the end of the
                          distraction

          ...
Materials & Methods

  Prospective clinical study
 Consecutively treated cases




         ©Sylvain Chamberland
Sample Size Estimation
                            between 2 Groups
            2(z1! " /2 + z1! # )2 s 2               N ...
> 5 mm               ^X              S-D    N

        Sample                   Le Fort 1 Selected
                       ...
Type 1 Error

                     •        To avoid type 1 error, since there was
                              multiple ...
Experimental Sample

                     • Inclusion criteria
                          ! Transverse deficiency > 5 mm

  ...
SARPE Patient Characteristics

               •
                                                                          ...
Observation
           • D1= Tx intiated in mandibular arch
           • T1= Prior to SARPE
           • T2= At the end of...
SARPE Patient Characteristics
                   Treatment time (months)   N   Mean   S-D   S-E   Min   Max




©Dr Sylvai...
SARPE Patient Characteristics
                   Treatment time (months)   N    Mean    S-D    S-E    Min     Max

       ...
Outcome Measures




©Dr Sylvain Chamberland
Outcome Measures
                  •        Study cast
                  •        Screw width
                          ! ...
Appliance Designs
              • Superscrew™                         (16 mm) (Klapper, JCO 1995)

                  ! 2 b...
Appliance Designs
              • Screw placed close to C res
                          !   (Braun et al, AJODO 2000)

   ...
Treatment Modality
         • Tx initiated in the mandibular arch
         • Appliance cementation 1 day to 1 week
       ...
Treatment Modality
                 • Bracketsafter expansion arch 2
                   months
                           ...
Our SARPE Technique
      •        Done by the same surgeon(DM)                    Midpalatal suture

                    ...
Our SARPE Technique
      •        Done by the same surgeon(DM)                             Midpalatal suture

           ...
Our SARPE Technique
      •        Subtotal Le Fort 1 osteotomy




©Dr Sylvain Chamberland
Our SARPE Technique
      •        Subtotal Le Fort 1 osteotomy



            Separation of the                          ...
Results of the Study

                                Error method
                                 • Coefficient of fidelit...
Dental Changes: Total/Net/Relapse
                                                                          Relapse T5-T3
...
Dental Changes
                                                                                 Relapse T5-T3
            ...
Expansion Pattern
                                            SARPE T3-T1              SARPE T5-T1                   Le Fo...
Expansion Pattern
                                            SARPE T3-T1              SARPE T5-T1                   Le Fo...
Skeletal e
                                                                                                  expansion

  ...
Skeletal e
                                                                                                  expansion

  ...
Changes F(time)                                                     Changes post SARPE
                                   ...
Relapse F(type of surgery)
         •        One way Anova
                                                           N   ...
Relapse F(time T3-T4-T5)
         •        Repeated measures Anova
         •        Relapse is related with time elapsed ...
Relapse F(type of appliance)
                                                N    Bonded   N    2 Bd Hx   p value

       ...
Relapse F(extraction pattern)
                                                    "1st M T5-T3
                           ...
Diastema F(" 1st molar)
        •" 1 M T3-T1 / Diastema T2 = 91%
                               st

                  ! r ...
A
                                            A
                                                               B




     ...
Skeletal " T3 / Dental " T3
               • Low correlation between Sk " / Dt "
                   ! r = 0,249; r2 = 0,06...
Lateral Rotation
        •        A- Inward Mvt                       Before expansion

        •        B- Palatal imping...
Alveolar bending
                                         Before
                                        expansion



    ...
Alveolar bending
                                         Before
                                        expansion



    ...
©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,...
Relapse vs Expansion

