J Stomatol Oral Maxillofac Surg 118 (2017) 279–282

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Original Article

Complications associated with surgically assisted rapid palatal

expansion without pterygomaxillary separation§
S. Cakarer *, B. Keskin, S.C. Isler, E. Cansiz, A. Uzun, C. Keskin
Istanbul University, Faculty of Dentistry, Department of Oral and Maxillofacial Surgery, Istanbul, Turkey

A R T I C L E I N F O A B S T R A C T

Article history: Introduction: The purpose of this retrospective clinical study was to evaluate the surgical complications
Received 30 November 2016 associated with the surgically assisted rapid palatal expansion (SARPE) which does not involve
Accepted 13 June 2017 pterygomaxillary separation (PMS).
Available online 19 June 2017
Patients and methods: A total of 40 (25 females, 15 males) skeletally mature patients, who had the
diagnosis of maxillary transverse maxillary deficiency (TMD), were treated surgically under local or
Keywords: general anesthesia. The mean follow-up time was 6 months.
Maxillary expansion
Results: Recorded perioperative and postoperative complications were discussed within the current
Complication
Orthognatic surgery
literature. No serious complications were observed intraoperatively. Eight patients (20%) showed
postoperative complications including neurosensory deficits, maxillary sinus infection, epistaxis, fistula
formation and incisional dehiscence.
Discussion: Neurosensory deficits were the most common findings. The present findings suggest that
minor complications were observed associated with SARPE without PMS. The technique may be
performed safely also under local anesthesia.
C 2017 Elsevier Masson SAS. All rights reserved.

1. Introduction 2. Materials and methods

A transverse maxillary deficiency (TMD) may be treated
either orthodontically or surgically. If the deficiency is large, the
recommended approach is surgically assisted rapid palatal
expansion (SARPE), as performed in the present study [1].
Various authors differ in terms of the areas considered to be
resistant to lateral maxillary expansion. The piriform aperture
pillars, zygomatic buttresses, pterygoid junctions, and midpalatal
synostosed suture have been considered to be resistant to
expansion. Dysjunction of the pterygoid plates is at the discretion
of the surgeon.
The literature is inconclusive in terms of the effect of
pterygomaxillary separation (PMS) on the outcomes of SARPE
[2,3]. Therefore, we evaluated the outcomes of SARPE without PMS
in terms of both intra- and postoperative complications, in the
context of the current literature. The advantages and disadvanta-
ges of local and general anesthesia were also assessed.
We retrospectively reviewed data on all patients who under-
went SARPE at Istanbul University Faculty of Dentistry, Depart-
ment of Oral and Maxillofacial Surgery, from January 2014 through
March 2016. The study was approved by our institutional ethics
committee. The same surgical team performed all operations using
the same technique. The orthodontist applied a tooth-borne, fixed,
hyrax-type, palatal expansion screw 1 or 2 days before surgery
(Fig. 1). We collected data on intra- and postoperative complica-
tions during the 6 months after surgery. The inclusion criteria were
skeletal maturity with a bilateral TMD > 5 mm; good oral hygiene;
and healthy periodontal structures. The exclusion criteria were the
presence of any maxillary sinus disease, previous maxillomandi-
bular intervention.
Predictive variables included demographic parameters (age and
gender) and the type of the anesthesia applied (local or general).
The primary outcome was the presence or absence of postopera-
tive complications.

§
The English in this document has been checked by at least two professional 2.1. Statistical analysis
editors, both native speakers of English. For a certificate, please see: http://www.
textcheck.com/certificate/tu5wbQ.
* Corresponding author. Statistical analysis was performed using the Number Cruncher
E-mail address: sirmacakar@yahoo.com (S. Cakarer). Statistical System 2007 (NCSS, Kaysville, UT, USA). We used the

http://dx.doi.org/10.1016/j.jormas.2017.06.008
2468-7855/ C 2017 Elsevier Masson SAS. All rights reserved.
280 S. Cakarer et al. / J Stomatol Oral Maxillofac Surg 118 (2017) 279–282

Fig. 1. The view of the tooth-borne expansion device.

independent t-test to compare descriptive variables (means  SD).

