Int. J. Oral Maxillofac. Surg.

2017; 46: 13061314

http://dx.doi.org/10.1016/j.ijom.2017.05.015, available online at http://www.sciencedirect.com

Research Paper
Orthognathic Surgery

Simulation of three surgical S. C. Mohlhenrich1,2, A. Modabber2,

K. Kniha2, F. Peters2, T. Steiner2,
F. Holzle2, U. Fritz1, S. Raith2

techniques combined with two

1
Department of Orthodontics, RWTH Aachen
University Hospital, Aachen, Germany;
2
Department of Oral and Maxillofacial
Surgery, RWTH Aachen University Hospital,

different bone-borne forces for Aachen, Germany

surgically assisted rapid palatal

expansion of the maxillofacial
complex: a finite element
analysis
S.C. Mohlhenrich, A. Modabber, K. Kniha, F. Peters, T. Steiner, F. Holzle, U. Fritz, S.
Raith: Simulation of three surgical techniques combined with two different bone-
borne forces for surgically assisted rapid palatal expansion of the maxillofacial
complex: a finite element analysis. Int. J. Oral Maxillofac. Surg. 2017; 46: 1306
1314. 2017 International Association of Oral and Maxillofacial Surgeons.
Published by Elsevier Ltd. All rights reserved.

Abstract. Surgically assisted rapid palatal expansion (SARPE) is a common treatment

to correct transverse maxillary deficiencies. Finite element analysis was simulated
for six designs of SARPE based on a computed tomography scan of a human skull:
median osteotomy with palatal (type A) or alveolar ridge (type B) bone-borne force,
additional lateral osteotomy with palatal (type C) or alveolar ridge (type D) bone-
borne force, and additional pterygomaxillary separation with palatal (type E) or
alveolar ridge (type F) bone-borne force. The transverse expansion was about
1.0 mm. The distribution of von Mises stress and the displacement were evaluated.
The largest stress distribution was after types A and B, followed by types C and D,
and finally types E and F. Displacement increased simultaneously. Palatal bone-
borne forces (types A, C, and E) led to higher stress distributions in the midface and
Key words: orthodontic; osteotomy; maxillofa-
maxilla, but to a more parallel expansion compared with alveolar ridge-borne forces
cial; surgically assisted rapid palatal expansion;
(types B, D, and F). The largest bony displacements at the midpalatal suture were finite element analysis method.
anterior in all models. Increased weakening of the bony pillar of the facial skeleton
and the use of palatal bone-borne forces leads to a decrease in stress distribution in Accepted for publication 21 May 2017
the midface and to a more parallel transverse expansion of the maxilla. Available online 10 June 2017

