Vol.
-
No.
-
Month 2015
Complications related to surgically assisted rapid palatal expansion Guhan Dergin, DDS, PhD, Sertac Aktop, DDS, PhD, Altan Varol, DDS, PhD, Faysal Ugurlu, DDS, PhD, and Hasan Garip, DDS, PhD Objective. The goals of this retrospective clinical study were to identify surgically assisted rapid palatal expansion (SARPE) complications and assess their incidence, with the aim of informing surgeons and orthodontists of the risks of this widely used procedure before they recommend it to patients. Study Design. Between June 2008 and July 2010, 60 patients (23 women and 37 men) underwent SARPE according to a defined multidisciplinary protocol at the University of Marmara, Istanbul, Turkey. Results. Twelve patients (20%) suffered from nasal bleeding. Of these 12, 2 patients suffered late-onset bleeding beginning on postoperative day 8, and in the other 10, nasal bleeding was insignificant. Three patients reported excessive lacrimation postoperatively. Minor problems related to pain and numbness were all temporary. Conclusions. SARPE procedures have traditionally been reported to be associated with low morbidity, especially in comparison with other orthognathic surgical procedures. However, many complications have been reported. (Oral Surg Oral Med Oral Pathol Oral Radiol 2015;-:1-7)
Transverse maxillomandibular discrepancy is a major component of several types of malocclusion.1 Maxillary construction can be corrected surgically or nonsurgically via orthodontic rapid palatal expansion (RPE) using a tooth-borne expander, surgically assisted rapid palatal expansion (SARPE), or segmental Le Fort osteotomy.2 The general indications for SARPE include skeletal maturity, (extreme) transverse maxillary hypoplasia, unilateral or bilateral anterior crowding, and the presence of buccal corridors (“black corridors”) when smiling and when orthodontic maxillary expansion has failed.3 Although the mid-palatal suture is an area of resistance in symmetric widening of the constricted maxilla, it is only one of many areas of resistance in the facial skeleton, such as the zygomaticomaxillary buttress, pterygoid junction, and piriform aperture.4,5 Brown first described the use of the mid-palatal split technique for maxillary expansion, and SARPE has become the preferred approach for correcting maxillary transverse deficiency in skeletally mature individuals.6 Shetty et al. concluded that the exclusive use of bilateral zygomaticomaxillary buttress osteotomy to facilitate SARPE was inadequate and stated that complete midpalatal and pterygomaxillary osteotomies were
essential to achieve predictable maxillary expansion in adults.7 SARPE procedures have traditionally been reported to be associated with low morbidity, especially in comparison with other orthognathic surgical procedures.8 However, many complications have been reported, ranging from life-threatening epistaxis to cerebrovascular accidents, including skull base fracture with reversible oculomotor nerve paralysis and orbital compartment syndrome.9-13 The goals of this retrospective clinical study were to identify SARPE complications and assess their incidence, with the aim of informing surgeons and orthodontists of the risks of this widely used procedure before they recommend it to patients.
The work was previously presented at the 4th ACBID International Oral and Maxillofacial Surgery Society Congress, 2010, at Antalya, Turkey. Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Marmara University, Istanbul, Turkey. Received for publication Oct 10, 2014; returned for revision Jan 6, 2015; accepted for publication Jan 16, 2015. Ó 2015 Elsevier Inc. All rights reserved. 2212-4403/$ - see front matter http://dx.doi.org/10.1016/j.oooo.2015.01.008
Surgically assisted rapid palatal expansion procedures have traditionally been reported to be associated with low morbidity, especially in comparison with other orthognathic surgical procedures. However, many complications have been reported. Two patients suffered late-onset bleeding beginning on postoperative day 8. Three patients reported excessive lacrimation.
MATERIALS AND METHODS Between June 2008 and July 2010, 60 patients (23 women and 37 men) underwent SARPE according to a defined multidisciplinary protocol at the University of Marmara, Istanbul, Turkey. The age of the participants ranged from 17 to 26 years. All patients presented with a total transverse maxillary deficiency greater than
Statement of Clinical Relevance
1
ORAL AND MAXILLOFACIAL SURGERY 2 Dergin et al.