              • Relapse T5-T3 / Dental expansion T3
                          (n = 27) : 25%
       ...
SARPE Skeletal Expansion
                     • Skeletal expansion greater than other
                          studies us...
Comparison to non-
                                surgical RPE
                     •Our data
                          !...
Comparison to non-
                                surgical RPE
                     •Our data
                          !...
Stability Compared to
                              Segmental Osteotomy
                                      SARPE
      ...
Stability Compared to
                          Segmental Osteotomy
            1st molar       27   -1,92 (25%)   ±1,74  ...
Stability Compared to
                          Segmental Osteotomy
            1st molar       27   -1,92 (25%)   ±1,74  ...
Comparison to Other Studies
                                                             -1,91    -1,01
             Exper...
Comparison to Other Studies
                                                            -1,91    -1,01
             Experi...
Comparison to Other Studies
                                                           -1,91    -1,01
             Experim...
Comparison to Other Studies
                                                           -1,91    -1,01
             Experim...
H1 : Relapse obtained after SARPE and osseous
                      distraction is less than 40% mm in 2/3 of the patients...
H1 : Relapse obtained after SARPE and osseous
                      distraction is less than 40% mm in 2/3 of the patients...
Clinical Implications
                     • If only transverse changes are needed
                          ! SARPE = Cho...
Clinical Implications
        •        When maxilla need to be repositioned AP or vertically in a
                 2nd pha...
But!: SARPE still indicated
              • For large transverse AP and vertical
                          changes or peri...
Aao 109th annual_session_boston_2009_closer look at the stability of sarpe 2009_sarpe_sylvain_chamberland_orthodontiste_qu...
Aao 109th annual_session_boston_2009_closer look at the stability of sarpe 2009_sarpe_sylvain_chamberland_orthodontiste_qu...
Aao 109th annual_session_boston_2009_closer look at the stability of sarpe 2009_sarpe_sylvain_chamberland_orthodontiste_qu...
Aao 109th annual_session_boston_2009_closer look at the stability of sarpe 2009_sarpe_sylvain_chamberland_orthodontiste_qu...
Aao 109th annual_session_boston_2009_closer look at the stability of sarpe 2009_sarpe_sylvain_chamberland_orthodontiste_qu...
Aao 109th annual_session_boston_2009_closer look at the stability of sarpe 2009_sarpe_sylvain_chamberland_orthodontiste_qu...
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Clinical prospective study on the stability of SARPE including short term data at debonding and long term data at 2 years out of orthodontic treatment.

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Aao 109th annual_session_boston_2009_closer look at the stability of sarpe 2009_sarpe_sylvain_chamberland_orthodontiste_quebec

