aao 109th annual_session_boston_2009_closer look at the stability of sarpe...

©Sylvain Chamberland

A Closer Look at the Stability of Surgically-Assisted Rapid Palatal

ExpansionJOMS 66 : 1895-1900, 2008

109th Annual SessionAmerican Association of Orthodontists

Boston2009

Dr Sylvain Chamberland, DMD, Cert. Ortho., M.Sc.

Diplomate of ABOFellow of RCDC(c)Member of EHASO

©Dr Sylvain Chamberland

The Research ProblemIs 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


“ 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

The Research Problem


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




•Document post-surgical changes with SARPE, differentiating dental and skeletal outcomes

• Provide data 2 years into retention for long term stability

Literature Review


Hierarchy of Stability

Proffit WR, Fields HW, Sarver DM, Contemporary Orthodontics, 4e ed, St-Louis : Mosby Elsevier, 2007, p. 715


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 : Mosby Elsevier, 2007, p. 715


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


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

n=39

Mean expansion = 4,29± 2,55 mm

Mean relapse= 1,97± 1,5 mm


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


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


Le Fort 1 Morbidity

• Pulpal necrosis

• Periodontal defectsB

A


• Aseptic necrosis

! Most likely to occur with Le Fort 1 osteotomies done in multiple segments in conjonction with superior repositioning and transverse expansion

Le Fort 1 Morbidity

Lanigan et al, J Oral Maxillofac Surg 48: 142-156, 1990

Courtesy of Dr Brian Alpert


• Nasopalatal cyst

• Fibrous healing

SARPE MorbidityA B

A B


• Asymmetric fracture of interdental septum + gingival defect

• 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

Cureton SL, Cuenin M, AJODO, 1999

SARPE Morbidity


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


Non-surgical RPE

• Post pubertal patients! 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

Bacetti et al, AO 2001

Lagravere et al JADA 2006; AO 2005

Spilane & McNamara SO,1995

Zimring & Isaacson, AO 1965

Krebs, EOS 1964


Byloff & Mossaz, 2004 (n=14)

Koudstal et al, 2009; T-B (n = 19)

Koudstal et al, 2009; B-B (n =23)

Berger et al, 1998 (n=28)

Pogrel et al, 1992 (n=12)

Stromberg & Holms, 1995 (n=20)

Bays & Greco, 1992 (n=19)

Nortway & Meade, 1997 (n=16)