The chi-squared test was used to evaluate qualitative data. A P-
value < 0.05 was considered to reflect statistical significance. We
found no significant difference between the complication-negative
and -positive groups in age, gender, or type of anesthesia (Table 1).
The complication rate was 20% but all complications were minor.
Fig. 2. Intraoperative view of the Le Fort I osteotomy line.

2.2. Surgical technique

All patients were informed that they could choose between

general or local anesthesia. Seven patients preferred local
anesthesia and thirty-three preferred general anesthesia. During
the operation, all patients received local anesthetics to ensure
hemostasis prior to incision. A full-thickness maxillary vestibular
incision, extending from the first molar to the contralateral first
molar, was performed, followed by subperiosteal dissection
exposing the maxilla from the piriform rim to the buttress.
Attached gingiva in the region of the interdental osteotomy was
atraumatically and minimally elevated to prevent possible tissue
necrosis of the anterior maxilla. An osteotomy at Le Fort I level was
created using a straight fissure burr [1] (Fig. 2). PMS was not
performed but bilateral nasal osteotomies were created. The
expansion device was activated before performance of the
interdental osteotomy; separation then followed. Interdental Fig. 3. Intraoperative view of the interdental separation.
osteotomy was performed with the aid of a round burr;
transpalatal osteotomy featured the use of a spatular osteotome
(Fig. 3). The expansion device was then closed and the flap was noted. Electrocauterization was used to manage small
repositioned and sutured. bleedings.

3. Results 3.2. Postoperative complications

The study cohort consisted of 40 patients, of whom slightly
more than half (62.5%) were female. The median follow-up time
was 6 months.
3.1. Intraoperative complications
During operation, the osteotome became displaced from the
palatal mucosa in three patients. The mucosa was sutured and no
postoperative dehiscence was observed. No hemorrhagic problem
Eight patients (20%) developed postoperative surgical compli-
cations. One patient experienced epistaxis 5 days after surgery.
Hemostasis was attained by applying an anterior nasal pack. One
patient developed a maxillary sinus infection 2 weeks after surgery
and four complained of numbness of the anterior maxilla. One
patient with cleft lip-palate (CLP) syndrome developed a fistula at
the site of the prior palatal cleft. He underwent iliac crest
augmentation to manage the fistula. One patient exhibited wound
dehiscence at the anterior maxilla 1 week after surgery. The wound

Table 1
Evaluation of the complication regarding age, gender and anesthesia.