0901-5027/01001306 + 09 2017 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Surgically assisted rapid palatal expansion
(SARPE) is a common treatment to correct
transverse maxillary deficiencies as well
as arch length in non-growing adolescents
and adult patients. These conditions are
characterized by a lateral crossbite, nar-
row palatal vault, dark spaces in the buccal
corridors, and dental crowding, with fre-
quent aesthetic and functional implica-
tions.
Various osteotomy techniques have
been described for the surgically assisted
expansion of the maxilla and different
investigations have demonstrated the clin-
ical effects of SARPE. However, with
regard to the effects of pterygomaxillary
disjunction (PMD) in particular, there is
still no consensus. The zygomatic buttress
and the pterygomaxillary junction are
known to be the most rigid bony pillars
of resistance1. While some authors advo-
cate disjunction of almost all articulating
maxillary structures to allow sufficient
transverse expansion24, others endorse
SARPE with as few osteotomies as possi-
ble to reduce the risk of postoperative
complications and morbidity59. Oppo-
nents of PMD miss an effect on the
expansion1012 and conclude that SARPE
provides a long-term stable orthodontic
bite correction and permanently enhances
the nasal airways as well as a transverse
shift of the segments over the whole bony
palate even without disconnection of the
pterygomaxillary suture13. Proponents of
PMD justify this as a different pattern of
expansion10.
The effects of the various surgical tech-
niques on the skeletal outcome have been
discussed in the recent literature. In a
Fig. 1. Process of segmentation of the compact and trabecular bone.
Simulation of techniques for SARPE
systematic review by Hamedi Sangsari
et al., focus was placed on the influence
of PMD during SARPE14. The authors
concluded that the literature is inconclu-
sive regarding the effect of PMD on the
outcomes of SARPE and that further con-
trolled trials are necessary. In a cadaveric
study, it was found that SARPE without
PMD resulted in a V-shaped transverse
maxillary expansion, while SARPE with
PMD led to a parallel transverse expan-
sion15.
Bone-borne expanders are becoming
increasingly popular compared to tradi-
tional tooth-borne devices. While tooth-
borne devices are popular and easy to
install and handle, the primary advantage
of bone-borne devices is direct transmis-
sion of the expansion forces to the bone
and the fact that they reduce dental tip-
ping, root resorption, cortical fenestration,
and orthodontic relapse. However, in this
respect, there is also no consensus in the
current literature about the ideal device.
Only a small number of clinical investiga-
tions have directly compared the dentos-
keletal effects of bone-borne and tooth-
borne SARPE1621. In comparisons be-
tween tooth-borne and bone-borne
devices, neither short-term nor long-term
advantages in dental and skeletal effects
have been found. However, hybrid devices
(toothbone-borne) generate similar skel-
etal effects, different dental movement
patterns, and fewer dental and periodontal
side effects. Therefore, they could be a
beneficial alternative to conventional
tooth-borne devices for SARPE proce-
dures. Furthermore, it has been reported
that bone-borne devices produce greater
1307
widening of the skeletal nasal floor and
fewer dental side effects in the first
molars22.
The treatment effects of SARPE with
temporary anchorage devices (TADs) for
transverse expansion can be compared
using biomechanical variables such as
displacement, strain, and stress through
the finite element analysis method
(FEM)2328. In addition to the influence
on the transverse development of the pal-
ate, a further focus of research is the
analysis of the effects of varying the sur-
gical protocol or the type of expander on
the craniofacial structures.
Recently, an investigation using FEM
analyzed the influence of four different
designs of rapid maxillary expander and
demonstrated significant differences
among the TADs27. All types exhibited
downward displacement and demonstrat-
ed more horizontal movement in the pos-
terior area. The combination of micro-
implants placed lateral to the midpalatal
suture and conventional hyrax arms on the
first premolar and first molar showed the
most transverse displacement. The rota-
tional movement of the dentoalveolar unit
was larger for the bone-borne devices with
or without hyrax arms. SARPE without
palatal implants showed the most trans-
verse displacement. The stresses around
the devices with micro-implants were
more concentrated on the palate than on
the alveolar ridge. The authors recom-
mended applying TADs to the palatal
slopes to support expanders for the effi-
cient treatment of maxillary transverse
deficiencies. It appears that no study has
yet completely evaluated the effects of
1308 Mohlhenrich et al.

different bone-borne devices with differ-

ent techniques for SARPE.
In this investigation a three-dimension-
al finite element model was used to evalu-
ate and compare the dentoskeletal stress
distribution and displacement of the cra-
niofacial structures by SARPE with and
without disconnection of the pterygoid
plates, as well as an osteotomy of the
lateral wall of the maxillary sinus, com-
bined with a bone-borne applied force
either on the palatal bone or alveolar ridge.
The aim of this study was to identify the
ideal surgical protocol for osteotomy and
expansion device to achieve the maximum
movement of the bony segments and si-
multaneously a minimum stress on the
bone.

