# Maximally Deficiency: Treatments and Applications for Adolescents
## 3 Orthognathic Surgery Approaches
### Skeletally Mature Adolescents
#### 3.1.2 Modified SARME
After both the post-expansion and 6-month follow-up periods, the SAMRE with pterygomaxillary disjunction group demonstrated significantly greater nasopharyngeal volume and minimum cross-sectional area of the pharynx [118]. Pterygomaxillary disjunction also led to a significant widening of the nasal wing base, a change that persisted up to 36 months post-surgery. However, considering that the SAMRE with pterygomaxillary disjunction involves more invasive surgical procedures, complications such as bleeding, facial nerve paralysis, and maxillary sinus infections are more commonly associated with this approach. In two recent Finite Element Analysis studies, when the pterygomaxillary plates were separated, less stress was observed on the bone and teeth. The separation of the pterygomaxillary junction in the SARME procedure helps reduce stress in the facial skeleton during maxillary expansion [119; 120]. Therefore, whether applying pterygomaxillary disjunction during SARME remains a complex consideration, involving factors such as surgical strategy, expansion outcomes, and associated complications. This will be an important basis for decision making by researchers and clinicians. * Palatal preservation: In conventional SARME, the palatal split is a critical step for relieving resistance to maxillary expansion, as initial reports identified the mid-palatal suture as the greatest resistance to expansion [4]. However, with further understanding, it has become evident that other craniofacial sutures also serve as significant limitations to maxillary expansion. Consequently, some studies have suggested omitting the palatal split in SARME procedures. [PERSON] et al. argued that removing resistance at the zygomatic buttress alone is sufficient to facilitate expansion [96]. This conservative technique has been supported by other researchers as well. For instance, [PERSON] et al., in a retrospective study, found that performing osteotomies only at the lateral and anterior walls of the maxilla yielded satisfactory results for most patients in their study [97]. Similarly, [PERSON] et al. recommended a mid-palatal cut combined with transection of the lateral support [98]. In contrast, some researchers advocate replacing the single midline split of the maxilla with two paramedian palatal osteotomies extending from the posterior nasal spine to a point just posterior to the incisive canal. * Segmental Le Fort I osteotomy: [PERSON] and [PERSON] et al. recommended a comprehensive bilateral maxillary osteotomy extending from the pyriform aperture to the pterygomaxillary fissure, accompanied by a mid-palatal split from the anterior to the posterior nasal spines [121]. This approach involves sectioning all articulations and areas of resistance, including anterior, lateral, posterior, and median supports of the maxillary arch. Combining a Le Fort I osteotomy with a sagittal osteotomy of the mid-palatal suture proved to be the most effective surgical method for maxillary expansion. [PERSON] et al. introduced a three-segment osteotomy involving bilateral transalveolar osteotomies between the lateral incisors and canines [99]. Compared to the conventional two-segment SARME, the three-segment technique offers several advantages: (1) Reduced aesthetic compromise, as the expansion space is divided into interproximal spaces between the lateral incisors and canines rather than forming a prominent midline diastema; (2) Less disruption of the midline dental papilla, particularly for adolescent patients; (3) Preservation of the nasopalatine bundle; (4) The possibility of performing asymmetric expansions in a conservative manner. However, a systematic review found no statistically significant difference between two-segment and three-segment techniques regarding maxillary expansion symmetry [113; 122; 123]. But the three-segmentSARME demonstrated greater transverse expansion, as well as increased dental tipping, as the central incisors and canines exhibited greater inward angulation, and the lateral incisors angled outward more prominently.