5 mm and a closed mid-palatal suture. This project was approved by the Ethics Committee of the Faculty of Dentistry, University of Marmara, and informed consent was obtained from all patients. Computed tomography (CT) was performed to evaluate the preoperative anatomy and to exclude inflammation of the maxillary sinus. All patients underwent similar treatment regimes. Each patient’s orthodontist inserted a Haas-type expander, with an acrylic splint cemented to the first premolars and molars.14 The patients selected for this study were all American Society of Anaesthesiologists (ASA) I group of patients to determine the complications related to surgery, rather than predisposing systemic-related complications, such as bleeding. SARPE was performed with the patient under general anesthesia with nasotracheal intubation. All of the surgeries were performed by the same surgical team, comprising the authors of this paper. A modified Le Fort I maxillary osteotomy, including separation of the pterygomaxillary suture, was performed. A horizontal incision was made through the mucoperiosteum above the mucogingival junction in the deepest part of the buccal vestibular space, extending from the canine region to the mesial surface of the first molar. The nasal mucosae were elevated gently from the lateral nasal wall. A horizontal low-level osteotomy was performed through the lateral wall of the maxilla, 6 mm superior to the apices of the anteroposterior teeth, by using tiny rounded burs and then a microsaw. Cuts were made on the level of the occlusal plane, extending posteriorly from the inferolateral aspect of the piriform rim to the inferior aspect of the junction of the maxillary tuberosity and pterygoid plate. The maxilla was separated from the pterygoid plate with a curved osteotome. In conjunction with this procedure, sagittal palatal osteotomy was performed from the midline of the alveolar bone, passing between the central incisors, to the posterior nasal spine. An osteotome was positioned in the interradicular space between the central incisors and manipulated to achieve equal and symmetric mobilization of the anterior maxilla. The surgeon placed a forefinger on the incisive papilla to feel the redirected osteotome as it transected the deeper portion of the mid-palatal suture. After the osteotomies were complete, the Hyrax appliance was activated to check whether it functioned properly. Immediate regression was then performed, leaving a 1-mm gap. All patients received prophylactic antibiotics for 7 days postoperatively. On postoperative day 3, the orthodontic team initiated SARPE by effecting 0.25-mm expansion. The patient was instructed to perform additional 0.5-mm expansions (0.25-mm expansion two times per day) until the total expansion was deemed satisfactory. The study follow-up was discontinued after the expansion procedure was complete, and the patients’
OOOO Month 2015
orthodontists provided orthodontic treatment. The expander was kept in place for a total of 6 months to minimize the potential for relapse. The type and level of discomfort were monitored objectively in all patients, and all complications arising from the early postoperative period to the end of the expansion period were recorded.
RESULTS Separation of the mid-palatal suture, mobilization of the segment(s), and subsequent expansion and stabilization during consolidation were successfully achieved in all 60 patients. Most difficulties encountered were related to protocol parameters. Bleeding Nasal bleeding occurred in 12 of 60 patients (20%). Nine patients experienced bleeding only on postoperative day 1, whereas one patient reported insignificant nasal bleeding while sniffing during postoperative week 1. However, two patients suffered late-onset bleeding beginning on postoperative day 8; one of these cases was severe and was accompanied by postnasal bleeding and vomiting of blood clots (Table I). Paresthesia Eleven patients reported paresthesia of the infraorbital nerve and related branches. Eight of these patients experienced paresthesia for less than 1 week, during which four patients reported numbness of teeth, and the remaining four reported paresthesia of teeth and lips. Seven of the eight patients with paresthesia for less than 1 week also reported infraorbital paresthesia; six patients experienced this symptom unilaterally and one bilaterally. Three patients suffered from unilateral infraorbital paresthesia for up to 2 weeks, but no patient experienced permanent damage. All these minor problems are related to postoperative edema and traction of tissues during surgery (Table II). Pain Seven patients suffered prolonged pain during the distraction procedure. Eight patients suffered from headaches, two of whom experienced pain for less than 1 week and five for less than 2 to 3 days postoperatively. One patient reported headache and pain at the surgical site when exposed to loud noise during the distraction period (Table III). Rare complications One patient developed a large hematoma in the cheek, one patient complained of tinnitus, and three patients
OOOO Volume -, Number
ORIGINAL ARTICLE Dergin et al. 3
-
Table I. Bleeding First day First week Late onset Total
9/60 1/60 2/60 12/60
15% 1.66% 3.33% 20%
reported excessive lacrimation. Of those experiencing excessive lacrimation, one patient show unilateral effects for 1 day, and two patients reported bilateral effects for 1 and 4 days, respectively. Complaints lasting less than 1 week were not counted as complications (Table IV).