  1. 1. A Closer Look at the Stability of Surgically-Assisted Rapid Palatal Expansion JOMS 66 : 1895-1900, 2008 109th Annual Session American Association of Orthodontists Boston 2009 Dr Sylvain Chamberland, DMD, Cert. Ortho., M.Sc. Diplomate of ABO Fellow of RCDC(c) Member of EHASO ©Sylvain Chamberland
  2. 2. The Research Problem Is 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
  3. 3. The Research Problem “ 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 ©Dr Sylvain Chamberland
  4. 4. Goal of this Research ©Dr Sylvain Chamberland
  5. 5. 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
  6. 6. 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
  7. 7. 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 ©Dr Sylvain Chamberland
  8. 8. Literature Review
  9. 9. Hierarchy of Stability Proffit WR, Fields HW, Sarver DM, Contemporary Orthodontics, 4e ed, St-Louis : ©Dr Sylvain Chamberland Mosby Elsevier, 2007, p. 715
  10. 10. 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 : ©Dr Sylvain Chamberland Mosby Elsevier, 2007, p. 715
  11. 11. 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
  12. 12. Multi-segmented Le Fort 1 & m Expansion m 9 9± 2 m ,55 m =3 surgical expansion • Average 50% loss of= 4,2 ± 1,5 n • on 1 of Relapse > 2 mm in 66%,97the patients si = an se p p x> 3 mm relapse • 28%nhad rela e ea an mandibular surgery •M Me Concurrent ! Greater relapse at 2nd, 1st molar and 2nd premolars (p< .02) Int J Adult Ortho Orthognath Surg 1992; 7: 139-146 ©Dr Sylvain Chamberland
  13. 13. 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
  14. 14. 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
  15. 15. Le Fort 1 Morbidity A • Pulpal necrosis B • Periodontal defects ©Dr Sylvain Chamberland
  16. 16. Le Fort 1 Morbidity • Aseptic necrosis ! Most likely to occur with Le Fort 1 osteotomies done in multiple segments in conjonction with superior repositioning and transverse Courtesy of Dr Brian Alpert expansion Lanigan et al, J Oral Maxillofac Surg 48: 142-156, 1990 ©Dr Sylvain Chamberland
  17. 17. SARPE Morbidity • A B Nasopalatal cyst A B • Fibrous healing ©Dr Sylvain Chamberland
  18. 18. SARPE Morbidity • Asymmetric fracture of interdental septum + gingival defect Cureton SL, Cuenin M, AJODO, 1999 • 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 ©Dr Sylvain Chamberland
  19. 19. 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
  20. 20. Non-surgical RPE • Post pubertal patients Krebs, EOS 1964 ! 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 Spilane & McNamara SO,1995 Bacetti et al, AO 2001 Zimring & Isaacson, AO 1965 Lagravere et al JADA 2006; AO 2005 ©Dr Sylvain Chamberland
  21. 21. Comparative study-1 -3,16 Byloff & Mossaz, 2004 (n=14) 5,54 8,70 -0,50 Koudstal et al, 2009; T-B (n = 19) 6,30 6,80 -0,60 Koudstal et al, 2009; B-B (n =23) 4,60 5,20 -1,01 Berger et al, 1998 (n=28) 4,77 Study 5,78 -0,88 Pogrel et al, 1992 (n=12) 6,62 7,50 -1,20 Stromberg & Holms, 1995 (n=20) 8,30 -0,45 Bays & Greco, 1992 (n=19) 5,78 -0,22 Nortway & Meade, 1997 (n=16) 5,50 -4,50 -2,25 0 2,25 4,50 6,75 9,00 mm Long term relapse Short term relapse Net expansion Maximum expansion ©Dr Sylvain Chamberland
  22. 22. Comparative study-1 -3,16 Byloff & Mossaz, 2004 (n=14) 36% 5,54 8,70 Koudstal et al, 2009; T-B (n = 19) 5,5% -0,50 6,30 6,80 Koudstal et al, 2009; B-B (n =23) 11% -0,60 4,60 5,20 -1,01 Berger et al, 1998 (n=28) 17.5% 4,77 Study 5,78 12% -0,88 Pogrel et al, 1992 (n=12) 6,62 7,50 8.3% -1,20 Stromberg & Holms, 1995 (n=20) 8,30 7% -0,45 Bays & Greco, 1992 (n=19) 5,78 6% -0,22 Nortway & Meade, 1997 (n=16) 5,50 -4,50 -2,25 0 2,25 4,50 6,75 9,00 mm Long term relapse Short term relapse Net expansion Maximum expansion ©Dr Sylvain Chamberland
