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Orthodontics/SARPE - Anterior Over-Expansion

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QUESTION: Dear Dr. Supan,

About 3 months I had SARPE surgery to correct a cross-bite.

I expanded as advised by my orthodontist for about 2-3 weeks after surgery.

My upper palate seems to have expanded properly in the back (upper molars seem to match the lower molars) but while posterior expansion seems fine, I'm seeing an unpleasant anterior over-expansion (especially on the right side). Lateral incisor, canine and premolars seem far out and are barely touching their lower counterparts.

Now, is this something that orthodontics will be able to correct? Lateral incisor, canine and premolars used to match fine before expansion but in order to get the back teeth to match, it moved the anterior teeth along.

The mustache area looks also further out than it used to.

Is this something that often occurs after SARPE and is part of aligning everything properly or was the expansion incorrect and over-done?

The initial expander has been replaced by a thinner retainer. Since it is been barely 3 months after the surgery, would it be a good idea to remove the retainer to allow some reversal?

My OD wants to wait but I'm afraid that if we wait longer the bones will heal completely (if they haven't already) making any reversal impossible without another surgery (which I definitely don't want).

I have attached some images. Those are all images I have. Unfortunately I don't have any radiographs with me to upload.

I appreciate your opinion.

Thank you.

ANSWER:


Dear Adrian,

I apologize for the delay. I had set my allexperts account to not active for the holidays, and now see that you have written a follow up. You have a very interesting question, and I have seen this situation before. It is not common, but it is not rare either. Rest assured, I do not believe you face a serious problem.

First, for legal reasons,  let me again state, what I write here are only my opinions based on very limited information. I appreciated your four images Adrian. My comments should not be viewed as any form of diagnosis, definitive or otherwise, or any form of treatment recommendation.  Indeed, in the ultimate analysis all final decisions, particularly clinical ones, should only be made by qualified doctors who have had a chance to see you in person and who have had an opportunity to take and analyze proper diagnostic records.

Also jetzt vorwaerts....

Let us examine your comments in sections.

(1)    You wrote:

“My upper palate seems to have expanded properly in the back (upper molars seem to match the lower molars) but while posterior expansion seems fine, I'm seeing an unpleasant anterior over-expansion (especially on the right side). Lateral incisor, canine and premolars seem far out and are barely touching their lower counterparts. “

Yes I do see the gap between the teeth. To achieve palatal expansion an Orthodontist can use many different types of appliances. One of the most popular is a Herbst Appliance. This appliance is of the fixed type meaning the doctor will cement it into place and then the patient will activate it on a regular basis. These fixed expansion appliances however do no always evenly expand, unlike say a workman’s shop vise (Schraubstock). Your surgical procedures may also have introduced certain factors.

I also see that you now do not have any further expander appliances in place. I do see what is called a TPA or Trans Palatal Holding Arch in place that goes from your upper left to upper right molar,  presumably to, in part, hold expansion that was achieved.

Why is this? First of all the upper jaw and roof of the mouth is formed in two sections. It is separated by a palatal suture. This suture stays open and does not fuse in young  children because it is one of many growth sutures. Just as the arms and legs grow longer, the roof of the mouth and therefore the width of the upper palate/jaw also widen with growth because of growth formation of the mid-palatal suture.

In young patients say < 15 years old, the palatal suture remains open and expansion is not a problem. With time the suture however begins to fuse, albeit slowly.  In older patients in their late teens and early 20’s the suture becomes “sticky” so to speak. The expander may not be able to achieve a nice and uniform broadening. The anterior and posterior segments may fuse somewhat differentially. There is some controversy still as t how late one can “expand” the skeletal upper jaw. I can tell you on an anecdotal basis I have had at least two patients in their 20’s  where I carefully tried Hyrax expansion and achieved what I consider at least some skeletal expansion as evidenced by the gap between the front teeth.

I have described all this Adrian, because you show a very large gap and I think that your jaw, and I assume you are no longer a teenager, is possibly experiencing slow fusion along the mid-palatal growth suture. It is in fact possible to experience some “ relapse” of the expansion when the appliance and the wire are removed.

It would seem plausible to ask your Orthodontist to consider removing the TPA appliance, removing the wire, and just allowing the pressure of the cheeks to push on both sides of the upper left and right back teeth. In so doing, and with the natural relapse tendency, you may see the bite discrepancy diminish somewhat.   The gap between the front teeth is not a problem, as it can be easily closed.