Materials and methods

The surface of a skull was digitized by
taking computed tomography (CT) scans,
which were obtained with a slice thickness
of 0.5 mm using a 128-row multi-slice CT Fig. 2. Clinical photographs of the two dif-
ferent types of bone expander: (A) palatal
scanner (Somatom Definition Flash; Sie- bone-borne device; (B) alveolar ridge bone-
mens, Erlangen, Germany). The resulting borne device.
CT data, in DICOM format (Digital Im-
aging and Communications in Medicine),
were exported into Proplan CMF 2.0 soft- expansion is usually about 12 mm14.
ware (Materialise, Leuven, Belgium) for Therefore, an expansion of 1 mm was
subsequent threshold-based segmentation. chosen for the simulation, as this is also
During this procedure, the compact and a commonly used guideline at the authors
trabecular bone were segmented as sepa- institution. As only linear material models
rate parts (Fig. 1). are used and small deformations are con-
Clinical pictures of the two types of sidered, the whole simulation has linear
bone expander that were investigated in characteristics. Thus, results correspond- Fig. 3. The three different types of osteotomy
this study are shown in Fig. 2. The three ing to scaled boundary conditions may be for the SARPE procedure, visualized as blue
different osteotomy types for SARPE obtained by applying the same factors to lines with a thickness of 1 mm, as modelled in
(Fig. 3) and two types of bone-borne force the results. The action of the bone-borne the simulations: (A) median osteotomy; (B)
application (palatal bone-borne force anchorage device was modelled as pre- additional lateral osteotomy; (C) additional
(PBBF) and alveolar ridge bone-borne lateral osteotomy with pterygomaxillary sep-
scribed displacements on single nodes of
force (ARBBF)) (Fig. 4) were simulated. aration.
the finite element mesh closest to the
In this manner, six different computer-
aided design (CAD) models were created:
(1) type A, comprising a median osteot-
omy and PBBF; (2) type B, comprising a
median osteotomy and ARBBF; (3) type
C, comprising a median and lateral osteot-
omy and PBBF; (4) type D, comprising a
median and lateral osteotomy and
ARBBF; (5) type E, comprising a median
and lateral osteotomy with pterygomaxil-
lary separation and PBBF; and (6) type F,
comprising a median and lateral osteot-
omy with pterygomaxillary separation and
ARBBF.
The force for the palatal bone-borne
expansion was initiated 5 mm lateral to
the midpalatal suture at the level of the
second premolars as well as first molars;
the force for the alveolar ridge bone-borne Fig. 4. Visualization of the force applications in the palatal view. The palatal bone-borne force
expansion was initiated between the application is indicated with red arrows and the alveolar ridge bone-borne force application is
premolars. The initial intraoperative indicated with blue arrows.

Fig. 5. Visualization of von Mises stresses in
the bone for all six configurations evaluated:
(A) median osteotomy, palatal bone-borne
force; (B) median osteotomy, alveolar ridge
Simulation of techniques for SARPE 1309
points of application (Fig. 4). The displa- Results
cements were measured on the transverse
The displacements of the oral marginal
(x), lateral (y), and sagittal (z) axes. The
ridge of the alveolar bone, the midpalatal
internal stress reaction was measured by
suture, and the maxillofacial landmarks
von Mises stress (MPa) and illustrated in
after the three different surgical proce-
colour contour bands for presentation of
dures for SARPE (median and/or lateral
the different levels of stress in each de-
osteotomy with/without pterygomaxillary
formed state (Fig. 5). Positive and nega-
separation) in combination with two dif-
tive values in the column of the stress
ferent force approaches for transverse ex-
spectrum indicate tension and compres-
pansion (palatal bone-borne and alveolar
sion, respectively.
ridge bone-borne forces) are reported in
Osteotomy planes were generated in the
Table 1 and shown in Figs 6 and 8. The
three-dimensional modelling software
von Mises stress distributions at the mid-
Blender (version 2.77; Blender Founda-
palatal as well as maxillofacial landmarks
tion, Amsterdam, the Netherlands) with a
are demonstrated in Figs. 7 and 9. As both
thickness of 1 mm; they were positioned
displacements and stresses were found to
according to the standard surgical proce-
be symmetrical in the investigated finite
dures for the different types of SARPE as
element model, it was decided to limit the
described above. The finite element mesh-
display of results to those from one side
ing was performed with the aid of the
(the left side was chosen at random).
software package ICEM CFD (version
16.0; Ansys Inc., Canonsburg, PA,
USA), resulting in tetrahedral meshes with
a mean number of 1,168,682 elements Displacement
(standard deviation 25,486 elements)
Basically, the vector sum for the amount
and a mean of 204,969 nodes (standard
of displacement of the alveolar bone mar-
deviation 3449 nodes). The actual finite
ginal ridge was greater in the anterior
element simulations were conducted with
segment (central and lateral incisor) than
ANSYS software (version 16.0; Ansys
in the posterior segment (first molar) in all
Inc., Canonsburg, PA, USA). In these
models, particularly in the transverse
simulations, cranial boundaries of the seg-
plane (Table 1). When only a median
mented region were located at approxi-
osteotomy was performed, a slightly larg-
mately half the height of the orbital
er movement was possible after ARBBF.
cavities, where all nodes at this demarca-
In contrast, larger displacements resulted
tion were rigidly fixed to constrain the
in all locations at the marginal ridge after
model in all spatial directions. The lateral
performing the median and lateral osteot-
opening by the bone-borne device was
omy, especially with pterygomaxillary
modelled with the prescribed lateral dis-
separation combined with PBBF.
placement of 0.5 mm on each side.
To measure the displacement of the
The selected stiffness values for the
midpalatal suture, it was divided into four
cancellous and trabecular bone were
sections using five points (AE), as de-
17,000 MPa and 3000 MPa, respective-
scribed by Lee et al., where point A is near
ly29,30. A Poisson ratio of 0.33 was as-
the incisive foramen and point E is near
sumed for both materials31.
the palatine bone23. The extent of the
midpalatal suture displacement was great-
er in the anterior area (points A, B) than in
the posterior area (points D, E) in all
bone-borne force; (C) median and lateral models. Also, in all models, the largest
osteotomy, palatal bone-borne force; (D) me- proportion of bone movement was located
dian and lateral osteotomy, alveolar ridge in the transverse dimension and almost no
bone-borne force; (E) median and lateral
osteotomy with pterygomaxillary separation,
changes were found in the sagittal plane
palatal bone-borne force; (F) median and lat- (Fig. 6). Larger bony shifts resulted for the
eral osteotomy with pterygomaxillary separa- palatal bone-borne force, especially after
tion, alveolar ridge bone-borne force. The median and lateral osteotomy with pter-
highest stress at the zygomaticomaxillary su- ygomaxillary separation. For these models
ture was found after median osteotomy in (types E and F), the lateral opening of the
types A and B; there was a substantial reduc- median gap was found to be relatively
tion in types B and C with the lateral osteot- uniform, while the models with only me-
omy, and the lowest stress was found after dian osteotomy (types A and B) showed
pterygomaxillary separation in types E and F.
proportionally larger opening in the ante-
For each osteotomy configuration, the appli-
cation of palatal bone-borne force showed rior region (point A) compared to the
larger stresses than alveolar ridge bone-borne posterior region of the same model
force (A > B; C > D; and E > F). (point E).
1310 Mohlhenrich et al.