DISCUSSION SARPE is a commonly used procedure for the correction of maxillary transversal deficiency. Conventional orthodontic RPE before closure of the mid-palatal suture has been reported to be highly successful in young patients,2,15,16 but this technique is not indicated in skeletally mature individuals because suture closure and the completion of transverse growth limit the range of maxillary expansion.17 Furthermore, RPE can produce unwanted effects in skeletally mature patients, including lateral tipping of posterior teeth,15,18 extrusion,19-21 periodontal membrane compression, buccal root resorption,22-24 alveolar bone bending,15 fenestration of the buccal cortex,7,22,25,26 palatal tissue necrosis,27 inability to open the mid-palatal suture, pain, and instability of the expansion.15,20,28-30 Bell and Epker showed that attempting orthodontic expansion with a palatal appliance in a skeletally mature patient may lead to pain and necrosis of the palatal mucosa.31 Mommaerts outlined an age-based treatment strategy for patients with maxillary constriction and stated that RPE should be used to treat maxillary constriction in patients younger than 12 years, whereas SARPE is indicated in patients older than 14 years to release areas of bony resistance in the midface.21 Most methods consider the zygomaticomaxillary junction to be a major site of resistance and recommend corticotomy through the zygomaticomaxillary buttress from the piriform rim to the maxillopterygoid junction to release this resistance. The mid-palatal suture has historically been considered the primary site of resistance. The pterygoid plates are also sites of considerable resistance, but because osteotomy carries an increased risk of injuring the pterygoid plexus, some surgeons choose not to address this resistance, without losing much mobility. When the pterygoid junction is not released, the opening of the maxillary halves is more V-shaped, with the apex of the V pointing dorsally.3-5,14
Reported complications of SARPE include significant hemorrhage, gingival recession,32 root resorption,21,33 injury to the branches of the maxillary nerve, infection, pain, devitalization of teeth and altered pulpal blood flow,34-36 periodontal breakdown,36,37 sinus infection,38 alar base flaring,39 extrusion of the teeth attached to the appliance,40 relapse, and unilateral expansion.12,13,41,42 Postoperative hemorrhage, pain, sinusitis, palatal tissue irritation or ulceration, asymmetric expansion, nasal septum deviation, periodontal problems, and relapse have been reported as minor complications.9-11 Although SARPE is considered to be associated with little risk of serious complications, several additional complications were encountered in the present study. Asymmetric expansion Verlinden et al. found asymmetric expansion in 5 of 73 cases and all required additional surgery.43 In clinical and experimental studies, Koudstaal et al. noted asymmetric expansion in 2 of 46 patients.44 Williams et al. mentioned an incidence of 8.33%,45 as we experienced in two of our patients (3.33%). Asymmetric expansion results from uncompleted osteotomies and frequently missed lateral nasal wall osteotomies. In our surgeries, we made sure that the lateral nasal wall osteotomy and nasal septum osteotomy were completed, and this might have decreased the rate of asymmetric expansion compared with the rates in the study by Verlinden et al. and Williams et al. but might have increased the incidence rate of bleeding in our cases. Soft-tissue necrosis One of the most frequently occurring complications is palatal tissue irritation caused by impingement of the expansion appliance against the palatal soft tissues,27,45 which may lead to aseptic pressure necrosis. Williams et al. reported one case of palatal soft tissue necrosis (0.83%) in their study on complications after SARPE.45 Lehman and Haas reported 3 cases (5.4%) of palatal mucosal ulceration,46 and Alpern and Yurosko reported 3 cases of palatal mucosal soft tissue aseptic necrosis.27 We did not observe this complication in our patients. Bleeding Major intraoperative or postoperative bleeding associated with maxillary surgery is an infrequent complication relative to the number of these procedures performed.13 Although intraoperative complications of SARPE are uncommon, the risk of bleeding increases when the pterygoid plates are separated from the maxilla. Betts et al. pointed out that bilateral release of the pterygoid plates from the maxilla was as
ORAL AND MAXILLOFACIAL SURGERY 4 Dergin et al.
OOOO Month 2015
Table II. Paresthesia
-
No.
