Modified-casted Appliance for Surgically-assisted Rapid Palatal Expansion: A Clinical Report

Transcription

1 Case report /jp-journals Modified-casted Appliance for Surgically-assisted Rapid Palatal Expansion: A Clinical Report 1 Puneet Batra, 2 Shyam Prasad, 3 Narendra Kumar, 4 Meenu Goel, 5 Saurabh Sonar, 6 Karan Bhalla ABSTRACT Transverse maxilla-mandibular discrepancies are a major component of several malocclusions. Surgically assisted rapid palatal expansion (SARPE) is a common treatment modality for older patients in the correction of a maxillary transverse deficiency. In such cases, retention of the appliance plays an important role and this becomes a problem in patients having enamel hypoplasia. Therefore, the design was modified of a tooth-borne rapid maxillary expansion appliance with provision for miniscrew skeletal anchorage in a Class II malocclusion case having anterior open bite with bilateral posterior crossbite and enamel hypoplasia. Keywords: Surgically assisted rapid palatal expansion, Implant, Class II malocclusion, Transverse discrepancy. How to cite this article: Batra P, Prasad S, Kumar N, Goel M, Sonar S, Bhalla K. Modified-casted Appliance for Surgically Assisted Rapid Palatal Expansion: A Clinical Report. J Ind Orthod Soc 2014;48(2): Source of support: Nil Conflict of interest: None Received on: 18/12/12 Accepted after Revision: 8/2/13 Introduction Transverse maxillomandibular discrepancies are a major component of several malocclusions. 1 Rapid maxillary expansion (RME) is a common treatment modality for younger patients in the correction of a maxillary transverse deficiency. In skeletally mature patients, the possibility of successful maxillary expansion decreases as sutures close and the resistance to mechanical forces increases. 2 Surgically assisted RME (SARME) has been proposed to produce better 1-3 Professor and Head, 4 Senior Lecturer, 5 Professor 6 Postgraduate Student 1,4-6 Department of Orthodontics, Institute of Dental Studies and 2 Department of Oral Surgery, Institute of Dental Studies and 3 Department of Prosthodontics, Institute of Dental Studies and Corresponding Author: Puneet Batra, Professor and Head Department of Orthodontics, Institute of Dental Studies and, drpuneet batra@gmail.com 134 treatment results in adults and to prevent complications by surgically releasing the closed sutures resisting the expansion forces. 3 It not only increases intermolar distance and palatal width but also, in certain cases, can improve nasal respiration. 4-8 The tooth-borne expanders for maxillary expansion have some undesirable side effects such as tooth tipping, dental relapse, cortical fenestrations, loss of anchorage, and seg mental maxillary tipping. In comparison, when using tooth tissue expanders most of the maxillary expansion is ortho pedic and at a more mechanically desired level with dental side effects. 9 This clinical report describes a modified-casted toothborne rapid maxillary expansion appliance with provision for miniscrew skeletal anchorage for surgically assisted rapid palatal expansion (SARPE) case having Class II malocclusion and an anterior open bite with a bilateral posterior crossbite. Case Report A 19-year-old male patient presented with a Class II malocclusion and an anterior open bite with a bilateral posterior crossbite and amelogenesis imperfacta (Fig. 1). The treatment plan was combined surgical and nonextraction orthodontic therapy. The surgery was divided into three stages, that is, SARME; maxillary osteotomy with superior positioning by 4 mm, followed by bilateral split sagittal osteotomy of 8.5 mm for mandibular advancement and rotation of 4 mm, and advance ment genioplasty of 4 mm. As the patient had amelo genesis imperfecta, a modified bonded split casted expansion appliance with bilateral buccal extension for implant placement was fabricated (Fig. 2). The rationale of the bonded appliance was to get more retention with miniscrew implants and to eliminate the undesirable dental effects of the splinted appliance. Appliance Fabrication Presurgically impressions were made and a master cast was poured in dental stone. Dental surveying was done on the master cast to mark the highest contour of convergence and placement of the prosthesis (Fig. 3). Block out was done to remove the undesired undercut. Complete metal crowns in nickel-chromium alloy were fabricated on the posterior teeth bilaterally with Hyrax palatal expander