Now, before we all pat ourselves on the back and declare victory, it is important to look at the lower jaw. Did the initial records show that the upper and lower jaw were small relative to the room needed to treat any crowding? Was perhaps only one saw small, and the other normal ?  I do not know if your lower teeth are currently crowded, and I can not rule out the possibility that your orthodontist has some strategy in mind to treat the lower “condition or problems”, whatever they may be. Unlike the upper jaw, lower jaw expansion is not really possible in the manner seen in the upper maxilla.

There are two considerations here. First of all the lower teeth may have an axial inclination which can be adjusted, especially on the one right side. The doctor may be looking to change the vertical axial inclinations of the teeth. The upper teeth can also be adjusted for their vertical axial inclinations so as to achieve a better meshing.

The second factor may be that the lower jaw or mandible will permit the lower teeth to in fact be moved a little in towards the tongue or out towards the cheeks. I know this is hard to visualize Adrian. Open your mouth and look at the lower teeth, and they form a “U” shaped arch. This “arch of bone” is where the teeth are embedded, much like perhaps cars parked on a “U” shaped curving road. Well, if the road is wide enough, the car can be parked on the left side, the middle, or the right side of the road. Likewise, the teeth are parked, roots in the bone, along the “U” shaped lower jaw. If the bone is wide enough along the gentle “U” shaped curvature of the lower jaw, the doctor can maneuver the teeth somewhat in and out. Just like you could park you car a little more to the left or the middle of the road, etc.

Ask you doctor Adrian if he/she has a plan to adjust the poor meshing of your back right teeth ( molars, premolars, and canines) by 1) Removing the current fixed upper Trans Palatal Appliance that you have going from molar to molar; 2) Possibly adjusting the axial inclinations of the upper and lower posterior teeth; and/or 3) moving the lower ( and maybe upper) teeth in a translational pattern so as to reduce the relative upper lower transverse discrepancy and thereby create a better meshing.

(2)   Now let to look at the rest of your question. You also wrote:

“Is this something that often occurs after SARPE and is part of aligning everything properly or was the expansion incorrect and over-done?

The initial expander has been replaced by a thinner retainer. Since it is been barely 3 months after the surgery, would it be a good idea to remove the retainer to allow some reversal?

My OD wants to wait but I'm afraid that if we wait longer the bones will heal completely (if they haven't already) making any reversal impossible without another surgery (which I definitely don't want) “

It is impossible for me to say for sure that any expansion was “ incorrect, excessive, or overdone”.  I do believe that perhaps the doctor realized that there may be some relapse, and therefore “over corrected” and therefore intentionally “overexpanded”. This is reasonable and good treatment. It is not “incorrect”. I think at this point Adrian, you are at a point where your dental team needs to evaluate the relapse potential, current degree of retained expansion, and whether some degree of “ intentional relapse” might be worth considering, so as to better harmonize the posterior molar, premolar, and canine bite relationships.  Realize of course that the “ contraction” will occur on both sides, and it is important for the doctors to monitor this if indeed they elect to remove the TPA  holding appliance.

So, do you wait or do you not wait. This Adrian is an individual decision. The degree and
amount of expansion achieved by surgery may dictate the timing. I don’t think it is possible to accurately say precisely “X” weeks. It is a dilemma.  So what do you do now. May I recommend the following steps:

(1)   Request a current evaluation by the Orthodontist and the Surgeon

(2)   An new and current occlusal radiograph may be helpful

(3)   Consider removal of the TPA appliance IF both the surgeon and orthodontist concur.

(4)   If removed monitor very carefully. If upper transpalatal width begins to diminish, wait until it becomes the proper dimension as determined by your orthodontist. The TPA can be adjusted and made narrower and possibly recemented if needed to now again proper post-surgical upper transpalatal dimensional width.

(5)   Another holding option would be make an impression for an upper clear appliance retainer that circumvents the upper braces and basically fits on the roof of your mouth and covers the teeth except of the outer side where the braces are.

(6)   All this however may be in appropriate depending on what strategies and diagnoses have been made for the lower orthodontic corrections.