Complication ( ) Complication (+) Total P

n: 32 n: 8 n: 40

Age 23.50  5.23 24.38  5.53 23.67  5.23 0.678

Gender
Male 13 40.63% 2 25.00% 15 37.50%
Female 19 59.38% 6 75.00% 25 62.50% 0.414
Anesthesia type
General anesthesia 26 81.25% 7 87.50% 33 82.50%
Local anesthesia 6 18.75% 1 12.50% 7 17.50% 0.677
 S. Cakarer et al. / J Stomatol Oral Maxillofac Surg 118 (2017) 279–282
was resutured and no further problem was reported. No
asymmetric/inadequate expansion, and no dental or periodontal
problem was noted in any patient.
4. Discussion
Although SARPE is commonly performed, little information is
available on the prevalence of postoperative complications
including pain, hemorrhage, infection, sinusitis, periodontal bone
loss, tooth devitalization/loss, palatal mucosal ulceration, asym-
metric expansion, relapse, or more serious issues including aseptic
necrosis and orbital complications [1]. Some reported unusual
complications included orbital compartment syndrome, bilateral
lingual anesthesia, and development of a nasopalatine canal cyst
[2].
Several authors have avoided surgical separation of the
pterygomaxillary junction, thus rendering surgery noninvasive.
No consensus has yet emerged on whether PTS is appropriate
during SARPE [4]. Few details on intra- and postoperative
complications associated with SARPE without PMS have appeared
[3]. Therefore, we discuss the complications of the present study to
inform oral and maxillofacial surgeons, and orthodontists.
4.1. Anesthesia for SARPE
SARPE can be performed under general or local anesthesia.
Authors vary in their views as to whether SARPE without PMS is safe
in terms of bleeding problems developing under local anesthesia
[5–8]. In the present study, only seven patients selected local
anesthesia without any additional sedation. SARPE without PMS
was safe in such patients. The principal problem was (psychological)
trauma during the lateral nasal wall osteotomies. However, all
patients were discharged 8 h after operation. We injected
methylprednisolone intravenously prior to operation to minimize
postoperative facial edema and found this to be useful. One
advantage of general anesthesia (from the viewpoint of the surgeon)
is that the patient is hypotensive during operation. We consider it
necessary to cease hypotensive anesthesia prior to wound closure to
allow any possible hemorrhage to be identified [9].
4.2. Hemorrhage
It has been speculated that PMS performed using an osteotome
might trigger postoperative vascular events. In maxilla-down
fracture cases, other factors, including late wound infection, a
pseudoaneurysm, a high-level pterygoid plate fracture, and
injuries to the descending palatine and sphenopalatine arteries
during forward maxillar mobilization, may trigger life-threatening
hemorragia. However, SARPE is associated with low morbidity,
especially when compared to maxilla-down fracture. In the large
SARPE case series (376 patients) of Politis et al., no life-threatening
hemorragia was noted [10]. On the other hand, Mehra et al.
reported a case of delayed life-threatening epistaxis after SARPE
[11]. Embolization has been used widely to treat vascular injuries
and head-and-neck bleeding, and to manage epistaxis, intracranial
aneurysms, and arterio-venous fistulae [12]. To the best of our
knowledge, the requirement for embolization of a postoperative
hemorrhage developing after SARPE has not been reported in the
literature.
Anterior and/or posterior nasal packing for 3–5 days is the
standard method used to treat epistaxis. In several case series of
hemorrhage developing after Le Fort I osteotomies, the vast
majority of initial episodes occurred within the first 14 postopera-
tive days [13]. Dergin et al. retrospectively evaluated complica-
tions after SARPE. Of all patients, 20% developed nasal bleeds
281
[14]. In the present study, only one patient (2.5%) developed
epistaxis 5 days after surgery. Hemostasis was achieved via
anterior nasal packing. As we did not perform PMS, the probable
cause of hemorrhage was traumatic osteotomy of the lateral nasal
wall. During such osteotomy, the osteotome should not be directed
medially or superiorly to prevent possible damage to the inferior
turbinate and the nasal mucoperiosteum. Also, during SARPE,
management of an injury to the descending palatine artery can be
more difficult than in maxilla-down fracture cases because it is not
possible to view the vessel directly. Also, risk of hemorrhage is