-4,50 -2,25 0 2,25 4,50 6,75 9,00

7,50

5,78

5,20

6,80

8,70

5,50

5,78

8,30

6,62

4,77

4,60

6,30

5,54

-0,88

-1,01

-0,60

-0,50

-3,16

-0,22

-0,45

-1,20

Comparative study-1

mm

Stu

dy

Long term relapse Short term relapseNet expansion Maximum expansion










-4,50 -2,25 0 2,25 4,50 6,75 9,00

7,50

5,78

5,20

6,80

8,70

5,50

5,78

8,30

6,62

4,77

4,60

6,30

5,54

-0,88

-1,01

-0,60

-0,50

-3,16

-0,22

-0,45

-1,20

Comparative study-1

mm

Stu

dy


12%

7%

6%

8.3%

17.5%

36%

5,5%

11%










-4,50 -2,25 0 2,25 4,50 6,75 9,00

7,50

5,78

5,20

6,80

8,70

5,50

5,78

8,30

6,62

4,77

4,60

6,30

5,54

-0,88

-1,01

-0,60

-0,50

-3,16

-0,22

-0,45

-1,20

Comparative study-1

mm

Stu

dy

Not taken from the maximum expansion point


12%

7%

6%

8.3%

17.5%

36%

5,5%

11%










-4,50 -2,25 0 2,25 4,50 6,75 9,00

7,50

5,78

5,20

6,80

8,70

5,50

5,78

8,30

6,62

4,77

4,60

6,30

5,54

-0,88

-1,01

-0,60

-0,50

-3,16

-0,22

-0,45

-1,20

Comparative study-1

mm

Stu

dy


Bias!: Selected cases. Observation:End of ortho 8 to 102 m


12%

7%

6%

8.3%

17.5%

36%

5,5%

11%










-4,50 -2,25 0 2,25 4,50 6,75 9,00

7,50

5,78

5,20

6,80

8,70

5,50

5,78

8,30

6,62

4,77

4,60

6,30

5,54

-0,88

-1,01

-0,60

-0,50

-3,16

-0,22

-0,45

-1,20

Comparative study-1

mm

Stu

dy


Still into treatment

12 months study period



12%

7%

6%

8.3%

17.5%

36%

5,5%

11%










-4,50 -2,25 0 2,25 4,50 6,75 9,00

7,50

5,78

5,20

6,80

8,70

5,50

5,78

8,30

6,62

4,77

4,60

6,30

5,54

-0,88

-1,01

-0,60

-0,50

-3,16

-0,22

-0,45

-1,20

Comparative study-1

mm

Stu

dy


Still into treatment

12 months study period



12%

7%

6%

8.3%

17.5%

36%

5,5%

11%

Small sample


SARPE!: Skeletal Expansion


• Kuo & Will, DCNA 1992! N = 15

! Ratio Skeletal / dental expansion = 84!% (range 50!% to 100 %)



• 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



•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




! N =14; Ratio Sk / D = 17 %



• 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)




! N =14; Ratio Sk / D = 17 %



• 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)


• They advocate : separation of

pterygoid junction + a rigid

appliance


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°



• 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



• 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



• 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)



Tipping of Buccal 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

" Sk / Dental expansion : 111!%– 7,15 ± 2,3!mm / 6,44 ± 1,92!mm

V-shape opening AP & vertically

! Pterygoïd jct

Tausche et al, AJODO 2007


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


• 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

Systematic review-2


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


Research Hypothesis


Research Hypothesis

• The relapse obtained after SARPE and osseous distraction is less than 40% mm in 2/3 of the patients


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)


Sub-hypothesis


Sub-hypothesis

• The diastema measured at the end of the distraction


Sub-hypothesis

• The diastema measured at the end of the distraction

• The screw change is a predictor of skeletal changes

©Sylvain Chamberland

Materials & Methods

Prospective clinical studyConsecutively treated cases


Sample Size Estimation between 2 Groups

• Power 80!%

• 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

N Relapse ^m S-D

Pogrel

Byloff

Philips

Subsample

12 0,88 0,48

14 2,6 1,8

1,364

39 1,97 1,5

12 3,06 1,31

n =2(z1!" /2 + z1!# )

2 sp2

(X1-X2 )2


Sample

• Le Fort 1 subjects > 5 mm! Control subsample !

Experimental

! Conclusion can be inferred

! t : p = 0.6487

! Wilcoxon : p = 0.4777

> 5 mm ^X S-D N

Le Fort 1 Selected subsample

SARPE Consecutive cases

7,36 1,59 12

7,60 1,57 38

• Historical Le Fort 1

! Phillips et al. study (1992)

! Selected Subsample : N =12

! Follow up at postorthodontics (at least 7,5 m post surgery)

Power 80%P < .05


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


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


SARPE Patient Characteristics

• N = 38! 19!, 19"

! Age ^m : 24.9 ± 9,7(range 15,1: 53,7)

• Expander type

! 17 bonded

! 21 banded

# cas

0

2

5

7

9

-,17] (17, 20] (20,25] (25,30] (30,35] (35, +

6

5

2

9

7

9

Distribution

# o

f p

atie

nts

Âge


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 2nd surgery

• T5= At debonding

• T6= At 2 years into retention



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

Treatment time (months) N Mean S-D S-E Min Max

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


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

! Nas. Cav.

Outcome Measures


• 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 )

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

Appliance Designs

Screw in line with 1st molarsToo forward


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

Aida TI, IJOMS 2003; 32: 54-62

Proffit, Contemporary Tx of dentofacial deformity; 358-361

Racey, JOMS 1992; 50: 114-115

Paccione et al, J Cran Surg 2001;12 (2); 175-181


Treatment Modality

• Brackets bonded in maxillary arch 2 months after expansion

• Expander removal : 6 months after expansion is stopped

• No other retention except the main arch wire


Our SARPE Technique

• Done by the same surgeon(DM)

• Subtotal Le Fort 1 osteotomy Piriform rim

Zygomaticomaxillary buttres

Pterygomaxillary junction

Midpalatal suture


Our SARPE Technique

• Done by the same surgeon(DM)

