Produção Nacional
Revisado por pares
Oral focal mucinosis associated with surgically assisted rapid maxillary expansion
2014; Elsevier BV; Volume: 145; Issue: 4 Linguagem: Inglês
10.1016/j.ajodo.2013.02.035
ISSN1097-6752
AutoresJosé Rino Neto, Michelle Sendyk, Lucio Marcus Uchida, Fábio Daumas Nunes, João Batista de Paiva,
Tópico(s)Oral and gingival health research
ResumoOral focal mucinosis is a rare soft-tissue lesion that might result from the overproduction of hyaluronic acid by fibroblasts. The lesions are commonly found on the gingiva and palate; however, other sites, such as the tongue, have also been reported. The diagnosis of oral focal mucinosis is based on histologic analysis, and treatment involves surgical excision. Recurrences of lesions have not been reported. This article presents a patient with oral focal mucinosis that might be associated with surgically assisted rapid maxillary expansion. Oral focal mucinosis is a rare soft-tissue lesion that might result from the overproduction of hyaluronic acid by fibroblasts. The lesions are commonly found on the gingiva and palate; however, other sites, such as the tongue, have also been reported. The diagnosis of oral focal mucinosis is based on histologic analysis, and treatment involves surgical excision. Recurrences of lesions have not been reported. This article presents a patient with oral focal mucinosis that might be associated with surgically assisted rapid maxillary expansion. Oral focal mucinosis is a rare soft-tissue lesion of unspecified etiology, first described in 1974 by Tomich,1Tomich C.E. Oral focal mucinosis. A clinicopathologic and histochemical study of eight cases.Oral Surg Oral Med Oral Pathol. 1974; 38: 714-724Abstract Full Text PDF PubMed Scopus (62) Google Scholar in which the connective tissue goes through focal myxoid degeneration.2Buchner A. Merrell P.W. Leider A.S. Hansen L.S. Oral focal mucinosis.Int J Oral Maxillofac Surg. 1990; 19: 337-340Abstract Full Text PDF PubMed Scopus (30) Google Scholar, 3Soda G. Baiocchini A. Bosco D. Nardoni S. Melis M. Oral focal mucinosis of the tongue.Pathol Oncol Res. 1998; 4: 304-307Crossref PubMed Scopus (24) Google Scholar, 4Saito I. Ide F. Enomoto T. Kudo I. Oral focal mucinosis.J Oral Maxillofac Surg. 1985; 43: 372-374Abstract Full Text PDF PubMed Scopus (18) Google Scholar, 5Iezzi G. Rubini C. Fioroni M. Piattelli A. Oral focal mucinosis of the gingiva: case report.J Periodontol. 2001; 72: 1100-1102Crossref PubMed Scopus (20) Google Scholar, 6Gabay E. Akrish S. Machtei E.E. Oral focal mucinosis associated with cervical external root resorption: a case report.Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010; 110: e75-e78Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar This soft-tissue lesion might result from the overproduction of hyaluronic acid by fibroblasts.5Iezzi G. Rubini C. Fioroni M. Piattelli A. Oral focal mucinosis of the gingiva: case report.J Periodontol. 2001; 72: 1100-1102Crossref PubMed Scopus (20) Google Scholar Only 52 cases affecting patients from 4 to 74 years of age have been reported.7Lee J.G. Allen G. Moore L. Gue S. Oral focal mucinosis in an adolescent: a case report.Aust Dent J. 2012; 57: 90-92Crossref PubMed Scopus (16) Google Scholar Oral focal mucinosis is commonly found on the gingiva and palate6Gabay E. Akrish S. Machtei E.E. Oral focal mucinosis associated with cervical external root resorption: a case report.Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010; 110: e75-e78Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar and on the mucosa overlying the maxillary alveolar process8Soares de Lima A.A. Naval Machado M.A. Martins W.D. Trindade Gregio A.M. Dirschnabel A.J. Folador Mattioli T.M. et al.Oral focal mucinosis.Quintessence Int. 2008; 39: 611-615PubMed Google Scholar, 9Madhusudhan A.S. Nagarajappa D.A.S. Manjunatha B.S. Swati Saawarn Charan Babu Oral focal mucinosis: report of two cases.Rev Odonto Cienc. 