  23. 23. Comparative study-1 -3,16 Byloff & Mossaz, 2004 (n=14) 36% 5,54 8,70 Koudstal et al, 2009; T-B (n = 19) 5,5% -0,50 6,30 6,80 Koudstal et al, 2009; B-B (n =23) 11% -0,60 4,60 5,20 -1,01 Berger et al, 1998 (n=28) 17.5% 4,77 Study 5,78 12% -0,88 Pogrel et al, 1992 (n=12) 6,62 7,50 8.3% -1,20 Stromberg & Holms, 1995 (n=20) 8,30 7% -0,45 Bays & Greco, 1992 (n=19) Not taken from the 5,78 Nortway & Meade, 1997 (n=16) 6% -0,22 maximum expansion point 5,50 -4,50 -2,25 0 2,25 4,50 6,75 9,00 mm Long term relapse Short term relapse Net expansion Maximum expansion ©Dr Sylvain Chamberland
  24. 24. Comparative study-1 -3,16 Byloff & Mossaz, 2004 (n=14) 36% 5,54 8,70 Koudstal et al, 2009; T-B (n = 19) 5,5% -0,50 6,30 6,80 Koudstal et al, 2009; B-B (n =23) 11% -0,60 4,60 5,20 -1,01 Berger et al, 1998 (n=28) 17.5% 4,77 Study 5,78 12% -0,88 Pogrel et al, 1992 (n=12) 6,62 7,50 8.3% -1,20 Bias!: Selected cases. Observation:End of ortho 8 to 102 m Stromberg & Holms, 1995 (n=20) 8,30 7% -0,45 Bays & Greco, 1992 (n=19) Not taken from the 5,78 Nortway & Meade, 1997 (n=16) 6% -0,22 maximum expansion point 5,50 -4,50 -2,25 0 2,25 4,50 6,75 9,00 mm Long term relapse Short term relapse Net expansion Maximum expansion ©Dr Sylvain Chamberland
  25. 25. Comparative study-1 -3,16 Byloff & Mossaz, 2004 (n=14) 36% 5,54 8,70 Koudstal et al, 2009; T-B (n = 19) 5,5% -0,50 6,30 ent d 6,80 Koudstal et al, 2009; B-B (n =23) 11% -0,60 reatm erio to t udy p 4,60 5,20 n Berger et al, 1998 (n=28) 17.5% -1,01 S till i hs st ont 4,77 Study 5,78 Pogrel et al, 1992 (n=12) 12% -0,88 12 m 6,62 7,50 8.3% -1,20 Bias!: Selected cases. Observation:End of ortho 8 to 102 m Stromberg & Holms, 1995 (n=20) 8,30 7% -0,45 Bays & Greco, 1992 (n=19) Not taken from the 5,78 Nortway & Meade, 1997 (n=16) 6% -0,22 maximum expansion point 5,50 -4,50 -2,25 0 2,25 4,50 6,75 9,00 mm Long term relapse Short term relapse Net expansion Maximum expansion ©Dr Sylvain Chamberland
  26. 26. Comparative study-1 -3,16 Byloff & Mossaz, 2004 (n=14) 36% 5,54 8,70 Koudstal et al, 2009; T-B (n = 19) 5,5% -0,50 6,30 ent d 6,80 Koudstal et al, 2009; B-B (n =23) 11% -0,60 reatm erio to t udy p 4,60 5,20 n Berger et al, 1998 (n=28) 17.5% -1,01 S till i hs st ont 4,77 Study 5,78 Pogrel et al, 1992 (n=12) 12% -0,88 12 m 6,62 7,50 8.3% -1,20 Bias!: Selected cases. Observation:End of ortho 8 to 102 m Stromberg & Holms, 1995 (n=20) 8,30 7% -0,45 Bays & Greco, 1992 (n=19) Not taken from the 5,78 Nortway & Meade, 1997 (n=16) 6% -0,22 maximum expansion point 5,50 -4,50 -2,25 0 2,25 4,50 6,75 9,00 mm Small sample Long term relapse Short term relapse Net expansion Maximum expansion ©Dr Sylvain Chamberland
  27. 27. SARPE!: Skeletal Expansion ©Dr Sylvain Chamberland
  28. 28. SARPE!: Skeletal Expansion • Kuo & Will, DCNA 1992 ! N = 15 ! Ratio Skeletal / dental expansion = 84!% (range 50!% to 100 %) ©Dr Sylvain Chamberland
  29. 29. SARPE!: Skeletal Expansion • 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 ©Dr Sylvain Chamberland
  30. 30. SARPE!: Skeletal Expansion ©Dr Sylvain Chamberland
  31. 31. SARPE!: Skeletal Expansion • 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 ©Dr Sylvain Chamberland
  32. 32. SARPE!: Skeletal Expansion • 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) ©Dr Sylvain Chamberland
  33. 33. SARPE!: Skeletal Expansion • 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 ration of ! Haas group : N =19;ocat : sepa a =19 e group+: N rigid a dv Hyrax tion They oid junc • pteryg ! Skeletal expansion : Haas = 6,9!mm; Hyrax = 6,3!mm e plianc ! Ratio Sk /ap = 71!% D " " " " (minor errors in the Tables. Position of the landmark Mx seem low) ©Dr Sylvain Chamberland
  34. 34. Tipping of Buccal Segments ©Dr Sylvain Chamberland
  35. 35. Tipping of Buccal Segments • Chun & Goldman, EJO 2003 (HAAS 4 bd) ! Mesiobuccal rotation of Pm et M ! Vestibular tipping of the molars = 7,04° ± 4,58° ©Dr Sylvain Chamberland
  36. 36. Tipping of Buccal Segments • 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 ©Dr Sylvain Chamberland
  37. 37. Tipping of Buccal Segments ©Dr Sylvain Chamberland
  38. 38. Tipping of Buccal Segments • 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 ©Dr Sylvain Chamberland
  39. 39. Tipping of Buccal Segments • 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) ©Dr Sylvain Chamberland