Table 1. Displacement (millimetres) of the oral marginal ridge of the alveolar bone with the three different osteotomy techniques and two types of
bone-borne expander.a
Type Dimension Central incisor Lateral incisor Canine First premolar Second premolar First molar
A x 0.133 0.071 0.029 0.006 0.017 0.041
y 0.672 0.657 0.639 0.600 0.558 0.515
z 0.059 0.040 0.024 0.012 0.002 0.017
VS 0.687 0.662 0.640 0.600 0.558 0.517
B x 0.120 0.041 0.006 0.026 0.048 0.072
y 0.688 0.672 0.654 0.613 0.566 0.515
z 0.110 0.090 0.090 0.062 0.046 0.024
VS 0.707 0.679 0.658 0.616 0.570 0.520
C x 0.187 0.022 0.084 0.145 0.182 0.236
y 1.223 1.217 1.217 1.172 1.121 1.051
z 0.173 0.167 0.162 0.150 0.138 0.122
VS 1.249 1.228 1.230 1.190 1.144 1.084
D x 0.113 0.012 0.090 0.131 0.155 0.193
y 0.870 0.864 0.864 0.831 0.793 0.739
z 0.158 0.153 0.150 0.141 0.131 0.116
VS 0.891 0.878 0.882 0.853 0.818 0.773
E x 0.232 0.030 0.121 0.181 0.229 0.295
y 1.362 1.362 1.363 1.334 1.287 1.215
z 0.178 0.182 0.183 0.178 0.170 0.157
VS 1.393 1.374 1.381 1.358 1.318 1.260
F x 0.139 0.001 0.101 0.138 0.168 0.211
y 0.900 0.896 0.893 0.868 0.832 0.779
z 0.147 0.144 0.142 0.136 0.128 0.116
VS 0.923 0.908 0.909 0.889 0.858 0.815
x, sagittal axis; y, transverse axis; z, vertical axis; VS, vector sum; PBBF, palatal bone-borne force; ARBBF, alveolar ridge bone-borne force.
a
A positive value indicates forward, outward, or upward displacement. Type A: median osteotomy and PBBF; type B: median osteotomy and
ARBBF; type C: median and lateral osteotomy and PBBF; type D: median and lateral osteotomy and ARBBF; type E: median and lateral
osteotomy with pterygomaxillary separation and PBBF; and type F: median and lateral osteotomy with pterygomaxillary separation and ARBBF.

