==== Front Biomedicine (Taipei) Biomedicine (Taipei) BioMedicine 2211-8020 2211-8039 China Medical University 10.37796/2211-8039.1007 bmed-10-04-049 Case Report Persistent palatal hypertrophy associated with rapid maxillary expansion procedure: Report of a rare case Ömezli Mehmet Melih Torul Damla Avcı Tolunay * Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Ordu University, Ordu, Turkey * Corresponding author. Tolunay Avci, Ordu University, Faculty of Dentistry, Department of Oral and Maxillofacial Surgery, Ordu, 52100, Turkey. E-mail address: tlny_4@hotmail.com (T. Avcı). 2020 01 12 2020 10 4 49 51 01 4 2020 13 5 2020 © the Author(s)2020This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).Maxillary transversal deficiency (MTD) is a common skeletal problem. If not treated on time, MTD evolve to a more complex malocclusion. This problem can affect facial growth and development. Rapid maxillary expansion (RME) procedure frequently used for the management. This technique is usually successful in young individuals but as the age advances and the articulations of the maxilla with surrounding facial bones get more rigid, it becomes ineffective. Undesirable side effects or results have been reported after use of RME in skeletally mature patients such as buccal tipping of posterior teeth, extrusion, periodontal tissue recession, fenestration of buccal cortex, necrosis of palatal tissue, failure in opening of midpalatal suture, pain, and relapse of expansion. Side effects of RME are often temporary and permanent damages are rarely seen. The aim of this report is to present the management of a permanent side effect of the RME procedure in a 13-year-old child. Complicationfood retentionpalatal hypertrophyside effect ==== Body Introduction Maxillary transversal deficiency (MTD) is a commonly encountered skeletal problem with an incidence of 8.5 to 22% in children and adolescents [1-3]. Syndromes that affect the craniofacial region, mouth breathing, trauma, parafunctional habits like thumb/finger-sucking, and surgical complications of cleft palate repair considered among the factors that contribute to the occurrence of the MTDs [2-4]. Clinically the MTDs usually present with posterior crossbite, crowding of the teeth, high/narrow palatal arch, and mouth breathing [5]. Rapid maxillary expansion (RME) is one of the most commonly used treatment approach to correct MTDs, since the use of fixed palatal expanders in the 1960s [6-9]. During RME treatment to rapidly correct the MTDs heavy forces are transmitted to the maxilla, and as well as the surrounding anatomical structures [10,11]. Based on the magnitude of the force applied, associated with the appliance used, or because of the patient related factors undesirable side effects like pain, swelling, edema, ulceration, gingival recession, root resorption, molar tipping, rotation of the mandible, open bite, and relapse have been reported previously [2,7,12]. The aim of this report is to present the management of palatal mucosal swelling persist after the removal of the RME appliance, and causes food retention in the palatal region. Case report A 13-year-old male patient was admitted to our clinic with complaints of swelling and food retention in the palatal region. The patient reported that he used RME appliance for 3 weeks and after removal of the appliance, swelling persisted in the palatal region (Figs. 1 and 2). He also added that although the swelling has followed for 3 months, no improvement in the palatal region was observed. Because of the food retention in the palatal region and the inflamed palatal mucosa, surgical correction of this region was planned. Informed consent was obtained from the parents of the patient. Under general anesthesia, the hypertrophic areas in the palatal region were excised with the help of scalpel and electrocautery. Smooth area that prevents the food retention was created. One week after the operation the healing was non-contributory. In regular follow up visits recovery observed without sequelae (Fig. 3). Discussion RME procedure is widely preferred treatment option for the management of MTDs [7,13]. Undesirable side effects like decubitae or swelling in palatal mucosa, pain, tooth tilting, root resorption, caries and periodontal problems have been reported after the RME procedure [2,7,14]. Schuster et al. suggested that side effects of RME are often temporary and permanent damages rather rare [14]. It is reported that the side effects of RME tend to be greater in adeloscence than it is in children associated with the degree of skeletal maturity [13,15,16]. Capelozza et al. reported to observed side effects such as pain, edema, and ulceration frequently after RME in mature patients [12]. In the present case