SURGICALLY ASSISTED RAPID MAXILLARY EXPANSION COMBINED WITH MAXILLARY PROTRACTION IN AN ADULT : A PATIENT REPORT SUSANA M.

DEON RIZZATTO , MARCEL M. FARRET, MICHEL A.LANES World Journal of Orthodontics 2009;10
Guided bybyDr.(Mrs.) P. V. Hazarey HOD ,Guide & Prof.

Presented byKumar Niwlikar (P.G. student)

Introduction
 The treatment of skeletal class III relationship in a

young (growing) patient can consist of rapid maxillary expansion and maxillary protraction with a face mask because RME disarticulates the sutures and allows orthopedic changes.
 So this approach is not promising in adults ,

camouflage or orthognathic surgery are the options ,depending on the severity of the anteroposterior discrepancy and the patients preference.

 Many adult patients transverse maxillary

deficiency with class III skeletal relationship,in this condition a surgically assisted rapid maxillary expansion with total Lefort I osteotomy is the therapy of choice.

 This case report describes a 20 year women who

sought orthodontic treatment at the school of dentistry at the Pontifical Catholic University of Rio Grande do Sul,Brazil.
 Patient s chief complait was the unesthetic

position of her maxillary right canine and facial esthetics

Findings
 Facial analysis showed a mandibular

deviation to right and an increased lower facial third.  profile was concave with retrusive lips.  6.5 mm crowding in the maxillary arch, a deviation of the maxillary midline to the right.  maxillary transeverse deficiency & posterior crossbite.

 3mm crowding in lower arch  Class III molar relationship an edge-to-edge

incisor relationship & an open bite between the lateral incisors and premolars on both sides.  OPG shows 3rd molars were partially with cystic extensions of their pericoronal space  Fourth molar was detected on max.left side

Treatment objectives
 to aling all teeth establish a normal overbite

& overjet  attain a stable occlusion  correct the posterior crossbite  match the dental midlines to each other and facial midline and improve the patient s facial and dental appearance

Treatment options
 3 treatment options were considered 1. Extraction of all second premolars with the

intent of eliminating the crowding without much retrusion of the incisors,avoid flattening of the facial profile . Disadvantage : As the pt.having straight to concave profile this option would have compromised her facial esthetics even further and was consequently rejected

 2. slow expansion of the maxilla and

interproximal enamel reduction (IPR) to align all the teeth in both arches.  Disadvantage: Because of the pts chief complaint of facial esthetics and the risk of increasing the maxillary posterior teeth recession via expansion

 3. SARME followed by maxillary protraction

with facemask and IPR of the mandibular posterior teeth as well as protrusion of the maxillary and mandibular incisors was the optimal option

Treatment initiation
 Treatment started in mandibular arch with

IPR ,levelling and aligning with a slight protrusion of the incisors & uprighting the lingually tipped posterior teeth to allow a larger expansion of the maxillary arch  Hyrax appliance was cemented to the 1st premolars & 1st molars and the pt.underwent surgery

 One week later , the first effects of the

orthopedic expansion were observed & face mask protraction was initiated .elastic producing force of 35o cN per side running at 15 degree angle downword to the palatal plane were applied 14 hours per day.  Hyrax appliance was activated for 3 weeks until there was transverse overcorrection.

Treatment progress
 After 3.5 months of maxillary protraction the facial esthetics had improved considerably due to an increased convexity in the facial profile.  Intraorally ,the diastema was reduced and sagittal relation between the two arches improved

 After 6 months of retention a transpalatal arch

replaced the Hyrax expander and brackets were bonded to max.teeth.  The molars and left canine presented a class I relationship with a good intercuspation of the most posterior teeth  Midlines coincided & their was adequate overjet and overbite .

Results
 Profile convexity was improved  Intraorally there was good transverse

relationship between the arches ,a normal overbite and overjet and class I molar & canine relationship  Final OPG shows no root resorption but good root parallelism

Normal SNA SNB ANB SN-GoGn U1-NA U1-NA L1-NB L1-NB U1-L1 IMPA FMA FMIA 82 80 2 32 22 4 25 4 131 93 25 62

pretreatment 76 76 0 39 18 7 22 4 140 85 29 66

postexpansion 75 76 -1 40 22 9 32 6 128 92 28 60

posttreatment 75 75 0 40 26 9 23 6 134 87 27 66

CONCLUSION
 In patients with mild skeletal class III

discrepancy , camouflage treatment with only maxillary osteotomy and protraction is feasible.
 The accomplished results are esthetically and

functionally satisfying and also help to prevent extractions and orthognathic surgery.

Thank you YOU THANK

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