2010; 25: 310-313Google Scholar; however, other sites, such as the tongue, have also been reported.4Saito I. Ide F. Enomoto T. Kudo I. Oral focal mucinosis.J Oral Maxillofac Surg. 1985; 43: 372-374Abstract Full Text PDF PubMed Scopus (18) Google Scholar The oral focal mucinosis lesion is a painless, sessile, or pedunculated mass that is similar in color to the surrounding mucosa.7Lee J.G. Allen G. Moore L. Gue S. Oral focal mucinosis in an adolescent: a case report.Aust Dent J. 2012; 57: 90-92Crossref PubMed Scopus (16) Google Scholar, 10Etges A. Sobral A.P.V. Santos J.N. Silva M.J.A. Araujo V.C. Mucinose oral focal: estudo clínico, histo-patológico e histoquímico.RPG Rev Pos Grad. 2000; 7: 140-144Google Scholar The lesion occurs predominantly in adults during the fourth or fifth decade of life, although there are rare cases reported in children and adolescents. Oral focal mucinosis shows a 2:1 female-to-male predilection.7Lee J.G. Allen G. Moore L. Gue S. Oral focal mucinosis in an adolescent: a case report.Aust Dent J. 2012; 57: 90-92Crossref PubMed Scopus (16) Google Scholar, 8Soares de Lima A.A. Naval Machado M.A. Martins W.D. Trindade Gregio A.M. Dirschnabel A.J. Folador Mattioli T.M. et al.Oral focal mucinosis.Quintessence Int. 2008; 39: 611-615PubMed Google Scholar Histologically, oral focal mucinosis is characterized by a well-circumscribed area of myxomatous tissue containing hyaluronic acid and elongated, fusiform, or ovoid fibroblasts. Inflammatory cells may be present in the center of the lesion.2Buchner A. Merrell P.W. Leider A.S. Hansen L.S. Oral focal mucinosis.Int J Oral Maxillofac Surg. 1990; 19: 337-340Abstract Full Text PDF PubMed Scopus (30) Google Scholar, 6Gabay E. Akrish S. Machtei E.E. Oral focal mucinosis associated with cervical external root resorption: a case report.Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010; 110: e75-e78Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar, 11Aldred M.J. Talacko A.A. Ruljancich K. Story R.D. Newland S. Chen S.T. et al.Oral focal mucinosis: report of 15 cases and review of the literature.Pathology. 2003; 35: 393-396Crossref PubMed Scopus (33) Google Scholar The mucosa overlying the lesion and the surrounding connective tissue are unaffected.7Lee J.G. Allen G. Moore L. Gue S. Oral focal mucinosis in an adolescent: a case report.Aust Dent J. 2012; 57: 90-92Crossref PubMed Scopus (16) Google Scholar, 11Aldred M.J. Talacko A.A. Ruljancich K. Story R.D. Newland S. Chen S.T. et al.Oral focal mucinosis: report of 15 cases and review of the literature.Pathology. 2003; 35: 393-396Crossref PubMed Scopus (33) Google Scholar The diagnosis of oral focal mucinosis is based on histologic analysis, and treatment involves surgical excision. Recurrences of lesions have not been reported.7Lee J.G. Allen G. Moore L. Gue S. Oral focal mucinosis in an adolescent: a case report.Aust Dent J. 2012; 57: 90-92Crossref PubMed Scopus (16) Google Scholar We present a case of oral focal mucinosis that might be associated with surgically assisted rapid maxillary expansion (RME). RME is used to treat young patients with maxillary atresia. In adults, this procedure has high failure rates because of the increased rigidity of maxillary sutures, causing dental inclinations, bone dehiscence, and gingival recession. Because of these complications, surgically assisted RME is indicated.9Madhusudhan A.S. Nagarajappa D.A.S. Manjunatha B.S. Swati Saawarn Charan Babu Oral focal mucinosis: report of two cases.Rev Odonto Cienc. 