2 JIOS Modified-casted Appliance for Surgically-assisted Rapid Palatal Expansion: A Clinical Report Fig. 1A: Extraoral photographs Fig. 1B: Intraoral photographs (11 mm) was attached to the prosthesis. Prepared teeth were painted with a thin coating of separating medium (George Taub). The wax pattern was made in type II casting wax with buccal extension for the placement of 1.2 mm wide implants and expander attached to the pattern (Fig. 4). Two opposing sprues 2 mm thick were provided at the occlusalaxial junction of the pattern bilaterally. At the junction of these sprues, a reservoir was provided that was attached to the main sprue (Fig. 5). The pattern was invested in phosphate-bonded investment. The pattern was first coated with The Journal of Indian Orthodontic Society, April-June 2014;48(2):

3 the appliance was expanded until the tissue between the central incisors blanched and then expanded the appliance 2 turns per day (0.5 mm) until the desired expansion was complete. The patient was seen by the orthodontist 3 weeks after the surgical procedure. The occlusal radiograph taken after SARPE (Fig. 7) showed a symmetric expansion at the midpalatal suture. The intercanine expansion was 11 mm with intermolar expansion was 8 and 17 mm of midline diastema was observed after the surgical procedure (Fig. 8). Twelve months after the surgical expansion the interproximal gingiva remains healthy but radiographically the bony fill appears immature and disorganized. Fig. 1C: Pretreatment lateral cephalogram comparatively thinner mix of investment material using a camel hair brush. A vaccum mixer (vac-u-vestor) was used for mixing the investment and the investing procedure was completed. The invested ring was placed in burn out furnace for 75 minutes at 800 C for thermal expansion to compensate for casting shrinkage. An induction casting machine was used. After retrieving the casting, it was cleaned by using sandblaster with 50 to 100 mg particle size abrasives. The casting was tried for fit on the densite stone dies and finally cemented on the posterior teeth. The expansion appliance was cemented with glass ionomer cement to all the teeth with two implants [Titanium microimplant 1.2 mm wide and 6 mm long, with long head and hexagonal in shape Absoanchor ] placed on the buccal surface to provide more retention 2 weeks before the surgical expansion (Fig. 6). The occlusal surface of the appliance was made compatible for the free movement of mandibular cusp in all eccentric movements. During the expansion procedure, Discussion RME promotes an increase in transverse dimensions and in the perimeter of the upper dental arch with a real gain of bone at the level of midpalatal suture. 10,11 In the present case, intercanine expansion of 11 mm with intermolar expansion Fig. 3: Dental surveying on the master cast Fig. 2: Modified bonded split-casted expansion appliance 136

4 JIOS Modified-casted Appliance for Surgically-assisted Rapid Palatal Expansion: A Clinical Report Fig. 4: Wax pattern made in type II casting wax with buccal extension Fig. 5: Two opposing sprues 2 mm thick placed at the occlusalaxial junction of the pattern bilaterally Fig. 6: Appliance placed intraorally of 8 mm was observed after the surgically assisted rapid palatal expansion. Complications that are related to the expansion appliance include its impingement on palatal soft tissue, loosening (more common with bone-borne distractors 12 ), and breakage and stripping or locking of the appliance screw Bonded acrylic RME appliance was recommended in cases of constricted maxilla where inferior and anterior movements of maxilla were restricted. Bonded RME appliances are designed to cover the posterior occlusal buccal segments so that the appliance not only serves as an expansion device but also intrudes on the freeway space through its vertical thickness. It acts as a functional appliance with small range of action. Theoretically, by infringing on the Fig. 7: Occlusal radiograph after surgically assisted rapid palatal expansion The Journal of Indian Orthodontic Society, April-June 2014;48(2):