With increasing cranial location of bone-borne force, and also using alveo- displacements resulted after the simula-
the maxillofacial landmarks, smaller lar ridge bone-borne force, did an in- tion of median and lateral osteotomy
displacements were found (Fig. 8). Only crease in displacement result at the with and without pterygomaxillary
after median osteotomy using palatal zygomaticomaxillary suture. The largest separation combined with palatal

Fig. 6. Line charts showing the displacement of the midpalatal suture in the vertical, transverse, and sagittal dimensions, as well as the vector sum.
 Simulation of techniques for SARPE 1311

Fig. 7. Bar chart of the von Mises stress distribution in the midpalatal suture after the three different osteotomy techniques (types A/B, C/D, E/F)
and bone-borne forces (A/C/E, B/D/F).

Fig. 8. Line chart of the vector sum displacement of the maxillofacial complex.

Fig. 9. Bar chart of the von Mises stress distribution in the maxillofacial complex after the three different osteotomy techniques (types A/B, C/D,
E/F) and bone-borne forces (A/C/E, B/D/F).
1312 Mohlhenrich et al.
bone-borne force, particularly in the
area of the maxilla.
Patterns of stress distribution
The von Mises stress analysis showed
higher values at the midpalatal suture
for palatal bone-borne force after each
osteotomy technique (Fig. 7). The von
Mises stress was the least for both forces
at point E, and an increase in stress was
found in the anteroposterior dimension
(points AD). Mostly, each additional
osteotomy resulted in a decrease in stress.
In proportion, the lateral osteotomy had
the greatest influence on stress reduction;
however the pterygomaxillary separation
also had a positive effect on the stress
outcome.
The analysis of von Mises stress gener-
ated at the maxillofacial landmarks
showed the highest values at the zygoma-
ticomaxillary and frontozygomatic
sutures, followed by the medial pterygoid
plate (Fig. 9). Especially at these land-
marks, a stress reduction was primarily
achieved through the use of alveolar ridge
bone-borne force. Less von Mises stress
was found at the maxillary tuberosity,
infraorbital margin, and particularly at
the zygomatic arch.
Discussion
The anterior piriform aperture pillars, lat-
eral zygomatic buttresses, posterior ptery-
goid junctions, and medial midpalatal
synostosed sutures are known as resis-
tance pillars of the maxillofacial complex
that can be weakened during SARPE32.
The effect of PMD remains a controversial
issue, and the literature is inconclusive
regarding the necessity of PMD in the
correction of transverse deficiencies. Fur-
thermore, it is not evident whether PMD
has a different effect on the surgical cor-
rection of posterior versus anterior trans-
verse discrepancies14. Lehman and Haas
found that SARPE without PMD led to a
sufficient weakening of the skeletal resis-
tance for maxillary expansion33. In con-
trast, Betts and Ziccardi reported the
necessity of weakening the bony struc-
tures from the piriform aperture to the
pterygomaxillary fissure, including the
midpalatal suture and the nasal septum,
as well as the pterygomaxillary junction34.
Recently, within the limitations of a
cadaveric study, it was also reported that
SARPE without PMD leads to a V-shaped
transverse maxillary expansion and that
SARPE with PMD results in a paralleled
transverse expansion in the anterior and
posterior regions of the maxilla15. Clinical
investigations by Sygouros et al. demon-
strated that the reduction in the buccal
alveolar width was significantly greater
in the premolar area in patients who did
not undergo separation of the pterygoid
plates during SARPE compared with
patients who underwent this separation11.
In contrast, Kilic et al. reported that more
expansion was achieved in the premolar
region in the group with PMD and in the
molar region in the group without PMD12.
In addition, Seeberger et al. concluded that
a transverse shift of the segments could be
achieved over the whole bony palate even
when no osteotomy of the pterygomaxil-
lary suture is performed13. In turn, no
difference between the two surgical tech-
niques was found in relation to the maxil-
lary disjunction pattern, irrespective of the
treatment given to the pterygoid Plates35.
Usually, the expansion can be done by
tooth-borne, bone-borne, or hybrid (tooth
