The upper jaw, called the maxilla in Latin, forms the middle part of the face; it contains the nasal cavity, and the upper teeth hang down from it. The video below illustrates this nicely. Whether it is narrow or not has to be assessed in relation to the rest of the skull, but above all in relation to its counterpart, the lower jaw. If the maxilla is narrow, the upper dental arch will also be narrow. The video clearly shows that in a normal dentition the upper teeth sit on the outside and the lower teeth on the inside. If the upper jaw is narrow, the upper teeth end up here and there inside the lower ones. This is called a crossbite.
A constriction of the upper jaw is a problem that many adult patients come to us with. Often the characteristic feeling has been present for years – that the upper row of teeth is too narrow, that it does not fit the lower one, that biting is therefore uncomfortable, or that the smile does not fill the face harmoniously. For many people, nasal breathing is restricted through the narrow nasal passages, easily leading to snoring and habitual mouth breathing.
Patients often also report that they noticed this already in childhood, but no treatment was carried out at the time, and in adulthood classic orthodontics can no longer solve the problem. There is a simple reason for this: while in childhood the midline suture of the upper jaw can easily be expanded, by adulthood this suture has ossified, and so the expander used in children is no longer sufficient. This is when surgically assisted maxillary expansion becomes necessary, SARME or SARPE for short.
The essence of SARME is that with surgical help we weaken those parts of the upper jaw that have completely ossified in adulthood and prevent expansion. This way, with the help of a special appliance, we can safely widen the upper dental arch in small steps. This treatment affects not only the position of the teeth, but also the aesthetics of the face and the airways. The smile becomes wider, breathing becomes freer, the bite is corrected, and we achieve a stable, long-term result.
Expansion of the upper jaw almost never happens on its own, but generally as the first step of a complex orthodontic treatment!
Diagnostics is always the first and most important step. In every case we take a digital impression, photographs, and X-ray images – most often a CBCT or a lateral cephalogram. With these we can precisely measure how much the upper jaw has narrowed, and how much expansion is needed for it to fit properly against the lower jaw.
We take the lower jaw as the reference because its width is fixed and cannot easily be expanded. The tongue, on the other hand, usually creates its own space, which is why expansion of the lower jaw is needed only very, very rarely.
Our calculations do not concern only the position of the teeth. We also take into account the proportions of the face, the aesthetics of the smile and the chewing function. The required expansion is determined with millimetre precision. We then prepare a detailed treatment plan in which the patient can see exactly what steps the process will consist of, at what pace the expansion will take place, and when the actual orthodontic treatment can begin.
It is particularly important for the patient to understand that SARME is not a frightening or unpredictable intervention, but a carefully pre-planned, step-by-step process that has been performed routinely for more than fifty years in the world’s leading clinics.
The first step of the treatment is the placement of the palatal mini-implants, the so-called TADs. These are tiny titanium screws that we fix into the palate and that provide stable anchorage for the expansion appliance. This is important because it means the forces do not have to be borne by the teeth; instead, we can move the bone directly.
The placement of the TADs is a fully digitally planned process. Based on the patient’s CBCT scan, we prepare a surgical guide that precisely determines where the implants should go. This precision means the procedure is fast, safe and predictable. After placement, we carry out another digital scan and obtain an impression so precise that, based on it, the laboratory can produce the expansion appliance, which fits perfectly onto the placed screws.
Most often we use a so-called Hybrid Hyrax or a Micro 4 appliance. The Hybrid Hyrax is fixed partly to the teeth and partly to the TADs, while the Micro 4 rests solely on the screws and thereby ensures ideal force transmission and stable, controlled expansion.
There is, after all, a difference between the bones of children and adults. Although we weaken the bones with the procedure described above, an adult’s thick bones are nevertheless more resistant than those of children. The plain Hyrax appliance is fixed only to the teeth and exerts force on the bones through them. However, if the bones are thick and strong, the teeth have to be pushed with a very large force for the expansion to work – so large a force that it would no longer be good for the teeth.
This is where the temporary implants placed into the palate, also known as mini-screws or TADs, come into play. These are titanium screws 10–14 mm long, which after careful planning we place at two precisely determined points on the palate. The Hyrax appliance is then made so that the greater part of the force needed for expansion is taken by the screws placed in the bone, protecting the teeth. Since there are no sensory nerves inside the bone, exerting force through the screws is painless.
A short video about the appliance:
And in this video we explain how the planning and execution of the implantation are carried out:
Orthodontics can be both a simple and a complex process, so it is by no means certain that everyone needs maxillary expansion. If you are about to start orthodontic treatment, feel free to turn to us, because we set up a personalised treatment plan for each of our patients, without unnecessary interventions.
Once the appliance is ready and has been placed in the patient’s mouth, the surgical procedure takes place. It is important to emphasise that this step does not happen in our clinic, but at our oral surgeon colleague, Dr. Krisztián Nagy.
Today we use the most modern, minimally invasive solution. This has many names: light SARME, lateral osteotomy, Glassman osteotomy or minimally invasive SARME. These are all different names for the same approach. The goal is to release the sutures of the upper jaw so that the expansion appliance is able to pull the two sides apart. During the surgery, in effect, an “assisted pathway” opens up in the bone, through which the expansion can safely take place. Below you can find an article by one of the world’s most famous oral surgeons, Mirko Raffaini, in which he describes this procedure.
https://pubmed.ncbi.nlm.nih.gov/40358521/
After the surgery, most patients report mild pain, swelling and nasal congestion. These are completely natural and are well managed with painkillers. In the first days it is best to rest, to avoid sport, physical exertion, and overly hot food and drink. Cold compresses, soft foods and strict oral hygiene all help with healing.
In most cases the bulk of the discomfort has already passed after 2–3 days!
The sutures are usually removed after about a week. Then, following a few days of rest, regular expansion with the placed appliance begins. At this point the patient activates the appliance at home, in small steps, according to the instructions received. This process takes weeks, and during it the upper jaw gradually opens up. New bone forms in the resulting gap, which ensures a stable result in the long term.
Even though this is a routine procedure, very significant changes can be achieved with it in a fairly short time. For exactly this reason we follow the process very closely; during the active phase of expansion, which usually lasts a few weeks, we check the expansion every 1–2 weeks.
Once the desired expansion has been achieved, we leave the appliance in place in a stabilising role. During this time, new bone forms and strengthens in the freshly opened gap. Generally about six weeks are needed before we can safely begin the actual orthodontic treatment.
This is the point at which we start the orthodontic treatment either with fixed braces or with Invisalign clear aligners, depending on which solution better suits the given patient’s needs and lifestyle. From here on, the goal is to align the entire dentition, fine-tune the bite and achieve the final aesthetic result.
SARME is a treatment that makes it possible for us to effectively treat a constriction of the upper jaw in adult patients as well. The process is always carefully planned, built up step by step and controlled. From diagnostics through the surgical assistance to the start of orthodontics, every detail is discussed in advance, so the patient knows exactly what to expect. The result of the treatment is not only a more beautiful smile, but also a more harmonious face, a stable bite and freer breathing.
This article was prepared by the professional team of Foxxi Buda Orthodontics.
Professional reviewers: Dr. Dominika Magyar Ph.D. and Dr. Zoltán Pulay – orthodontic specialists
The content of the article is reliable and based on professional sources, including relevant studies from the PubMed database.
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