Transverse Problems

The present article describes a specific protocol for maxillary segmentation in patients with a transverse skeletal maxillomandibular discrepancy, which can be resolved through orthopedic treatment with rapid palatal expansion. In grown patients, a surgical aid is usually required to allow reopening of the midpalatal suture, simultaneously releasing both the piriform and malar buttresses. The authors propose two techniques for maxillary expansion: segmentation and SARPE (surgically assisted rapid palatal expansion)/SAMARPE (surgically assisted miniscrew-assisted rapid palatal expansion). Segmentation is indicated in cases where maxillary surgery is needed for some reason (vertical and anteroposterior), and the transverse discrepancy is less than 7 mm. This technique involves a minimally invasive Le Fort I procedure and interdental and longitudinal osteotomies. The four fragments allow for maxillary expansion, which is carefully achieved by palatal subperiosteal elevation under the lateral segments. The four segments are then included in the splint and fixed with wire ligatures around the braces. SARPE/SAMARPE, on the other hand, is indicated in skeletally mature patients with an isolated transverse maxillary deficiency, and patients who will eventually sustain a regular orthognathic procedure but have a transverse discrepancy in excess of 6 mm, which cannot be solved through segmentation. SARPE involves the surgical release of the sites of resistance combined using orthopedic forces. The authors propose a surgical technique that entails the full release of all areas of resistance—midpalatal, piriform, zygomatic, and pterygoid—and which is performed under local anesthesia and sedation on an ambulatory basis.