  40. 40. V-shape opening AP & Tipping of Buccal vertically ! Pterygoïd jct 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 Tausche et al, AJODO 2007 " Sk / Dental expansion : 111!% – 7,15 ± 2,3!mm / 6,44 ± 1,92!mm ©Dr Sylvain Chamberland
  41. 41. 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
  42. 42. Systematic review-2 • 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 ©Dr Sylvain Chamberland
  43. 43. 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
  44. 44. Research Hypothesis ©Dr Sylvain Chamberland
  45. 45. Research Hypothesis • The relapse obtained after SARPE and osseous distraction is less than 40% mm in 2/3 of the patients ©Dr Sylvain Chamberland
  46. 46. 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
  47. 47. Sub-hypothesis ©Dr Sylvain Chamberland
  48. 48. Sub-hypothesis • The diastema measured at the end of the distraction ©Dr Sylvain Chamberland
  49. 49. Sub-hypothesis • The diastema measured at the end of the distraction • The screw change is a predictor of skeletal changes ©Dr Sylvain Chamberland
  50. 50. Materials & Methods Prospective clinical study Consecutively treated cases ©Sylvain Chamberland
  51. 51. Sample Size Estimation between 2 Groups 2(z1! " /2 + z1! # )2 s 2 N Relapse ^m S-D n= p (X1 -X 2 )2 Pogrel 12 0,88 0,48 • Power 80!% Byloff 14 2,6 1,8 1,364 Philips 39 1,97 1,5 Subsample 12 3,06 1,31 • 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 ©Dr Sylvain Chamberland
  52. 52. > 5 mm ^X S-D N Sample Le Fort 1 Selected 7,36 1,59 12 subsample Power 80% SARPE Consecutive P < .05 cases 7,60 1,57 38 • Historical Le Fort 1 • Le Fort 1 subjects > 5 mm ! Phillips et al. study (1992) ! Control subsample ! Experimental ! Selected Subsample : N =12 ! Conclusion can be inferred ! Follow up at ! t : p = 0.6487 postorthodontics (at least ! Wilcoxon : p = 0.4777 7,5 m post surgery) ©Dr Sylvain Chamberland
  53. 53. 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
  54. 54. 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
  55. 55. SARPE Patient Characteristics • Distribution N = 38 9 9 9 ! 19!, 19" 7 7 # of patients # cas 6 ! Age ^m : 24.9 ± 9,7 5 5 (range 15,1: 53,7) • 2 Expander type 2 0 ! 17 bonded -,17] (17, 20] (20,25] (25,30] (30,35] (35, + Âge ! 21 banded ©Dr Sylvain Chamberland
  56. 56. 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 2 surgery nd • T5= At debonding • T6= At 2 years into retention ©Dr Sylvain Chamberland
  57. 57. SARPE Patient Characteristics Treatment time (months) N Mean S-D S-E Min Max ©Dr Sylvain Chamberland
  58. 58. SARPE Patient Characteristics Treatment time (months) N Mean S-D S-E Min Max T1-T2 (Distraction completed) 38 0,68 0,22 0,04 0,46 1,81 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
  59. 59. Outcome Measures ©Dr Sylvain Chamberland
  60. 60. Outcome Measures • 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 ©Dr Sylvain Chamberland ! Nas. Cav.
  61. 61. Appliance Designs • 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 ) ©Dr Sylvain Chamberland
  62. 62. Appliance Designs • 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 Too forward Screw in line with 1st molars ©Dr Sylvain Chamberland
  63. 63. 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 Racey, JOMS 1992; 50: 114-115 Aida TI, IJOMS 2003; 32: 54-62 Paccione et al, J Cran Surg 2001;12 (2); Proffit, Contemporary Tx of dentofacial 175-181 deformity; 358-361 ©Dr Sylvain Chamberland
  64. 64. Treatment Modality • Bracketsafter expansion arch 2 months bonded in maxillary • Expander removal : 6 months after expansion is stopped • No other retention except the main arch wire ©Dr Sylvain Chamberland
  65. 65. Our SARPE Technique • Done by the same surgeon(DM) Midpalatal suture Zygomaticomaxillary buttres • Subtotal Le Fort 1 osteotomy Piriform rim Pterygomaxillary junction ©Dr Sylvain Chamberland