although at 13 years of age, a permanent swelling due to the mucosal hypertrophy in the palatal region was observed. Alterations in palatal mucosa may be seen during RME treatment. However, palatal mucosa irritations reported healing completely within a short period of time once the appliance is removed [14]. Also, Brunetto et al. reported that the anatomy of the palatal region may affect the success of the RME procedure [17]. In the present case the patient has a high-arched atypical palatal anatomy before the initiation of the treatment, and during RME procedure swelling was occurred in the palatal mucosa that causes food retention and prevents maintenance of oral hygiene. We think that the anatomy of the palatal region increases the susceptibility to the occurrence of this complication by preventing the application of force homogeneously. In addition, we think that uncontrolled use of force triggers permanent hypertrophy in the palatal mucosa. Subsequently, increased hypertrophy caused food retention and ultimately led to inflammation of the mucosa. Conclusion Although rare, permanent complications may occur in immature patients after RME treatment. Therefore, to prevent these complications appropriate treatment approach/appliance should be chosen, and regular follow-up with a strict oral hygiene regimen should be provided. It should not be forgotten that in many cases, some complications can be prevented by switching to a different appliance or by interrupting its use. Fig. 1 The view of patient's palatal region before orthodontic treatment. Fig. 2 Hypertrophic mucosa on palatal region 3 months after orthodontic treatment. Fig. 3 Recovered palatal mucosa 2 months after surgery. ==== Refs References 1 Menon S Manerikar R Sinha R Surgical management of transverse maxillary deficiency in adults J Maxillofac Oral Surg 2010 9 3 241 6 22190797 2 Alyessary AS Othman SA Yap AU Radzi Z Rahman MT Effects of non-surgical rapid maxillary expansion on nasal structures and breathing: A systematic review International orthodontics 2019 17 1 12 9 30732977 3 Da Silva Filho OG Santamaria M Jr Capelozza Filho L Epidemiology of posterior crossbite in the primary dentition J Clin Pediatr Dent 2007 32 1 73 8 18274476 4 Modëer T Odenrtck L Lindner Anders Sucking habits and their relation to posterior cross-bite in 4-year-old children European Journal of Oral Sciences 1982 90 4 323 8 5 Pereira MD Prado GP Abramoff MM Aloise AC Masako Ferreira L Classification of midpalatal suture opening after surgically assisted rapid maxillary expansion using computed tomography Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010 110 1 41 5 20417136 6 Lagravere MO Carey J Heo G Toogood RW Major PW Transverse, vertical, and anteroposterior changes from bone-anchored maxillary expansion vs traditional rapid maxillary expansion: a randomized clinical trial Am J Orthod Dentofacial Orthop 2010 137 3 304 20197161 7 Kurt G Altug AT Turker G Kilic B Kilic E Alkan A Effects of Surgical and Nonsurgical Rapid Maxillary Expansion on Palatal Structures J Craniofac Surg 2017 28 3 775 80 28468164 8 Haas AJ Rapid expansion of the maxillary dental arch and nasal cavity by opening the midpalatal suture Angle Orthod 1961 31 2 73 90 9 Handelman CS Wang L BeGole EA Haas AJ Nonsurgical rapid maxillary expansion in adults: report on 47 cases using the Haas expander Angle Orthod 2000 70 2 129 44 10833001 10 Giudice Lo A Barbato E Cosentino L Ferraro CM Leonardi R Alveolar bone changes after rapid maxillary expansion with tooth-born appliances: a systematic review Eur J Orthod 2018 40 3 296 303 29016774 11 Bazargani F Feldmann I Bondemark L Three-dimensional analysis of effects of rapid maxillary expansion on facial sutures and bones Angle Orthod 2013 83 6 1074 82 23745976 12 Capelozza Filho L Cardoso Neto J da Silva Filho OG Ursi WJ Non-surgically assisted rapid maxillary expansion in adults Int J Adult Orthodon Orthognath Surg 1996 11 1 57 66 9046628 13 Taylor N Johnson P Surgically Assisted Rapid Maxillary Expansion Orthognathic Surgery: Principles, Planning and Practice 2016 620 9 14 Schuster G Borel-Scherf I Schopf PM Frequency of and complications in the use of RPE appliances-results of a survey in the Federal State of Hesse, Germany J Orofac Orthop 2005 66 2 148 61 15827702 15 Bishara SE Staley RN Maxillary expansion: clinical implications Am J Orthod Dentofacial Orthop 1987 91 1 3 14 3541577 16 Melsen B Palatal growth studied on human autopsy material. A histologic microradiographic study Am J Orthod 1975 68 1 42 54 1056143 17 Brunetto DP Sant'Anna EF Machado AW Moon W Nonsurgical treatment of transverse deficiency in adults using Microimplant-assisted Rapid Palatal Expansion (MARPE) Dental Press J Orthod 2017 22 1 110 25 28444019