-
Month 2015
Complications related to surgically assisted rapid palatal expansion Guhan Dergin, DDS, PhD, Sertac Aktop, DDS, PhD, Altan Varol, DDS, PhD, Faysal Ugurlu, DDS, PhD, and Hasan Garip, DDS, PhD Objective. The goals of this retrospective clinical study were to identify surgically assisted rapid palatal expansion (SARPE) complications and assess their incidence, with the aim of informing surgeons and orthodontists of the risks of this widely used procedure before they recommend it to patients. Study Design. Between June 2008 and July 2010, 60 patients (23 women and 37 men) underwent SARPE according to a defined multidisciplinary protocol at the University of Marmara, Istanbul, Turkey. Results. Twelve patients (20%) suffered from nasal bleeding. Of these 12, 2 patients suffered late-onset bleeding beginning on postoperative day 8, and in the other 10, nasal bleeding was insignificant. Three patients reported excessive lacrimation postoperatively. Minor problems related to pain and numbness were all temporary. Conclusions. SARPE procedures have traditionally been reported to be associated with low morbidity, especially in comparison with other orthognathic surgical procedures. However, many complications have been reported. (Oral Surg Oral Med Oral Pathol Oral Radiol 2015;-:1-7)
Transverse maxillomandibular discrepancy is a major component of several types of malocclusion.1 Maxillary construction can be corrected surgically or nonsurgically via orthodontic rapid palatal expansion (RPE) using a tooth-borne expander, surgically assisted rapid palatal expansion (SARPE), or segmental Le Fort osteotomy.2 The general indications for SARPE include skeletal maturity, (extreme) transverse maxillary hypoplasia, unilateral or bilateral anterior crowding, and the presence of buccal corridors (“black corridors”) when smiling and when orthodontic maxillary expansion has failed.3 Although the mid-palatal suture is an area of resistance in symmetric widening of the constricted maxilla, it is only one of many areas of resistance in the facial skeleton, such as the zygomaticomaxillary buttress, pterygoid junction, and piriform aperture.4,5 Brown first described the use of the mid-palatal split technique for maxillary expansion, and SARPE has become the preferred approach for correcting maxillary transverse deficiency in skeletally mature individuals.6 Shetty et al. concluded that the exclusive use of bilateral zygomaticomaxillary buttress osteotomy to facilitate SARPE was inadequate and stated that complete midpalatal and pterygomaxillary osteotomies were
essential to achieve predictable maxillary expansion in adults.7 SARPE procedures have traditionally been reported to be associated with low morbidity, especially in comparison with other orthognathic surgical procedures.8 However, many complications have been reported, ranging from life-threatening epistaxis to cerebrovascular accidents, including skull base fracture with reversible oculomotor nerve paralysis and orbital compartment syndrome.9-13 The goals of this retrospective clinical study were to identify SARPE complications and assess their incidence, with the aim of informing surgeons and orthodontists of the risks of this widely used procedure before they recommend it to patients.
The work was previously presented at the 4th ACBID International Oral and Maxillofacial Surgery Society Congress, 2010, at Antalya, Turkey. Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Marmara University, Istanbul, Turkey. Received for publication Oct 10, 2014; returned for revision Jan 6, 2015; accepted for publication Jan 16, 2015. Ó 2015 Elsevier Inc. All rights reserved. 2212-4403/$ - see front matter http://dx.doi.org/10.1016/j.oooo.2015.01.008
Surgically assisted rapid palatal expansion procedures have traditionally been reported to be associated with low morbidity, especially in comparison with other orthognathic surgical procedures. However, many complications have been reported. Two patients suffered late-onset bleeding beginning on postoperative day 8. Three patients reported excessive lacrimation.
MATERIALS AND METHODS Between June 2008 and July 2010, 60 patients (23 women and 37 men) underwent SARPE according to a defined multidisciplinary protocol at the University of Marmara, Istanbul, Turkey. The age of the participants ranged from 17 to 26 years. All patients presented with a total transverse maxillary deficiency greater than
Statement of Clinical Relevance
1
ORAL AND MAXILLOFACIAL SURGERY 2 Dergin et al.