  66. 66. Our SARPE Technique • Done by the same surgeon(DM) Midpalatal suture Zygomaticomaxillary buttres • Subtotal Le Fort 1 osteotomy Piriform rim Pterygomaxillary junction Widening of the osteotomy cut : lateral rotation hemimaxillae Piriform aperture Zygomatic buttress ©Dr Sylvain Chamberland
  67. 67. Our SARPE Technique • Subtotal Le Fort 1 osteotomy ©Dr Sylvain Chamberland
  68. 68. Our SARPE Technique • Subtotal Le Fort 1 osteotomy Separation of the Per-op diastema of 1 to pterygoïd junction Separation with osteotome 1,5 mm of the midpalatal suture ©Dr Sylvain Chamberland
  69. 69. Results of the Study Error method • Coefficient of fidelity!: ! 99,94!% on dental cast ! 99,90!% on PA Ceph ©Dr Sylvain Chamberland
  70. 70. Dental Changes: Total/Net/Relapse Relapse T5-T3 Net expansion T5-T1 Maximal expansion T3-T1 • All significant : p < .0001 Canine -2,74 2,80 5,69 ! Expansion -1,84 1st premolar 5,49 7,61 ! Relapse -1,75 2nd premolar 6,04 7,86 ! Net expansion -1,92 1st molar 5,56 7,60 • Md 1st molar 2nd molar -4,15 3,28 7,36 ! Expansion : p = .0005 0,25 Lower 1st molar 1,59 1,39 ! Relapse : p = .5321 -6,75 -4,50 -2,25 0 2,25 4,50 6,75 9,00 ! Net expansion : p = .0129 Mean changes (mm) Closer look at the stability of Surgically- Assisted Rapid Palatal Expansion ©Dr Sylvain Chamberland JOMS 66: 1895-1900, 2008
  71. 71. Dental Changes Relapse T5-T3 Net expansion T5-T1 Maximal expansion T3-T1 • Canine Canine -2,74 2,80 5,69 ! Expand less 1st premolar -1,84 5,49 7,61 ! Not include into RPE -1,75 2nd premolar 6,04 7,86 ! Relapse more -1,92 1st molar 5,56 !Finishing and arch coordination 7,60 -4,15 • 2nd molar 3,28 2nd molar 7,36 0,25 Lower 1st molar 1,59 ! No ! bonded vs banded 1,39 -6,75 -4,50 -2,25 0 2,25 4,50 6,75 9,00 ! Relapse due to arch form Mean changes (mm) coordination Closer look at the stability of Surgically- Assisted Rapid Palatal Expansion ©Dr Sylvain Chamberland JOMS 66: 1895-1900, 2008
  72. 72. Expansion Pattern SARPE T3-T1 SARPE T5-T1 Le Fo 1 ort 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 6 • Expansion at 1st Pm vs 2nd M ! SARPE at T3 ! Posterior expansion anterior expansion ! In contrary to previous litterature and non-surgical RPE May be explained by the separation of the ! Supported by recent CT scan study (Loddi et al, J Cranio Surg 2008) pterygoïd junction ! SARPE at T5 : Greater relapse 2nd M may be explained by arch form coordination ! ©Dr Sylvain Chamberland Le Fort 1 : Posterior expansion > anterior expansion
  73. 73. Expansion Pattern SARPE T3-T1 SARPE T5-T1 Le Fo 1 ort 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 6 • Expansion at 1st Pm vs 2nd M ! SARPE at T3 ! Posterior expansion anterior expansion ! In contrary to previous litterature and non-surgical RPE May be explained by the separation of the ! Supported by recent CT scan study (Loddi et al, J Cranio Surg 2008) pterygoïd junction ! SARPE at T5 : Greater relapse 2nd M may be explained by arch form coordination ! ©Dr Sylvain Chamberland Le Fort 1 : Posterior expansion > anterior expansion
  74. 74. Skeletal e expansion Skeletal Changes X " Mx T2-T1 " Mx T5-T1 3,44 3,63 S-d 1,39 1,54 • N 36 23 Significant skeletal expansion! Paired T p < .0001 p < .0001 ! 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 ©Dr Sylvain Chamberland
  75. 75. Skeletal e expansion Skeletal Changes X " Mx T2-T1 " Mx T5-T1 3,44 3,63 S-d 1,39 1,54 • N 36 23 Significant skeletal expansion! Paired T p < .0001 p < .0001 ! 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 ©Dr Sylvain Chamberland
  76. 76. Changes F(time) Changes post SARPE at 1st molar / at Mx / at Nasal cavity • Skeletal expansion 8,00 70 65 58 ! Mx & Nas. Cav. 6,00 53 % Skeletal expansion 47 Expansion (mm) 45 ! Stable • Most of the relapse 4,00 35 ! Dental 2,00 18 • % Sk/Dental 0 0,68 6,65 15,49 23,11 0 ! Increased from 45!% to 65!% Time post SARPE (months) " 1st Molar ! Consistent with other studies " Nasal cavity " Mx ©Dr Sylvain Chamberland % "Mx / " 1st Molar
  77. 77. Relapse F(type of surgery) • One way Anova N F value p ! No significant effect Bimax 6 • Any combination of surgical Md Mx 7 5 F ( 26) = (3, ) 0.32 0.8125 0 8125 variables Nil 9 ! (Md, Mx, Bimax, No 2nd phase) Total 27 ! No significant effect ! p = 0.0670 to 0.4525 ©Dr Sylvain Chamberland
