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Orthognathic classification - Upper jaw too narrow / Smile distrator

The smile distractor is Dr Defrancq’s baby, since he designed and developed it. The device works perfectly and is the most hygienic on the market. The device is available through Titamed®. There are now more than 6000 such devices worldwide.
Historical note: It is interesting to note that the transverse maxillary (and mandibular deficiency) was the last dimension to be mastered in orthognathic surgery. In the 1950s and 1960s, the control of the anteroposterior dimension was the issue (bilateral sagittal split of the lower jaw), followed in the 1970s and 1980s by the mastering of the vertical dimension (with the advent of the Le Fort I osteotomy in the upper). In the 1990s, the work of the Russian surgeon Ilisarov attracted attention in the West. This resulted in the introduction of the principle of osteo distraction, meaning slow and sustained lengthening procedures of bones. The principle was extended to facial bones, and applied in the upper (surgical assisted palatal expansion) as well as the lower jaw. Miniature devices were developed to apply easily and hygienically. The smile distractor (Titamed®) is the most notorious one.
Facial Sculpture Clinic - Dr Joël Defrancq - Jaw surgery and implant reconstructive surgery SARPE (Surgical Assisted Rapid Palatal Expansion)

indications are frequently seen in orthognathic patients. Older children, adolescents, and adults (13 years of age and older) are best helped with a surgical assisted rapid palatal expansion, if a widening of the maxilla is indicated. We use a modular device called smile distractor (Titamed®) to obtain the broadening. The device is extremely versatile and thin (4mm) and by far the most hygienic on the market. Moreover, the anchoring is with two mini foot plates on the palatal bone. Those plates adapt completely to the palatal arch form.
The indications
The indication is a narrow upper jaw or a teeth problem created by an excessively narrow upper jaw. A narrow upper jaw can be seen in literally all mentioned indications in the field of orthognathic surgery (class I, II, III, long face, short face, etc). This surgery is often essential from an orthognathic perspective and is usually planned at the start of orthodontics as a separate surgery. It certainly prevents a lot of relapses seen in the past due to the lost transversal occlusal fittings.

The benefit of the surgery is overwhelming and essential:

  • Quality of life: This results in easier breathing and the elimination of a major cause of snoring and sleep apnoea.
  • Aesthetic: It affects the overall facial aesthetics and, in particular, the smile aesthetics and dark corridors when the patient smiles.
  • Last but not least, it offers a lifetime of occlusal stability.
The surgery
Facial Sculpture Clinic - Dr Joël Defrancq - Jaw surgery and implant reconstructive surgery Maxillary expansion is a totally different surgical operation to osteotomies. It is carried out by a phenomenon called osteo-distraction. It is a bony distraction, with the action not on the teeth, but directly on the bone. Only the bone gradually becomes and phisically broader, and new bone is laid down in the fracture sides. The teeth themselves therefore don’t flare out. 

Horizontal bony incisions are well above the root of the teeth and are followed by one vertical bony incision in the middle between the two front teeth. The two halves of the upper jaw (right and left side) are then mobilised very slightly independently of each other.

The surgery itself is only the initial phase in a skeletal transversal broadening.
After surgery and during activation
After the surgery, we leave the jaw to heal for some days. Then, we remove the tiny little blocking screw and teach you to activate the expansion with a shilliday key twice a day. The expansion starts a few days after the surgery by a very gradual opening of the voluntarily created midline fracture in the days or weeks after the surgery. This is done at a rate of 0.5mm a day by turning the distraction device twice a day. Over time, new bone grows in and fills the gap created by the movement. The effect of the distraction is visible from the gradual opening (diastema) between the front teeth. Once the expansion is completed (usually 10 to 14 days), the blocking screw of the smile distractor is re-inserted. We keep the distraction device in place for 4-6 months. Regard it as a nice piercing…
It is important to realise that nature itself closes the opening between the two front teeth. This phenomenon is called ‘“mesial drift’. It means nature takes care that all teeth shift towards the midline. Orthodontics are merely to guide those movements.
During the activation
Facial Sculpture Clinic - Dr Joël Defrancq - Jaw surgery and implant reconstructive surgery
  1. You should feel some pressure in the upper jaw during the turning.
  2. A new colour in the centre of the distraction module does appear (blue, green, yellow, and white) after each turn (twice a day a new colour).
  3. Each day the diastema between the two front teeth should become 0,5 mm broader. After a week, there is a 3-4mm diastema between the front teeth. Usually, the distraction goes on for one to two weeks.
  4. The distraction module on the palate should stay totally immobile at all times for the first 3-4 months. After four months there is some ‘vibrational’ movement.
Note: Many orthodontists worldwide still use a tooth-born device called a ‘hyrax’”. The hyrax is fixed onto the upper teeth. All forces are applied directly to the teeth, and only indirectly on the bone. Therefore, this device often causes flaring of the teeth. This flaring of the more posterior teeth is cumbersome, since the final result becomes much more unpredictable and relapse is never far away.
 
Facial Sculpture Clinic - Dr Joël Defrancq - Jaw surgery and implant reconstructive surgery

Facial Sculpture Clinic - Dr Joël Defrancq - Jaw surgery and implant reconstructive surgery
Postoperative instructions & frequently asked questions

Does SARPE (smile distractor) affect breathing in a favourable way?

One of the benefits of maxillary expansion with the smile distractor (Titamed®) is better nasal breathing and a favourable effect on snoring and sleep-apnoea. This is because the wider the palate becomes, the more the suspensory muscles of the soft palate become stretched. Furthermore, the lower cage of the nose becomes wider.

Does SARPE (smile distractor) affect the smile and any black corridors?

Broadening the narrow upper jaw in a stable and bony manner enhances greatly the overall aesthetics and, in particular, the smile of a person. The procedure fills up the black corridors near the laughing mouth corners. Hence also the name of the distractor: smile distractor (Titamed®).

My orthodontist wants to use a hyrax after the SARPE instead of a bone borne device such as a Smile Distractor. Is this okay?

An major disadvantage of the hyrax is that mouth hygiene is difficult during the five to six months that the device should be in the mouth. And so, they often cut down the necessary time for this reason. Another major disadvantage is that during the time (six months) the device is in place orthodontics are impossible, since the device is tooth bearing. Cutting on the time frame makes the hyrax device even more unpredictable. Most importantly, the hyrax is fixed onto the upper teeth. All forces are applied directly to the teeth, and only indirectly to the bone. Therefore, this device often causes flaring of the teeth. This flaring of the more posterior teeth is cumbersome, since the final result becomes much less predictable and relapse is never far away.

From what age onwards do you recommend a smile distractor?

To perform a SARPE safely, the definitive teeth should be in place. If teeth still have to descend, then their roots can get damaged by the surgery, especially the canins. Practically, and after a mouth examination, 12-13 years old.

My daughter is seven years old and the orthodonist wants to apply a hyrax in order to widen the upper jaw?

Most probably this is a good idea since at that age the bone of the palate is not yet fused and can be distracted slowly. The mechanics are different. SARPE is in essence an RPE (rapid palatal expansion). The activation is 0.5mm a day. The Hyrax is an SPE device (slow palatal expansion) for young children 6-7-8 years old and is activated 0.5mm a week.