Yes Adrian, this is a complex issue, and I hope the long answers have not proven too confusing. I would very much welcome a follow up question on this with what you are advised and with new images.  I hope my comments have been helpful Adrian .

I am told the website here encourages readers like you to rate the answers and to resubmit with follow up questions. Good luck with your upcoming Doctor visits, and thank you for writing. Happy new year Adrian, and do write again  soon

To all readers, please allow a week for a reply. I am in full time Private Practice, lecture on occasion, and am involved in many volunteer activities. I am therefore not always able to respond to questions straight away. I also will sometimes consult with other doctors on complex questions. This of course takes time.  Also, there are occasional holidays when the account is temporarily set on inactive. Your understanding is appreciated.

Paul Supan, DDS, MA, MPH
Board Certified Orthodontist in Leesburg Va

Specialist in Orthodontics
Specialist in Dental Public Health
http://www.braces.com
http://www.leesburgbraces.com



---------- FOLLOW-UP ----------

QUESTION: Hello Dr. Supan, Thank you so much for your reply. It was extremely helpful and very complete. I appreciate it.

I understand your comments should not be viewed as any form of diagnosis, definitive or otherwise, or any form of treatment recommendation.

Currently I have one concern that is bothering me the most.

It's about the facial changes from the expansion in the frontal area, specifically in the mustache area. (See mustache area photo above).

By expanding the complete maxilla the lateral incisor, canine and premolars were moved along (where no expansion was needed). This has given me some a kind of protruding maxilla, with an unpleasant monkey look.

I understand the front teeth will be slowly moved into a more smooth round curve (currently is more like a square) but is this protruding maxilla the new bone shape? can it get constricted or retracted in the front by orthodontics alone?

Thank you very much in advance.

Answer

Dear Adrian,

Thank you again for writing in follow up.

Again, excuse my preamble here, but let me again state that any comments should not be viewed as any form of diagnosis, definitive or otherwise, or any form of treatment recommendation.  Adrian, as you know, in the ultimate analysis all final decisions, particularly clinical ones, should only be made by qualified doctors who have had a chance to see you in person and who have had an opportunity to take and analyze proper diagnostic records.

Now, in your latest follow up question you asked about the protrusive what is often termed “ bi-maxillary protrusion” look of your current facial profile. You wrote:

Currently I have one concern that is bothering me the most.

It's about the facial changes from the expansion in the frontal area, specifically in the mustache area. (See mustache area photo above).

By expanding the complete maxilla the lateral incisor, canine and premolars were moved along (where no expansion was needed). This has given me some a kind of protruding maxilla, with an unpleasant monkey look.

I understand the front teeth will be slowly moved into a more smooth round curve (currently is more like a square) but is this protruding maxilla the new bone shape? can it get constricted or retracted in the front by orthodontics alone?  


Assuming your pre-treatment facial profile   was acceptable to you, the current   facial “protrusive” characteristic which you describe is likely more due to dental (tooth related) factors in contrast to anything skeletal (jaw bone) related. I say this because the transverse expansion which you experienced was in the transverse ( side to side; left and right) directions. It likely had little if any effect in the anterior posterior directions.

I therefore would surmise that the protrusive changes are due to changes in the axial inclinations of the anterior upper and lower incisors.  The following diagram from “ ThenextDDS”  website shows this very nicely. Incidentally, I have a paper which will appear in Spring 2016 on Endodontics on this website.

http://www.thenextdds.com/uploadedImages/The_Next_DDS/Clinical_Images/05%20Hunt.

Adrian, I think you can see that the solution is to change the axial inclination of the incisors. Orienting them in a more upright and vertical position will help to reduce the bi-maxillary protrusive appearance. This can be done only up to a point. To achieve further axial reorientation of the incisors may require some reproximation or  “slenderization”.

Also Adrian, the direct impact of a dental, or for that matter skeletal change is not necessarily very dramatic. The facial profile is largely a function of “soft tissue drape” This describes the overlying skin, muscle, fat, and other tissues which all overly the jaw bones and teeth of the face.

Adrian, there are some fairly sophisticated Orthodontic diagnostic imaging programs available nowadays, and Germany has an excellent state of the art Orthodontic community. Ask your Orthodontist to consider doing an analysis where they can visualize a likely change in facial profile by simulating c change in the axial inclination of the incisors. There are a number of metrics used to analyze facial profile.  Here are a few links.