• Subtotal Le Fort 1 osteotomy Piriform rim

Zygomaticomaxillary buttres

Pterygomaxillary junction

Midpalatal suture

Zygomatic buttress Piriform aperture

Widening of the osteotomy cut : lateral rotation hemimaxillae


• Subtotal Le Fort 1 osteotomy

Our SARPE Technique


• Subtotal Le Fort 1 osteotomy

Separation of the pterygoïd junction Separation with osteotome

of the midpalatal suture

Per-op diastema of 1 to 1,5 mm

Our SARPE Technique


Results of the Study

Error method• Coefficient of fidelity!:

! 99,94!% on dental cast

! 99,90!% on PA Ceph


• All significant : p < .0001

! Expansion

! Relapse

! Net expansion

• Md 1st molar! Expansion : p = .0005

! Relapse : p = .5321

! Net expansion : p = .0129

Dental Changes: Total/Net/Relapse

Closer look at the stability of Surgically-Assisted Rapid Palatal Expansion

JOMS 66: 1895-1900, 2008

Canine

1st premolar

2nd premolar

1st molar

2nd molar

Lower 1st molar

-6,75 -4,50 -2,25 0 2,25 4,50 6,75 9,00

1,39

7,36

7,60

7,86

7,61

5,69

1,59

3,28

5,56

6,04

5,49

2,80

0,25

-4,15

-1,92

-1,75

-1,84

-2,74

Mean changes (mm)

Relapse T5-T3Net expansion T5-T1Maximal expansion T3-T1


Dental Changes

• Canine! Expand less

! Not include into RPE

! Relapse more!Finishing and arch coordination

• 2nd molar

! No ! bonded vs banded

! Relapse due to arch form coordination

Closer look at the stability of Surgically-Assisted Rapid Palatal Expansion

JOMS 66: 1895-1900, 2008

Canine

1st premolar

2nd premolar

1st molar

2nd molar

Lower 1st molar

-6,75 -4,50 -2,25 0 2,25 4,50 6,75 9,00

1,39

7,36

7,60

7,86

7,61

5,69

1,59

3,28

5,56

6,04

5,49

2,80

0,25

-4,15

-1,92

-1,75

-1,84

-2,74

Mean changes (mm)

Relapse T5-T3Net expansion T5-T1Maximal expansion T3-T1


•Expansion at 1st Pm vs 2nd M! SARPE at T3

! Posterior expansion = anterior expansion

! In contrary to previous litterature and non-surgical RPE

! Supported by recent CT scan study (Loddi et al, J Cranio Surg 2008)

! SARPE at T5 : Greater relapse 2nd M may be explained by arch form coordination

! Le Fort 1 : Posterior expansion > anterior expansion

SARPE T3-T1 SARPE T5-T1 Le Fo ort 1

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 66

Expansion Pattern

May be explained by the separation of the pterygoïd junction


• Significant skeletal expansion!

! 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

Skeletal e expansion

" Mx T2-T1 " Mx T5-T1

X 3,44 3,63

S-d 1,39 1,54

N 36 23

Paired T p < .0001 p < .0001

Skeletal Changes


• Skeletal expansion! Mx & Nas. Cav.

! Stable

• Most of the relapse! Dental

• % Sk/Dental! Increased from 45!% to 65!%

! Consistent with other studies

Changes F(time)

0

2,00

4,00

6,00

8,00

0,68 6,65 15,49 23,110

18

35

53

70

45 47

58

65

Ex

pan

sio

n (

mm

)

Time post SARPE (months)

% S

ke

leta

l e

xp

an

sio

n

" 1st Molar" Nasal cavity" Mx% "Mx / " 1st Molar

Changes post SARPE at 1st molar / at Mx / at Nasal cavity


Relapse F(type of surgery)

• One way Anova

! No significant effect

• Any combination of surgical variables

! (Md, Mx, Bimax, No 2nd phase)

! No significant effect

! p = 0.0670 to 0.4525

N F value p

Bimax

Md

Mx

Nil

Total

6

7 F (3, 26) = 0 8125

5

( ) 0.32

0.8125

9

27


Relapse F(time T3-T4-T5)

1st M T3 1st M T4 1st M T5 1st M T6

1st M width

N

p value

Mean

%

50,22 49,13 48,24 47,22

38 30 27 19

p = .0 0008

p = .0 0118

p < .0001

T4-T3 T5-T4 T5-T3

-1,09 -0,89 -1,98

55!% 45!% 100!%

• 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

! 55!% relapse entre T4-T3

! 45!% relapse entre T5-T4


Relapse F(type of appliance)