bone-borne) device. Bone-borne expan-
ders are becoming increasingly popular
for the correction of transverse maxillary
deficiencies. Three-dimensional investi-
gations on cone beam CT (CBCT) showed
that tooth-borne and bone-borne devices
have similar effects on the skeleton and
are associated with low complication
rates18,19. Tooth-borne devices have sev-
eral disadvantages due the large amount of
force directed into the dental, periodontal,
and bone tissue during the transverse ex-
pansion, which can result in buccal tipping
or root exposure of the anchor teeth, as
well as periodontal problems and outward
rotation of the palatal segments of the
maxilla16,3638. Bone-borne expanders
can reduce these side effects. However,
although bone-borne expanders can be
placed in extremely narrow palates, this
can increase the operating time, there is
the need for a second surgery, these
devices are expensive, and wound infec-
tions are possible3640. Hybrid devices
require additional steps due to the need
for mini-implant placement in the anterior
palate, but they appear to have significant
benefits in terms of less tipping and re-
duced bone and tooth resorption, particu-
larly in the premolar area21. These devices
are usually used in growing children.
The FEM used in this investigation is an
established method for midfacial and cra-
nial stress distribution, focusing on rapid
palatal expansion with and without surgi-
cal assistance. It was possible to segment
the cortical and cancellous bone separate-
ly in the three-dimensional skull prepara-
tion. This allowed more precise imaging
of the cortical and cancellous bone struc-
tures in this FEM. In other studies, the
bone has been examined as a unit, or the
cortical bone has been defined with an
overall thickness23,2528. Differences be-
tween the results of this study and other
previous investigations can possibly be
explained by this fact.
Holberg et al. investigated the stresses
on the midface and cranial base during
surgically assisted rapid maxillary expan-
sion, to determine whether surgically
assisted separation of the maxilla from
the cranial base can be considered justified
and necessary26. The superior orbital fis-
sure, the oval foramen, the spinous fora-
men, the round foramen, the lacerated
foramen, the optic foramen, and the carot-
id sulcus were particularly affected. They
concluded that to protect the cranial base
from undesirable side effects, separation
of the pterygomaxillary junction is a rea-
sonable and necessary additional measure
for surgically assisted palatal suture ex-
pansion. In addition, Han et al. suggested
that the combination of Le Fort I and a
paramedian osteotomy with pterygomax-
illary separation is an effective procedure
for increasing the expansion of the maxil-
la, with fewer side effects caused by ex-
cessive stresses around the anchor teeth25.
de Assis et al. demonstrated similar
results28. They reported that steps in the
zygomaticomaxillary buttress and ptery-
gomaxillary disjunction seem to be impor-
tant to decrease the harmful dissipation of
tensions during SARPE. In contrast, Lee
et al. analyzed stress distribution and dis-
placement of the craniofacial structures
resulting from bone-borne rapid maxillary
expanders with and without surgical assis-
tance. Differences in the surgical protocol
were based on variations in the osteotomy
techniques, such as separation of the mid-
palatal and pterygomaxillary sutures, as
well as Le Fort I corticotomy23. They
reported that surgical models showed sim-
ilar amounts of stress and displacement
along the teeth, midpalatal sutures, and
craniofacial sutures.
In this context, the present study
showed consistent findings. The results
demonstrated that displacements at the
midpalatal suture were larger after median
and lateral osteotomy combined with pter-
ygomaxillary separation; the majority of
displacement was in the transverse plane
(Fig. 6). In general, the amount of alveolar
bone displacement was highest in the an-
terior part of the maxilla (point A) for both
types of force application, and this is
consistent with the results of Lee
et al.23. Regarding the stress analysis, it
was found that at the midpalatal suture the
von Mises stress decreased with increas-
ing weakness of the skeletal structures
(Fig. 7). In particular, the location of the