2010; 25: 310-313Google Scholar, 10Etges A. Sobral A.P.V. Santos J.N. Silva M.J.A. Araujo V.C. Mucinose oral focal: estudo clínico, histo-patológico e histoquímico.RPG Rev Pos Grad. 2000; 7: 140-144Google Scholar, 11Aldred M.J. Talacko A.A. Ruljancich K. Story R.D. Newland S. Chen S.T. et al.Oral focal mucinosis: report of 15 cases and review of the literature.Pathology. 2003; 35: 393-396Crossref PubMed Scopus (33) Google Scholar, 12Murray J.M. Cleall J.F. Early tissue response to rapid maxillary expansion in the midpalatal suture of the rhesus monkey.J Dent Res. 1971; 50: 1654-1660Crossref PubMed Scopus (43) Google Scholar In our patient, the association between oral focal mucinosis and surgically assisted RME was established by the appearance of an oral focal mucinosis lesion in the region where the maxillary sutures were opened. Murray and Cleall12Murray J.M. Cleall J.F. Early tissue response to rapid maxillary expansion in the midpalatal suture of the rhesus monkey.J Dent Res. 1971; 50: 1654-1660Crossref PubMed Scopus (43) Google Scholar reported that 14 days after the midpalatal suture was opened with RME in rhesus monkeys, the suture connective tissue appeared to be cellular and disorganized. This procedure applies heavy forces to open the suture, resulting in the formation of osteoid tissues. In our patient, we considered the possibility that fibroblasts stimulated by trauma from the surgically assisted RME produced hyaluronic acid, not osteoid tissues, causing the oral focal mucinosis. A 20-year-old white woman came to the clinic at the Faculty of Dentistry at the University of São Paulo, São Paulo, Brazil, for orthodontic preparation for orthognathic surgery. Her complaint was a bilateral posterior crossbite (Fig 1, A). After the diagnosis of maxillary atresia was made, a hyrax palatal expander was placed on the first premolars and the first molars, and the patient was referred for surgically assisted RME. A subtotal LeFort I osteotomy was used to perform the surgically assisted RME. During the procedure, the maxillary tuberosity was separated from the pterygoid plateau, and it was associated with osteotomy of the anterior region of the maxilla.13Bell W.H. Jacobs J.D. Surgical-orthodontic correction of horizontal maxillary deficiency.J Oral Surg. 1979; 37: 897-902PubMed Google Scholar After 5 days, the patient returned to the clinic and was instructed to activate the screw in the appliance by a quarter turn in the morning and a quarter turn in the evening daily until the desired expansion was achieved. Eight months after the surgically assisted RME procedure, the appearance of an asymptomatic neoformation on the attached gingiva of the labial surface of the maxillary central incisors was noted. The soft-tissue lesion was round, approximately 10 mm in diameter, firm, and sessile. The overlying mucosa was not ulcerated and was the same color as the surrounding mucosa, although a slight erythematous area was noted (Fig 1, B). The patient was in good overall health. The intraoral examination showed good oral hygiene and periodontal health. The maxillary central incisors had a positive pulp vitality test, and no radiographic changes were noted in the area of the lesion. The lesion was completely removed by performing a full-thickness mucoperiosteal flap on the buccal and mesial surfaces of the maxillary right central incisor and on the mesial surface of the maxillary left central incisor under local anesthesia. Periodontal debridement was then performed, and the flap was repositioned and sutured. The extracted tissue was sent to pathology for examination. The histologic sections showed