reduced if the surgeon remains in the subperiosteal plane when
working laterally, thus not dissecting soft tissue [15].
4.3. Maxillary sinus infection
Persistent maxillary sinusitis (that requires treatment) is
thought to be uncommon after Le Fort osteotomy, but the true
incidence remains unclear. Such sinusitis may be caused by: (1)
changes in the mechanism by which sinus mucus is cleared; (2)
retention of a blood clot in the sinus cavity; (3) dental infection; (4)
a foreign body; or, (5) anatomical blockage of the osteomeatal
opening. The most common cause is unrecognized preoperative
chronic sinusitis [9]. In the present study, one patient developed a
maxillary sinus infection. She presented with a complaint of
defluxion. Computed tomography (CT) revealed congestion of the
left middle meatus. We consulted with ear, nose, and throat (ENT)
specialists and performed functional endoscopic sinus surgery
(FESS) under general anesthesia. During examination, we observed
pus draining from the maxillary sinus to the inferior meatus via a
fistula, and a foreign body. This was removed and diagnosed
histopathologically as an aspergillosis. We prescribed penicillin
and metronidazole. Three weeks later, the patient was completely
asymptomatic. Fungal infection of the maxillary sinus after SARPE
is unusual. The trauma associated with the lateral nasal wall
osteotomies may trigger fistula formation from the inferior meatus
to maxillary sinus, thus modifying the flora of the maxillary sinus
by introducing a fungus. To manage such complications, CT of the
maxillary sinus and consultation with ENT specialists are advised.
Some unusual reported complications of SARPE were delayed
life-threatening epistaxis and bilateral lingual anesthesia
[11,16]. In the present study, the aspergillosis in the maxillary
sinus might be considered unusual.
4.4. Nerve injury
Alterations in blood flow and injury to the branches of the
maxillary nerve have been reported to cause tooth numbness and
paresthesia of the lips and the infraorbital region [14]. Subjective
changes in somatosensory function, cutaneous numbness, and
numbness of the facial and palatal gingiva, have also been reported
in the literature [17,18]. Four of our patients reported temporary
bilateral numbness of the teeth and the gingiva, with temporary
bilateral slight facial paresthesia, possibly associated with trauma
to the infraorbital nerve imparted by the tissue retractors. All
numbness resolved by 6 months after surgery.
4.5. Complications in patients with cleft lip and palate
Orthognathic surgery is usually the final phase of treatment in
CLP patients. More than 25% of such patients develop significant
maxillary hypoplasia that requires both local surgical intervention
and maxillary Le Fort I osteotomy [19]. The present study included
only two CLP patients. The cleft area was opened after termination
of expansion in one patient with a slight unilateral cleft palate. This
patient underwent secondary surgery, including iliac crest bone
augmentation; the defect was closed successfully. No further
282 S. Cakarer et al. / J Stomatol Oral Maxillofac Surg 118 (2017) 279–282
complaint was noted. Generally, the cleft maxilla is narrow and
may require surgical expansion. Wolford and Stevao [3] described
soft tissue techniques permitting surgical expansion of the maxilla
while maintaining a viable blood supply to all segments [20]. The
complications associated with Le Fort I osteotomy are well-known,
but those of SARPE in CLP patients are not. Prospective cohort
studies are required.
4.6. Dehiscence
In the present study, we performed complete Le Fort I incisions
exposing the anterior maxilla from the first molar to the first
contralateral molar. This afforded an optimal surgical view for
dissection of the lateral nasal mucosa, lateral nasal osteotomy, and
interdental osteotomy. A full horizontal vestibular incision was
created 5 mm above the mucogingival junction to prevent possible
necrosis. Our preference is to create the incision via electrocautery
and then modify it using a #15 blade. In the present study, only one
patient experienced dehiscence of this incision 1 week after
operation, but the bone was not exposed. The incision line was
resutured and no other complaint was noted. Incisions may be
created with a scalpel, via electrocautery, or both, depending on
the preference of the surgeon. We prefer to use a Colorado tip to
ensure both good hemostasis and surgical precision, as reported by