At this point Adrian, here is your plan of action to consider:

http://www.tweedortho.com/course/Reading_files/Tweed_Reading4.pdf

http://www.slideshare.net/drfaizan/steiners-analysis

http://pocketdentistry.com/2-dentofacial-assessment/


Also, do watch that BBC series on the beauty of the face.  I mentioned this TV series to another person from Canada who had written with concerns about her facial aesthetics. I think it is very informative when it comes to summarizing facial aesthetics.

http://www.bbc.co.uk/programmes/b00pfqy6/episodes/guide

http://topdocumentaryfilms.com/the-human-face/


I hope my comments have been helpful. As you know Adrian, the website here encourages readers like you to rate the answers and to resubmit with follow up questions. Thank you for writing.

Servus aus Virginia !

Paul Supan, DDS, MA, MPH
Board Certified Orthodontist

Specialist in Orthodontics
Specialist in Dental Public Health
http://www.braces.com
http://www.leesburgbraces.com

Please allow a full week for a reply; my replies are generally fairly extensive and researched. I am in full time Private Practice, lecture on occasion, and am involved in many volunteer activities. I am therefore not always able to respond to questions straight away. I sometimes consult with other doctors on complex interdisciplinary questions. This of course takes time.  Your understanding is appreciated.  

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Paul Supan, DDS, MA, MPH

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First may I say please set your questions to Public so other readers can benefit from the response. Also, if you look at my comprehensive answers, they are not short 1 or 2 paragraph quickie replies that anyone can type out in < 5 minutes. Instead I often will ask other colleagues in other specialties for their advice in order to provide you the questioner with a more interdisciplinary perspective. This all takes time. I ask for readers to therefore allow 5-7 days. You will be rewarded with a very detailed response.

Because of the nature of Orthodontic questions, any pictures of the teeth and X-ray images would be very helpful. If you write to me and explain that you have crooked overlapping front teeth can be interpreted in many many ways, and my goal is to provide a specific response that meets your needs.

I hold double specialty credentials. I am Board Certified in Orthodontics and Board Eligible in Dental Public Health. I welcome questions regarding Braces, Invisible Braces, & Invisalign, as well as issues involving combination Cosmetic Dentistry and Orthodontic treatment. Orthodontics alone sometimes is not enough to achieve that perfect smile. Gingival (gum) re-contouring, tooth reshaping, bonding and other services are sometimes needed. I also have substantial experience in the areas of Infection Control and Sterilization in the Dental Environment. My personal websites braces.com and Leesburgbraces.com are non-commercial for information purposes only and may provide you with some background to more precisely frame your question for allexperts.com.

Please allow a week for a reply. I am in full time Private Practice, lecture on occasion, and am involved in many volunteer activities. I am therefore not always able to respond to questions straight away. Your understanding is appreciated.

Experience

Board Certified Orthodontist (ABO Diplomate) with over 25 years of Private Practice experience. Second Specialty Certificate in Dental Public Health with research experience at NIH, and Epidemiology Training & Research at Harvard, NIH, and the Centers for Disease Control (CDC) in Atlanta. Postgraduate Masters degree from the Harvard School of Public Health, as well as a Master of Arts Degree in Education.

Organizations
American Dental Association, American Association of Orthodontists, Academy of General Dentistry, College of Diplomates of the ABO, OSAP - Office Sterilization & Asepsis Procedures Organization, Others

Publications
Available upon Request.

Education/Credentials
BS College of William & Mary, DDS Medical College of Virginia, Masters of Public Health (MPH) Degree Harvard School of Public Health. Dental Public Health Specialty Certificate from NIH. Orthodontic Specialty Certificate from University of Rochester Eastman Dental Center. USPHS clinical research experience at NIH, and Epidemiology Training & Research at Harvard, NIH, and the Centers for Disease Control. Fellow of the Academy of General Dentistry (FAGD), and Fully Board Certified Diplomate of the American Board of Orthodontics. Board Eligible in Dental Public Health. Visiting Adjunct Associate Professor at the Meharry Medical College School of Dentistry, Nashville, Tennessee.

Awards and Honors
Available upon Request Please see my personal websites braces.com and Leesburgbraces.com for further personal background.

Past/Present Clients
Available upon Request

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