• Banded expander has the same efficacy of bonded expander

! Similar dental expansion

! Similar skeletal expansion

! Similar relapse

N Bonded N 2 Bd Hx p value

Exp. 1st M T3-T1

Sk Exp Mx

Relapse 1st M T5-T3

17 7,91 21 7,34 .2727

15 3,85 12 3,04 .7090

16 -1,70 11 -2,23 .4410


Relapse F(extraction pattern)

• 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

"1st M M T5-T3

N Mean S-D Paired T

Extraction

Non-Extraction

6 -2,97 ± 1,40p = 0 1366

17 -1,68 ± 1,85p = 0.1366


•" 1st M T3-T1 / Diastema T2 = 91%! 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

Diastema F(" 1st molar)

! Expansion rate too slow (.3 mm / jrs)

! Callus ossification ! bone consolidation


• A-Telescoping zygomatic arch

• B-Minimal palatal separation

• C-Impinging of the screw into the palate

• Appliance = totally inadequate

C

A A

B


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


Before expansion

After expansionA

B

Lateral Rotation• A- Inward Mvt

• B- Palatal impingement

• Therefore!: place the screw 3- 4 mm away from palatal mucosa

• Supported Koodstaal et al, 2009

! Increase in palatal width results in decrease in depth... explained by tipping of the maxillary segments


• A-moderate separation

• B-Impingement

• C-Inward Mvt

Alveolar bendingBefore

expansion

After expansionC

A

B


" Skeletal" / " Screw


" 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


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


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


Comparison to non-surgical RPE

•Our data! 3,58!mm skelettal!: 65!% of the mean net dental

expansion (5,56!mm)


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


SARPEE Le Fort 1

N Mean S-D N Mean S-D p value

Canine

1st premolar

2nd premolar

1st molar

2nd molar

26 -2,74 1,75 12 -0,74 1,85 .0026

22 -1,84 2,11 9 -1,31 1,67 .5130

27 -1,75 2,55 11 -2,05 1,45 .7099

27 -1,92 1,74 12 -3,06 1,31 .0491

24 -4,15 1,89 8 -3,69 1,08 .5193

Stability Compared to Segmental Osteotomy

• No significant difference! 1st Pm, 2nd Pm, 1st M, 2nd M

• Canine : relapse more because of arch coordination


• 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


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 treatmentMeasured from the maximum expansion point


1st molar 27 -1,92 (25%) ±1,74 12 -3,06 (42%) ±1,31 .0491


Experimentals (n=38; 27;19)

Controls (n=12)

Controls (n=39)


Koudstal et al, 2009 (n = 19) T-B

Koudstal et al, 2009 (n =23) B-B






-4,50 -2,25 0 2,25 4,50 6,75 9,00

4,6

7,50

5,78

5,20

6,80

8,70

4,28

7,36

7,59

5,50

5,78

8,30

6,62

4,77

4,60

6,30

5,54

2,31

4,30

5,56

-0,88

-1,01

-0,60

-0,50

-3,16

-1,97

-3,06

-1,91

-0,22

-0,45

-1,20

-1,01

mm

Comparison to Other Studies

Long Term Relapse Short Term RelapseNet expansion Maximum expansionLong term exp



Controls (n=12)

Controls (n=39)









-4,50 -2,25 0 2,25 4,50 6,75 9,00

4,6

7,50

5,78

5,20

6,80

8,70

4,28

7,36

7,59

5,50

5,78

8,30

6,62

4,77

4,60

6,30

5,54

2,31

4,30

5,56

-0,88

-1,01

-0,60

-0,50

-3,16

-1,97

-3,06

-1,91

-0,22

-0,45

-1,20

-1,01

mm



Relapse>>

>>



Controls (n=12)

Controls (n=39)









-4,50 -2,25 0 2,25 4,50 6,75 9,00

4,6

7,50

5,78

5,20

6,80

8,70

4,28

7,36

7,59

5,50

5,78

8,30

6,62

4,77

4,60

6,30

5,54

2,31

4,30

5,56

-0,88

-1,01

-0,60

-0,50

-3,16

-1,97

-3,06

-1,91

-0,22

-0,45

-1,20

-1,01

mm


But ! NS


Relapse>>

>>

Relapse <

<



Controls (n=12)

Controls (n=39)









-4,50 -2,25 0 2,25 4,50 6,75 9,00

4,6

7,50

5,78

5,20

6,80

8,70

4,28

7,36

7,59

5,50

5,78

8,30

6,62

4,77

4,60

6,30

5,54

2,31

4,30

5,56

-0,88

-1,01

-0,60

-0,50

-3,16

-1,97

-3,06

-1,91

-0,22

-0,45

-1,20

-1,01

mm


But ! NS


Relapse>>

>>

Relapse <

<

"Exp.