5 Fig. 8: Occlusal view after surgically assisted rapid palatal expansion freeway space with the displacement of the mandible (2-3 mm) below the intercuspal position. A constant passive force is exerted on the maxilla and the mandible. 16 Enamel hypoplasia or amelogenesis imperfecta can be consi dered an exclusive ectodermal disturbance which can cause white flecks, narrow horizontal bands, lines of pits, grooves, and discoloration of teeth varying from yellow to dark brown. 17,18 In the present case report enamel hypoplasia was present; therefore, a modified-bonded split-casted expan - sion appliance with bilateral buccal extension was cemen ted with glass ionomer cement to all the teeth and two miniscrew implants were placed to augment retention. The major advantage of using miniscrews in this case is that the forces are acting directly to the bone at the mechanically desired level, which prevents dental tipping and keeps segmental tipping to a minimum in addition to reinforcement of retention. CONCLUSION Appliance design is very critical for the success of this procedure. Casted appliance was supplemented with boneborne anchorage using miniscrew implants. REFERENCES 1. Suri L, Taneja P. Surgically assisted rapid palatal expansion: a literature review. Am J Orthod Dentofacial Orthop 2008;133: Baumrind S, Korn EL. Transverse development of human jaws between the ages of 8.5 and 15.5 years, studied longitudinally with the use of implant. J Dent Res 1990;69: Betts NJ, Vanarsdall RL, Barber HD, Higgins-Barber K, Fonseca RJ. Diagnosis and treatment of transverse maxillary deficiency. Int J Adult Orthod Orthognath Surg 1995;10: Bays RA, Greco JM. Surgically assisted rapid palatal expansion. J Oral Maxillofac Surg 1992;50: Pogrel MA, Kaban BL, Vargervik K, Baumrind S. Surgically assisted rapid maxillary expansion in adults. Int J Adult Orthod Orthognath Surg 1992;7: Vanarsdall RL. Periodontal/orthodontic relationships. In: Graber TM, Vanarsdall RL, editors. Orthodontics: current principles and techniques. 2nd ed. Mosby, St. Louis, pp Northway WM, Meade JB. Surgically assisted rapid maxillary expansion: a comparison of technique, response and stability. Angle Orthod 1997;67: Berger JL, Pangrazio-Kulbersh V, Borguis T, Kaczynski R. Stability of orthopedic and surgically assisted rapid palatal expansion over time. Am J Orthod Dentofac Orthop 1998; 114: Koudstaal MJ, Smeets JBJ, Kleinrensink GJ, Schulten AJM, Karel GH. Relapse and stability of surgically assisted rapid maxillary expansion: an anatomic biomechanical study. J Oral Maxillofac Surg 2009;67: Haas AJ. Rapid expansion of the maxillary dental arch and nasal cavity by opening the midpalatal suture. Angle Orthod 1961; 31: Haas AJ. The treatment of maxillary deficiency by opening the midpalatal suture. Angle Orthod 1965;35: Neyt NM, Mommaerts MY, Abeloos JV, De Clercq CA, Neyt LF. Problems, obstacles and complications with transpalatal distraction in noncongenital deformities. J Craniomaxillofac Surg 2002;30: Silverstein K, Quinn PD. Surgically-assisted rapid palatal expansion for management of transverse maxillary deficiency. J Oral Maxillofac Surg 1997;55: Mehra P, Cottrell DA, Caiazzo A, Lincoln R. Life-threatening, delayed epistaxis after surgically assisted rapid palatal expansion: a case report. J Oral Maxillofac Surg 1999;57: Chuah C, Mehra P. Bilateral lingual anesthesia following surgically assisted rapid palatal expansion: report of a case. J Oral Maxillofac Surg 2005;63: Sarver DM and Johnston MW. Skeletal changes in vertical and anterior displacement of the maxilla with bonded rapid palatal expansion appliances. Am J Orthod 1989;5: Crab JJ. The restoration of hypoplastic anterior teeth using acidetched technique. J Dent 1975;3: Shafer WG. A textbook of oral pathology. 4th ed. Philadelphia: WB Saunders