5 mm and a closed mid-palatal suture. This project was approved by the Ethics Committee of the Faculty of Dentistry, University of Marmara, and informed consent was obtained from all patients. Computed tomography (CT) was performed to evaluate the preoperative anatomy and to exclude inflammation of the maxillary sinus. All patients underwent similar treatment regimes. Each patient’s orthodontist inserted a Haas-type expander, with an acrylic splint cemented to the first premolars and molars.14 The patients selected for this study were all American Society of Anaesthesiologists (ASA) I group of patients to determine the complications related to surgery, rather than predisposing systemic-related complications, such as bleeding. SARPE was performed with the patient under general anesthesia with nasotracheal intubation. All of the surgeries were performed by the same surgical team, comprising the authors of this paper. A modified Le Fort I maxillary osteotomy, including separation of the pterygomaxillary suture, was performed. A horizontal incision was made through the mucoperiosteum above the mucogingival junction in the deepest part of the buccal vestibular space, extending from the canine region to the mesial surface of the first molar. The nasal mucosae were elevated gently from the lateral nasal wall. A horizontal low-level osteotomy was performed through the lateral wall of the maxilla, 6 mm superior to the apices of the anteroposterior teeth, by using tiny rounded burs and then a microsaw. Cuts were made on the level of the occlusal plane, extending posteriorly from the inferolateral aspect of the piriform rim to the inferior aspect of the junction of the maxillary tuberosity and pterygoid plate. The maxilla was separated from the pterygoid plate with a curved osteotome. In conjunction with this procedure, sagittal palatal osteotomy was performed from the midline of the alveolar bone, passing between the central incisors, to the posterior nasal spine. An osteotome was positioned in the interradicular space between the central incisors and manipulated to achieve equal and symmetric mobilization of the anterior maxilla. The surgeon placed a forefinger on the incisive papilla to feel the redirected osteotome as it transected the deeper portion of the mid-palatal suture. After the osteotomies were complete, the Hyrax appliance was activated to check whether it functioned properly. Immediate regression was then performed, leaving a 1-mm gap. All patients received prophylactic antibiotics for 7 days postoperatively. On postoperative day 3, the orthodontic team initiated SARPE by effecting 0.25-mm expansion. The patient was instructed to perform additional 0.5-mm expansions (0.25-mm expansion two times per day) until the total expansion was deemed satisfactory. The study follow-up was discontinued after the expansion procedure was complete, and the patients’
OOOO Month 2015
orthodontists provided orthodontic treatment. The expander was kept in place for a total of 6 months to minimize the potential for relapse. The type and level of discomfort were monitored objectively in all patients, and all complications arising from the early postoperative period to the end of the expansion period were recorded.
RESULTS Separation of the mid-palatal suture, mobilization of the segment(s), and subsequent expansion and stabilization during consolidation were successfully achieved in all 60 patients. Most difficulties encountered were related to protocol parameters. Bleeding Nasal bleeding occurred in 12 of 60 patients (20%). Nine patients experienced bleeding only on postoperative day 1, whereas one patient reported insignificant nasal bleeding while sniffing during postoperative week 1. However, two patients suffered late-onset bleeding beginning on postoperative day 8; one of these cases was severe and was accompanied by postnasal bleeding and vomiting of blood clots (Table I). Paresthesia Eleven patients reported paresthesia of the infraorbital nerve and related branches. Eight of these patients experienced paresthesia for less than 1 week, during which four patients reported numbness of teeth, and the remaining four reported paresthesia of teeth and lips. Seven of the eight patients with paresthesia for less than 1 week also reported infraorbital paresthesia; six patients experienced this symptom unilaterally and one bilaterally. Three patients suffered from unilateral infraorbital paresthesia for up to 2 weeks, but no patient experienced permanent damage. All these minor problems are related to postoperative edema and traction of tissues during surgery (Table II). Pain Seven patients suffered prolonged pain during the distraction procedure. Eight patients suffered from headaches, two of whom experienced pain for less than 1 week and five for less than 2 to 3 days postoperatively. One patient reported headache and pain at the surgical site when exposed to loud noise during the distraction period (Table III). Rare complications One patient developed a large hematoma in the cheek, one patient complained of tinnitus, and three patients
OOOO Volume -, Number
ORIGINAL ARTICLE Dergin et al. 3
-
Table I. Bleeding First day First week Late onset Total
9/60 1/60 2/60 12/60
15% 1.66% 3.33% 20%
reported excessive lacrimation. Of those experiencing excessive lacrimation, one patient show unilateral effects for 1 day, and two patients reported bilateral effects for 1 and 4 days, respectively. Complaints lasting less than 1 week were not counted as complications (Table IV).