• 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

H1 : Relapse obtained after SARPE and osseous distraction is less than 40% mm in 2/3 of the patients

0!%

10,0!%

20,0!%

30,0!%

40,0!%

50,0!%

'-,-3] (-3 to -1] (-1 to 1] (1 to 3]

9,1!%

18,2!%

50,0!%

22,7!%

3,7!%

29,6!%

40,7!%

25,9!%

SARPE: Post-Tx changes

% o

f p

atie

nt

Relapse (mm)

First MolarFirst Premolar

0!%

14,0!%

28,0!%

42,0!%

56,0!%

70,0!%

'-,-3] (-3 to -1] (-1 to 1] (1 to 3]

11,1!%

44,4!%

33,3!%

11,1!%

0!%

8,3!%

25,0!%

66,7!%

LeFort 1:Post-Tx Changes

Relapse (mm)



• 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

H1 : Relapse obtained after SARPE and osseous distraction is less than 40% mm in 2/3 of the patients

0!%

10,0!%

20,0!%

30,0!%

40,0!%

50,0!%

'-,-3] (-3 to -1] (-1 to 1] (1 to 3]

9,1!%

18,2!%

50,0!%

22,7!%

3,7!%

29,6!%

40,7!%

25,9!%

SARPE: Post-Tx changes

% o

f p

atie

nt

Relapse (mm)


0!%

14,0!%

28,0!%

42,0!%

56,0!%

70,0!%

'-,-3] (-3 to -1] (-1 to 1] (1 to 3]

11,1!%

44,4!%

33,3!%

11,1!%

0!%

8,3!%

25,0!%

66,7!%

LeFort 1:Post-Tx Changes

Relapse (mm)


66%


Clinical Implications

• If only transverse changes are needed! SARPE = Choice # 1

MC; tx:18m CS; tx:~22mYP; tx:~24m


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


But!: SARPE still indicated

• For large transverse AP and vertical changes or periodontally compromised patients

(Personal opinion)


• SARPE! Improved stability not proven from the maximum

expansion point

! 2 mm overexpansion recommended

! Tipping et rotation of hemimaxillae

• Once normal transverse relationship is achieved = new case to diagnose and Tx plan

Clinical Implications

tx:18m: 2Y ret tx:22m; 2 surg tx:27m; 2 surg


Final Discussion

• SARPE

– Long term stability proven; relapse at 2 y N-S

• Le Fort 1 : No data from sequential PA ceph & no long term data

SARPE long g term relap pse 2Y SARPE lo ong term changes

N Mean S-D p value N Mean S-D p value

Canine

1st premolar

2nd premolar

1st molar

2nd molar

Low. 1st Molar

18 0,02 0,73 .9090 18 2,41 2,01 < .0001

16 -0,44 1,45 .2467 16 4,94 2,23 < .0001

19 -0,56 1,43 .1067 19 5,36 2,47 < .0001

19 -1,01 1,13 .0011 19 4,60 2,09 < .0001

17 -0,59 1,34 .0857 16 2,59 1,31 < .0001

19 -0,23 1,50 .5057 19 0,69 2,45 .2320


Relapse T5-T32 y out of txNet expansion T5-T1Maximal expansion T3-T1Sans titre 1

Canine

1st premolar

2nd premolar

1st molar

2nd molar

1st lower molar

-6 -4 -2 0 2 4 6 8

0,69

2,59

4,60

5,36

4,94

2,41

1,39

7,36

7,60

7,86

7,61

5,69

1,59

3,28

5,56

6,04

5,49

2,80

0,02

-0,48

-0,56

-1,01

-0,59

-0,23

0,25

-4,15

-1,92

-1,75

-1,84

-2,74

Dental changes: Total/Net/Relapse

Mean changes (mm)

Te

eth


Thank You Dr Proffit

For your precious advice and help


I also want to thank my wife Carole and my children Pier-EricVanessaRichardfor their patience and their love

Thank You !

aao 109th annual_session_boston_2009_closer look at the stability of sarpe...

Health & Medicine

dr sylvain chamberlandmulti

expansion average

mean expansion

greater relapse

short term relapse

maximum expansion point

mmmean relapse

sarpe stability