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Question
2013-12-20

Dear Doctor Teig

My name is Domingos Savio, I am 49 years old and I live in Brazil. I would like to ask some explanation over a problem I had during an operation Sarpe.
I was recently diagnosed with transverse maxillary constriction with posterior crossbite.
(Class I Malocclusion on Left), and the doctor recommended me a surgically assisted rapid palatal expansion
In spite of the Malocclusion only on the left side, the surgery was practiced on both sides (bilateral cut).
The procedure was undergone in ambulatory with local anesthesia and lasted around 50 minutes.
Two days after the surgery, following the surgeon indication, I myself started to activate the expander (Hyrax) at home, turning the screw four times a day.
On the second day of activation, I noticed the right side started to expand extremely outwards, and the left side (with serious crossbite), remained blocked, with meaningless movement.
I reduced the opening from four to two times a day, but started experiencing strong pain near my right ear, until I was forced to stop the opening.
One week after the surgery I had an extreme asymmetry on the right side of my face, visible even externally.

Unfortunately the surgeon was absent during the post-op, and I met him only 15 days after the operation.
He took off the stitches and locked the Hyrax with a piece of wire, considering the result of the surgery as normal and set a return to his office three months later.
Desperate as I was, by seeing my face with a terrible asymmetry, I went to the orthodontist and explained to him what had happened. Only 22 days after the surgery the orthodontist decided to unlock the Hyrax and unscrewed it to eliminate the asymmetry, and said the right side was in a good position, but the left side should be cut again in a new surgery, four months later.
I was told the problem happened because there was a blockage of the zygomatic bone of the left side, preventing the Hyrax from working properly, and pushing the right side excessively outwards, causing the asymmetry.

I felt completely upset and lost when I heard the proposal of a second surgery, only a few days after having had the first one. I decided after that, not to undergo another surgery with the same doctor and changed also the orthodontist.
I still have the malocclusion on the left side, and would like to ask you some questions about what could have been done to avoid all the distress I went through.

1- Is it possible to make adjustments on the Hyrax, in order to keep the minimum opening that occurred on the left side, and at the same time, reduce the excess of opening on the right side?
In other words, is it possible to work on the screw, to make independent adjustments on each side of the Hyrax to correct the asymmetry occurred during the expansion?

2 - What corrective procedure is typically used when a palatal expansion is asymmetric? Is that procedure performed during the expansion phase or later?

3 ���� a surgery like mine, with bilateral cut, when one side remain blocked and the other side expand excessively, what would be the correct procedure to apply?

4 ���� the first surgery bones have already been cut. In case of a second surgery to expand the left side, remained blocked, would there be risks to cut the same bones again?

I understand that from far and over the Internet, may be a little difficult to have a clear idea of the case, but I just hope to receive an explanation from you about what really happened, what could have been done and right now, what could be the best solution for my problem.

I sincerely thank you for your help.
Send my best regards
Domingos Savio

Answer
Domingos - As far as I know the Hyrax is made such that both sides move equally.  I don't know of an appliance that allows the two sides to move at different rates.

When a palatal expansion occurs unequally it usually happens due to the surgeons mistake at not completely separating the lower portion of the maxilla from the upper portion.  It usually is recognized by the surgeon that the bone is not completelyloose.  A corrective procedure, if recognized during the surgery could be corrected then.  If not realized until after the surgery is finished, the surgeon needs to gain access and completely remove any connections to the upper maxilla.  

So the correction procedure would open the wounds that were sutures and the maxilla is exposed and all areas where the bone was cut needs to be examined to see if there is an incomplete cut.  Those still fixed areas need cutting.

There is definitely risks in performing a second surgery in the same area.  It is imperative that the blood flow to the area is not compromised.  A quality surgeon could correct this procedure.

So from your explanation of what has occurred since the surgery, it seems that the surgeon did not completely cut and sever the bone or he cut it a such a level where the bones could not expand.  That is almost impossible if the bone cuts are done at the correct level.  Obstruction from the zygoma or zygomatic arch is almost impossible in my mind.  That is cut way too high or the cuts angled up towards the back of the upper jaw.

So this can be corrected, bit only by a skilled surgeon. I wish you well and hope you can find one.

Dentistry

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Joel S. Teig, DMD, Diplomate ABOMS, retired

Expertise

I am a board certified oral and maxillofacial surgeon and I am available to answer questions related to tooth extractions, implant insertion, facial recontruction, facial and oral tumor removal, TMJ dysfunction and various successful treatments, including surgery if all else fails, and occlusal discrepancy requiring orthognathic or jaw surgery.

Experience

Board Certified Oral and Maxillofacial Surgeon practicine for over 20 years. Assistant Clincal Professor and State University School of Dentistry.

Organizations
American Dental Association, American Association of Oral and Maxillofacial Surgeons, American Board of Oral and Maxillofacial Surgeons

Education/Credentials
BA -University of Connecticut DMD - University of Pennsylvania School of Dental Medicine

Awards and Honors
National Honor Society (OKU), Philadelphia County Dental Society, Mosby Book Award, Oral Surgery Honors, Summa Cum Laude

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