Sullivan [21]. It is important, during incision, to spare sufficient soft
tissue to allow appropriate closure at the end of the operation. It is
thus important to create the incision at least 5 mm above the
mucogingival junction.
Disclosure of interest
The authors declare that they have no competing interest.
Acknowledgement
The authors thank ‘‘ARK Biostatistical Office’’ for the statistical
analyses.
References
[1] Williams BJ, Currimbhoy S, Silva A, O’Ryan FS. Complications following surgi-
cally assisted rapid palatal expansion: a retrospective cohort study. J Oral
Maxillofac Surg 2012;70:2394–402.
[2] Suri L, Taneja P. Surgically assisted rapid palatal expansion: a literature review.
Am J Orthod Dentofacial Orthop 2008;133:290–302.
[3] Hamedi Sangsari A, Sadr-Eshkevari P, Al-Dam A, Friedrich RE, Freymiller E,
Rashad A. Surgically assisted rapid palatomaxillary expansion with or without
pterygomaxillary disjunction: a systematic review and meta-analysis. J Oral
Maxillofac Surg 2016;74:338–48.
[4] Kilic E, Kilic B, Kurt G, Sakin C, Alkan A. Effects of surgically assisted rapid
palatal expansion with and without pterygomaxillary disjunction on dental
and skeletal structures: a retrospective review. Oral Surg Oral Med Oral Pathol
Oral Radiol 2013;115:167–74.
[5] Furquim LZ, Janson G, Furquim BD, Iwaki Filho L, Henriques JF, Ferreira GM.
Maxillary protraction after surgically assisted maxillary expansion. J Appl Oral
Sci 2010;18:308–15.
[6] Rana M, Gellrich NC, Rana M, Piffkó J, Kater W. Evaluation of surgically assisted
rapid maxillary expansion with piezosurgery versus oscillating saw and chisel
osteotomy – a randomized prospective trial. Trials 2013;17:49. http://
dx.doi.org/10.1186/1745-6215-14-49.
[7] Robiony M, Polini F, Costa F, Zerman N, Politi M. Ultrasonic bone cutting for
surgically assisted rapid maxillary expansion (SARME) under local anaesthe-
sia. Int J Oral Maxillofac Surg 2007;36:267–9.
[8] Hernandez-Alfaro F, Mareque Bueno J, Diaz A, Pagés CM. Minimally invasive
surgically assisted rapid palatal expansion with limited approach under
sedation: a report of 283 consecutive cases. J Oral Maxillofac Surg
2010;68:2154–8.
[9] Posnick JC. Risk and complications specific to Le fort I osteotomy, Principles
and Practice of Orthognathic Surgery. Ch.17.2013
[10] Politis C. Life-threatening haemorrhage after 750 Le Fort I osteotomies and
376 SARPE procedures. Int J Oral Maxillofac Surg 2012;41:702–8.
[11] Mehra P, Cottrell DA, Caiazzo A, Lincoln R. Life-threatening, delayed epistaxis
after surgically assisted rapid palatal expansion: a case report. J Oral Maxi-
llofac Surg 1999;57:201–4.
[12] Avelar RL, Goelzer JG, Becker OE, de Oliveira RB, Raupp EF, de Magalhães PS.
Embolization of pseudoaneurysm of the internal maxillary artery after ortho-
gnathic surgery. J Craniofac Surg 2010;21:1764–8.
[13] Garg S, Kaur S. Evaluation of post-operative complication rate of Le Fort I
osteotomy: a retrospective and prospective study. J Maxillofac Oral Surg
2014;13:120–7.
[14] Dergin G, Aktop S, Varol A, Ugurlu F, Garip H. Complications related to
surgically assisted rapid palatal expansion. Oral Surg Oral Med Oral Pathol
Oral Radiol 2015;119:601–7.
[15] Humber CC, Lanigan DT, Hohn FI. Retrograde hemorrhage (hemolacria) from
the lacrimal puncta after a Le Fort I osteotomy: a report of 2 cases and a review
of the literature. J Oral Maxillofac Surg 2011;69:520–7.
[16] Chuah C, Mehra P. Bilateral lingual anesthesia following surgically assisted
rapid palatal expansion: report of a case. J Oral Maxillofac Surg 2005;63:416–
8.
[17] Thygesen TH, Bardow A, Norholt SE, Jensen J, Svensson P. Surgical risk factors
and maxillary nerve function after Le Fort I osteotomy. J Oral Maxillofac Surg
2009;67:528–36.
[18] Je˛drzejewski M, Smektała T, Sporniak-Tutak K, Olszewski R. Preoperative,
intraoperative, and postoperative complications in orthognathic surgery: a
systematic review. Clin Oral Investig 2015;19:969–77.
[19] Saltaji H, Major MP, Alfakir H, Al-Saleh MA, Flores-Mir C. Maxillary advance-
ment with conventional orthognathic surgery in patients with cleft lip and
palate: is it a stable technique? J Oral Maxillofac Surg 2012;70:2859–66.
[20] Wolford LM, Stevao EL. Correction of jaw deformities in patients with cleft lip
and palate. Proc (Bayl Univ Med Cent) 2002;15:250–4.
[21] Sullivan SM. Techniques in orthognathic surgery. An issue of atlas of the oral
and maxillofacial surgery clinics of North America. Elsevier; 2016.