force seemed to have an influence. While
particularly high values were present for
palatal bone-borne force, the application
on the alveolar ridge seemed to lead to a
considerable reduction of the von Mises
stress in the area of the midpalatal suture.
Due to the incorporation of palatal bone-
borne force into the expansion devices,
which were positioned at the centre of
resistance of the nasomaxillary complex,
the maxilla at the alveolar ridge was de-
void of stresses and strains. Additionally,
by displacement of the distraction vector
superiorly, the alveolar ridge bone-borne
force displayed a rotation of the maxilla,
as opposed to the midpalatal suture of the
palatal bone-borne force. A similar phe-
nomenon has been described by MacGin-
nis et al. between tooth-borne and palatal-
borne expansion in terms of transverse
expansion stress24. They suggested that
the palatal force causes the maxilla to bend
laterally, while preventing unwanted rota-
tion of the complex. Finally, these results
suggest that the positive effect of maxi-
mum bony weakening of the maxillofacial
complex and the use of alveolar ridge
force could be additive.
An increased displacement change in
the midface (zygomatic and zygomatico-
maxillary suture, zygomatic arch, infraor-
bital margin) was found compared to that
in the maxilla (anterior and posterior nasal
spine, maxillary tuberosity, pterygoid
hamulus) (Fig. 8). The displacements in
the midface (at about 0.0160.128 mm),
as well as in the maxilla (at about 0.256
0.695 mm), were small. The transition
seems to be in the range between the
medial and lateral pterygoid plate. Fur-
thermore, the displacements were mostly
higher with the use of a palatal force, and
the bony shifts were larger than those in
the investigation of Lee et al23. However,
in contrast to the present study, they sim-
ulated an expansion of only about 0.5 mm
transversely.
The stresses recorded at the measure-
ment points of the midface in this study
were usually lower upon pterygomaxillary
separation than those with median or in
combination with lateral osteotomy
(Fig. 9). The highest von Mises stress
value of about 103.781 MPa was found
after median osteotomy and palatal force
application at the frontozygomatic suture;
von Mises stress of about 101.079 MPa
was found at the zygomaticomaxillary
suture. After median and lateral osteotomy
with pterygomaxillary separation, the
stress values were about 32.664 MPa
and 11.597 MPa, respectively. Usually,
stress distribution in the maxilla is the
focus of interest2528. However, Holberg
Simulation of techniques for SARPE
et al. reported a von Mises stress distribu-
tion at the frontozygomatic suture of about
150.9 MPa without surgery and 88.0 MPa
after lateral osteotomy with PMD26. Lee
et al. reported values of about 8.238 MPa
after median osteotomy and 8.522 MPa
after maximum weakening of the bony
pillars at the zygomaticofrontal suture,
as well 10.310 MPa and 9.296 MPa, re-
spectively27.
Like Holberg et al., who reported that
the von Mises stress depends on the sur-
gical procedures26, this study also found
significant differences between the differ-
ent surgical techniques. Usually, the high-
est values were observed after median and
lateral osteotomy at the measurement
points, especially at the medial pterygoid
plate. Here again there were higher stress
values under palatal force application. In
contrast, MacGinnis et al. found the high-
est tensile stresses near the zygomatico-
maxillary sutures, radiating from the
inferior part of the orbit down to the
zygomaticomaxillary buttress24.
In conclusion, within the limitations of
this FEM investigation, it should be
expected that increased weakening of
the bony pillars of the maxillofacial com-
plex, such as with an additional lateral
osteotomy in combination with pterygo-
maxillary separation, will lead to less
stress distribution across the maxillofacial
complex as well as at the midpalatal suture
and will allow a more uniform transverse
expansion of the maxilla. Large bony dis-
placements in the anterior segment of the
maxilla will result in transverse movement
and a decrease in the cranial base direc-
tion. Furthermore, the application of a
palatal bone-borne force will result in
higher stress in the whole maxillofacial
complex, except the midpalatal suture,
where it decreases compared with alveolar
ridge bone-borne force. In addition, the
force comes close to the centre of resis-
tance of the maxilla, leading to a more
uniform expansion.
Funding
No funding.
Competing interests
No conflict of interest.
Ethical approval
Not required.
Patient consent
Not required.
1313
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Address:
Stephan Christian Mohlhenrich
Department of Orthodontics
University Hospital RWTH
Aachen
Pauwelsstrae 30
52074 Aachen
Germany
Tel.: +49 241 8080844
Fax: +49 241 8082430
E-mail: smoehlhenrich@ukaachen.de