  78. 78. Relapse F(time T3-T4-T5) • 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 1st M T3 1st M T4 1st M T5 1st M T6 1st M width 50,22 49,13 48,24 47,22 ! 55!% relapse entre T4-T3 N 38 30 27 19 ! 45!% relapse entre T5-T4 p = .0 0008 p value p = .0 0118 p < .0001 T4-T3 T5-T4 T5-T3 Mean -1,09 -0,89 -1,98 % 55!% 45!% 100!% ©Dr Sylvain Chamberland
  79. 79. Relapse F(type of appliance) N Bonded N 2 Bd Hx p value Exp. 1st M T3-T1 17 7,91 21 7,34 .2727 Sk Exp Mx 15 3,85 12 3,04 .7090 Relapse 1st M T5-T3 16 -1,70 11 -2,23 .4410 • Banded expander has the same efficacy of bonded expander ! Similar dental expansion ! Similar skeletal expansion ! Similar relapse ©Dr Sylvain Chamberland
  80. 80. Relapse F(extraction pattern) "1st M T5-T3 N Mean S-D Paired T Extraction 6 -2,97 ± 1,40 p = 0 1366 0.1366 Non-Extraction 17 -1,68 ± 1,85 • 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 ©Dr Sylvain Chamberland
  81. 81. Diastema F(" 1st molar) •" 1 M T3-T1 / Diastema T2 = 91% st ! 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 ! Expansion rate too slow (.3 mm / jrs) ! Callus ossification ! bone consolidation ©Dr Sylvain Chamberland
  82. 82. A A B C • A-Telescoping zygomatic arch • B-Minimal palatal separation • C-Impinging of the screw into the palate • Appliance = totally inadequate ©Dr Sylvain Chamberland
  83. 83. 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
  84. 84. Lateral Rotation • A- Inward Mvt Before expansion • B- Palatal impingement • Therefore!: place the screw 3- 4 mm away from palatal mucosa After expansion • Supported Koodstaal et A B al, 2009 ! Increase in palatal width results in decrease in depth... explained by tipping of the maxillary segments ©Dr Sylvain Chamberland
  85. 85. Alveolar bending Before expansion • A-moderate separation • B-Impingement C After expansion • C-Inward Mvt A B ©Dr Sylvain Chamberland
  86. 86. Alveolar bending Before expansion • A-moderate separation • B-Impingement C After expansion • C-Inward Mvt A B ©Dr Sylvain Chamberland
  87. 87. ©Dr Sylvain Chamberland
  88. 88. " Skeletal" / " Screw ©Dr Sylvain Chamberland
  89. 89. " 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
  90. 90. 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
  91. 91. 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
  92. 92. Comparison to non- surgical RPE •Our data ! 3,58!mm skelettal!: 65!% of the mean net dental expansion (5,56!mm) ©Dr Sylvain Chamberland
  93. 93. 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
  94. 94. Stability Compared to Segmental Osteotomy SARPE E Le Fort 1 N Mean S-D N Mean S-D p value Canine 26 -2,74 1,75 12 -0,74 1,85 .0026 1st premolar 22 -1,84 2,11 9 -1,31 1,67 .5130 2nd premolar 27 -1,75 2,55 11 -2,05 1,45 .7099 1st molar 27 -1,92 1,74 12 -3,06 1,31 .0491 2nd molar 24 -4,15 1,89 8 -3,69 1,08 .5193 • No significant difference ! 1st Pm, 2nd Pm, 1st M, 2nd M • ©Dr Sylvain Chamberland Canine : relapse more because of arch coordination
  95. 95. Stability Compared to Segmental Osteotomy 1st molar 27 -1,92 (25%) ±1,74 12 -3,06 (42%) ±1,31 .0491 • 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 ©Dr Sylvain Chamberland
  96. 96. Stability Compared to Segmental Osteotomy 1st molar 27 -1,92 (25%) ±1,74 12 -3,06 (42%) ±1,31 .0491 np oint • Relapse of SARPE is comparable atosiLe Fort 1 exp n o ! T : t = -2,03, df = 37; p = 0.0491 ximum em a th ! Wilcoxon : S = 176; p = 0.0608 df rom15,2 ± 5,1 months • easu e MeanrT5-T3 : M patients were out of ortho treatment • All ©Dr Sylvain Chamberland
  97. 97. Comparison to Other Studies -1,91 -1,01 Experimentals (n=38; 27;19) 5,56 7,59 4,6 -3,06 Controls (n=12) 4,30 7,36 -1,97 Controls (n=39) 2,31 4,28 -3,16 Byloff & Mossaz, 2004 (n=14) 5,54 8,70 -0,50 Koudstal et al, 2009 (n = 19) T-B 6,30 6,80 -0,60 Koudstal et al, 2009 (n =23) B-B 4,60 5,20 -1,01 Berger et al, 1998 (n=28) 4,77 5,78 -0,88 Pogrel et al, 1992 (n=12) 6,62 7,50 -1,20 Stromberg & Holms, 1995 (n=20) 8,30 -0,45 Bays & Greco, 1992 (n=19) 5,78 -0,22 Nortway & Meade, 1997 (n=16) 5,50 -4,50 -2,25 0 2,25 4,50 6,75 9,00 mm Long Term Relapse Short Term Relapse ©Dr Sylvain Chamberland Net expansion Maximum expansion Long term exp
