# Maximally Deficiency: Treatments and Applications for Adolescents
## 3 Orthognathic Surgery Approaches
### Skeletally Mature Adolescents
#### 3.1.2 Modified SARME  
While conventional SARME has proven effective in achieving stable maxillary transverse expansion, the development of modified SARME techniques has aimed to address specific clinical challenges. These include accommodating unique medical histories, achieving greater or more precise expansion, and meeting higher aesthetic standards. Modified SARME offers tailored approaches that decrease complication risk, enhance treatment efficiency, and expand its applicability to diverse patient needs. The primary principle of these modified incision techniques remains consistent: to release the resistance areas in the midface that impede lateral expansion. These resistance areas are classified into four categories: anterior support (piriform aperture pillars), lateral support (zygomatic buttresses), posterior support (pterygoid junctions), and median support (mid-palatal suture) [114]. * Cortical osteotomy:  
[PERSON] et al. proposed the use of selective dentoalveolar osteectomies to section the cortical bone and reduce resistance to orthodontic movement [115]. Similarly, [PERSON] and [PERSON] et al. recommended both labial and palatal cortical osteectomies for expansion [93]. There is reason to believe that cortical osteotomy could enhance the efficiency of SARME. However, sufficient clinical research--whether through retrospective studies or randomized controlled trials--is currently lacking to provide solid evidence-based support. * Pterygomaxillary disjunction:  
Although some scholars suggest avoiding attempts to separate the maxilla from the pterygoid plates to prevent entering the pterygomaxillary junction, believing that such separation requires significant force and is prone to fractures, later studies have recognized the pterygomaxillary junction as a key resistance area [116]. In cases where pterygomaxillary disjunction was performed, the SAMRE resulted in more uniform maxillary expansion. In contrast, the SAMRE without pterygomaxillary disjunction demonstrated greater anterior maxillary expansion, confirming a V-shaped suture opening pattern, with less posterior expansion compared to the SAMRE with pterygomaxillary disjunction group [94; 117]. The maxillary expansion without pterygomaxillary disjunction showed differential expansion between the anterior and posterior regions, up to 3 mm, with the anterior region expanding more than the posterior region [113]. However, some studies have suggested that pterygomaxillary disjunction might be more effective in patients over 20 years of age, but no analysis of its additional benefits for younger patients has been provided [95]. In terms of anterior-posterior analysis, maxillary expansion was greater in the alveolar bone than in the palatal region. Although significant increases in the middle and lower facial heights were observed in the SAMRE with pterygomaxillary disjunction group at the end of the activation phase, these changes were reversed and returned to baseline during the stabilization phase. Regarding the direction of bone movement, the SAMRE with pterygomaxillary disjunction group showed outward segmental tipping from anterior to posterior, whereas the SAMRE without pterygomaxillary disjunction group exhibited inward tipping [113]. For pterygomaxillary disjunction, the tipping of the teeth primarily occurred in the SAMRE without pterygomaxillary disjunction group. The SAMRE with pterygomaxillary disjunction group showed lower buccal tipping of the molars, both immediately after device removal and after a 6-month follow-up. The SAMRE without pterygomaxillary disjunction group demonstrated greater molar tipping, resulting in a larger molar expansion compared to the SAMRE with pterygomaxillary disjunction group, particularly in the dental-supported device group [113]. As for pterygomaxillary disjunction, studies found that maxillary expansion improved nasal width and respiratory function.