DISCUSSION SARPE is a commonly used procedure for the correction of maxillary transversal deficiency. Conventional orthodontic RPE before closure of the mid-palatal suture has been reported to be highly successful in young patients,2,15,16 but this technique is not indicated in skeletally mature individuals because suture closure and the completion of transverse growth limit the range of maxillary expansion.17 Furthermore, RPE can produce unwanted effects in skeletally mature patients, including lateral tipping of posterior teeth,15,18 extrusion,19-21 periodontal membrane compression, buccal root resorption,22-24 alveolar bone bending,15 fenestration of the buccal cortex,7,22,25,26 palatal tissue necrosis,27 inability to open the mid-palatal suture, pain, and instability of the expansion.15,20,28-30 Bell and Epker showed that attempting orthodontic expansion with a palatal appliance in a skeletally mature patient may lead to pain and necrosis of the palatal mucosa.31 Mommaerts outlined an age-based treatment strategy for patients with maxillary constriction and stated that RPE should be used to treat maxillary constriction in patients younger than 12 years, whereas SARPE is indicated in patients older than 14 years to release areas of bony resistance in the midface.21 Most methods consider the zygomaticomaxillary junction to be a major site of resistance and recommend corticotomy through the zygomaticomaxillary buttress from the piriform rim to the maxillopterygoid junction to release this resistance. The mid-palatal suture has historically been considered the primary site of resistance. The pterygoid plates are also sites of considerable resistance, but because osteotomy carries an increased risk of injuring the pterygoid plexus, some surgeons choose not to address this resistance, without losing much mobility. When the pterygoid junction is not released, the opening of the maxillary halves is more V-shaped, with the apex of the V pointing dorsally.3-5,14
Reported complications of SARPE include significant hemorrhage, gingival recession,32 root resorption,21,33 injury to the branches of the maxillary nerve, infection, pain, devitalization of teeth and altered pulpal blood flow,34-36 periodontal breakdown,36,37 sinus infection,38 alar base flaring,39 extrusion of the teeth attached to the appliance,40 relapse, and unilateral expansion.12,13,41,42 Postoperative hemorrhage, pain, sinusitis, palatal tissue irritation or ulceration, asymmetric expansion, nasal septum deviation, periodontal problems, and relapse have been reported as minor complications.9-11 Although SARPE is considered to be associated with little risk of serious complications, several additional complications were encountered in the present study. Asymmetric expansion Verlinden et al. found asymmetric expansion in 5 of 73 cases and all required additional surgery.43 In clinical and experimental studies, Koudstaal et al. noted asymmetric expansion in 2 of 46 patients.44 Williams et al. mentioned an incidence of 8.33%,45 as we experienced in two of our patients (3.33%). Asymmetric expansion results from uncompleted osteotomies and frequently missed lateral nasal wall osteotomies. In our surgeries, we made sure that the lateral nasal wall osteotomy and nasal septum osteotomy were completed, and this might have decreased the rate of asymmetric expansion compared with the rates in the study by Verlinden et al. and Williams et al. but might have increased the incidence rate of bleeding in our cases. Soft-tissue necrosis One of the most frequently occurring complications is palatal tissue irritation caused by impingement of the expansion appliance against the palatal soft tissues,27,45 which may lead to aseptic pressure necrosis. Williams et al. reported one case of palatal soft tissue necrosis (0.83%) in their study on complications after SARPE.45 Lehman and Haas reported 3 cases (5.4%) of palatal mucosal ulceration,46 and Alpern and Yurosko reported 3 cases of palatal mucosal soft tissue aseptic necrosis.27 We did not observe this complication in our patients. Bleeding Major intraoperative or postoperative bleeding associated with maxillary surgery is an infrequent complication relative to the number of these procedures performed.13 Although intraoperative complications of SARPE are uncommon, the risk of bleeding increases when the pterygoid plates are separated from the maxilla. Betts et al. pointed out that bilateral release of the pterygoid plates from the maxilla was as
ORAL AND MAXILLOFACIAL SURGERY 4 Dergin et al.
OOOO Month 2015
Table II. Paresthesia