  98. 98. Comparison to Other Studies -1,91 -1,01 Experimentals (n=38; 27;19) 5,56 7,59 4,6 -3,06 Controls (n=12) 4,30 7,36 -1,97 Controls (n=39) 2,31 4,28 -3,16 Byloff & Mossaz, 2004 (n=14) 5,54 8,70 Koudstal et al, 2009 (n = 19) T-B > -0,50 6,30 6,80 Relapse > -0,60 Koudstal et al, 2009 (n =23) B-B 4,60 5,20 Berger et al, 1998 (n=28) > -1,01 4,77 5,78 Pogrel et al, 1992 (n=12) > -0,88 6,62 7,50 -1,20 Stromberg & Holms, 1995 (n=20) 8,30 -0,45 Bays & Greco, 1992 (n=19) 5,78 -0,22 Nortway & Meade, 1997 (n=16) 5,50 -4,50 -2,25 0 2,25 4,50 6,75 9,00 mm Long Term Relapse Short Term Relapse ©Dr Sylvain Chamberland Net expansion Maximum expansion Long term exp
  99. 99. Comparison to Other Studies -1,91 -1,01 Experimentals (n=38; 27;19) 5,56 But ! NSControls (n=12) 7,59 4,6 < -3,06 4,30 7,36 Relapse Controls (n=39) -1,97 2,31 4,28 Byloff & Mossaz, 2004 (n=14) < -3,16 5,54 8,70 Koudstal et al, 2009 (n = 19) T-B > -0,50 6,30 6,80 Relapse > -0,60 Koudstal et al, 2009 (n =23) B-B 4,60 5,20 Berger et al, 1998 (n=28) > -1,01 4,77 5,78 Pogrel et al, 1992 (n=12) > -0,88 6,62 7,50 -1,20 Stromberg & Holms, 1995 (n=20) 8,30 -0,45 Bays & Greco, 1992 (n=19) 5,78 -0,22 Nortway & Meade, 1997 (n=16) 5,50 -4,50 -2,25 0 2,25 4,50 6,75 9,00 mm Long Term Relapse Short Term Relapse ©Dr Sylvain Chamberland Net expansion Maximum expansion Long term exp
  100. 100. Comparison to Other Studies -1,91 -1,01 Experimentals (n=38; 27;19) 5,56 But ! NSControls (n=12) 7,59 4,6 < -3,06 4,30 7,36 Relapse Controls (n=39) -1,97 2,31 4,28 Byloff & Mossaz, 2004 (n=14) < -3,16 5,54 8,70 Koudstal et al, 2009 (n = 19) T-B > -0,50 6,30 6,80 Relapse > "Exp. -0,60 Koudstal et al, 2009 (n =23) B-B 4,60 5,20 Berger et al, 1998 (n=28) > -1,01 4,77 5,78 Pogrel et al, 1992 (n=12) > -0,88 6,62 7,50 -1,20 Stromberg & Holms, 1995 (n=20) 8,30 -0,45 Bays & Greco, 1992 (n=19) 5,78 -0,22 Nortway & Meade, 1997 (n=16) 5,50 -4,50 -2,25 0 2,25 4,50 6,75 9,00 mm Long Term Relapse Short Term Relapse ©Dr Sylvain Chamberland Net expansion Maximum expansion Long term exp
  101. 101. H1 : Relapse obtained after SARPE and osseous distraction is less than 40% mm in 2/3 of the patients • 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 LeFort 1:Post-Tx Changes 70,0!% SARPE: Post-Tx changes 66,7!% First Molar First Premolar 50,0!% 56,0!% 50,0!% First Molar First Premolar 40,0!% 40,7!% 42,0!% 44,4!% % of patient 30,0!% 29,6!% 33,3!% 25,9!% 28,0!% 20,0!% 22,7!% 25,0!% 18,2!% 14,0!% 10,0!% 11,1!% 11,1!% 9,1!% 8,3!% 3,7!% 0!% 0!% 0!% '-,-3] (-3 to -1] (-1 to 1] (1 to 3] '-,-3] (-3 to -1] (-1 to 1] (1 to 3] ©Dr Sylvain Chamberland Relapse (mm) Relapse (mm)
  102. 102. H1 : Relapse obtained after SARPE and osseous distraction is less than 40% mm in 2/3 of the patients • SARPE : 25!% of patients relapse > 3!mm (4,26 mm) • Le Fort 1 : 67!% of patients relapse > 3!mm 66% • SARPE : 41!% relapse a mean 2!mm LeFort 1:Post-Tx Changes 70,0!% SARPE: Post-Tx changes 66,7!% First Molar First Premolar 50,0!% 56,0!% 50,0!% First Molar First Premolar 40,0!% 40,7!% 42,0!% 44,4!% % of patient 30,0!% 29,6!% 33,3!% 25,9!% 28,0!% 20,0!% 22,7!% 25,0!% 18,2!% 14,0!% 10,0!% 11,1!% 11,1!% 9,1!% 8,3!% 3,7!% 0!% 0!% 0!% '-,-3] (-3 to -1] (-1 to 1] (1 to 3] '-,-3] (-3 to -1] (-1 to 1] (1 to 3] ©Dr Sylvain Chamberland Relapse (mm) Relapse (mm)
  103. 103. Clinical Implications • If only transverse changes are needed ! SARPE = Choice # 1 MC; tx:18m YP; tx:~24m CS; tx:~22m ©Dr Sylvain Chamberland
  104. 104. 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
  105. 105. But!: SARPE still indicated • For large transverse AP and vertical changes or periodontally compromised patients ©Dr Sylvain Chamberland (Personal opinion)

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