fragments of mucosa that were partially covered with hyperparakeratinized stratified squamous epithelium with the areas of acanthosis. The lamina propria consisted of dense connective tissue permeated by an intense, diffuse mononuclear inflammatory infiltrate. Throughout the connective tissue, there were areas of loose myxomatous material that were stained with alcian blue and interpreted as mucin. The histopathologic findings were consistent with the diagnosis of oral focal mucinosis (Fig 2). One week after surgery, the surgical site had healed without complications, and the sutures were removed (Fig 3, A). The operative site was assessed 2 months and 1 year after surgery (Fig 3, B and C). The patient was observed for 2 years after surgery, and there were no signs of recurrence. The lesion site was also monitored radiographically, and bone changes were not observed (Fig 4). The etiology of oral focal mucinosis is unknown.11Aldred M.J. Talacko A.A. Ruljancich K. Story R.D. Newland S. Chen S.T. et al.Oral focal mucinosis: report of 15 cases and review of the literature.Pathology. 2003; 35: 393-396Crossref PubMed Scopus (33) Google Scholar Tomich1Tomich C.E. Oral focal mucinosis. A clinicopathologic and histochemical study of eight cases.Oral Surg Oral Med Oral Pathol. 1974; 38: 714-724Abstract Full Text PDF PubMed Scopus (62) Google Scholar described oral focal mucinosis as the counterpart to cutaneous focal mucinosis and suggested that it is caused by the overproduction of hyaluronic acid by fibroblasts during collagen production. The cause of this overproduction is unknown, and the idea that local trauma is the predisposing factor remains controversial.1Tomich C.E. Oral focal mucinosis. A clinicopathologic and histochemical study of eight cases.Oral Surg Oral Med Oral Pathol. 1974; 38: 714-724Abstract Full Text PDF PubMed Scopus (62) Google Scholar, 14Gnepp D.R. Vogler C. Sotelo-Avila C. Kielmovitch I.H. Focal mucinosis of the upper aerodigestive tract in children.Hum Pathol. 1990; 21: 856-858Abstract Full Text PDF PubMed Scopus (23) Google Scholar, 15Talacko A.A. Lacy M.F. Besly W.J. Aldred M.J. Oral focal mucinosis: report of two cases with ulceration.Pathology. 2004; 36: 582-583Crossref PubMed Scopus (16) Google Scholar Inflammatory lesions described in the literature for differential diagnoses of oral focal mucinosis include gingivitis, fibrous hyperplasia, pyogenic granuloma, peripheral giant cell granuloma, and gingival tumors such as peripheral ossifying fibroma and peripheral fibroma.8Soares de Lima A.A. Naval Machado M.A. Martins W.D. Trindade Gregio A.M. Dirschnabel A.J. Folador Mattioli T.M. et al.Oral focal mucinosis.Quintessence Int. 2008; 39: 611-615PubMed Google Scholar, 16Manor Y. Merdinger O. Katz J. Taicher S. Unusual peripheral odontogenic tumors in the differential diagnosis of gingival swellings.J Clin Periodontol. 1999; 26: 806-809Crossref PubMed Scopus (23) Google Scholar The histologic differential diagnosis for oral focal mucinosis includes soft-tissue myxoma and odontogenic myxoma.4Saito I. Ide F. Enomoto T. Kudo I. Oral focal mucinosis.J Oral Maxillofac Surg. 1985; 43: 372-374Abstract Full Text PDF PubMed Scopus (18) Google Scholar, 8Soares de Lima A.A. Naval Machado M.A. Martins W.D. Trindade Gregio A.M. Dirschnabel A.J. Folador Mattioli T.M. et al.Oral focal mucinosis.Quintessence Int. 2008; 39: 611-615PubMed Google Scholar A myxoma can be an infiltrative growth, whereas focal mucinosis usually manifests as a localized area of myxomatous connective tissue.1Tomich C.E. Oral focal mucinosis. A clinicopathologic and histochemical study of eight cases.Oral Surg Oral Med Oral Pathol. 1974; 38: 714-724Abstract Full Text PDF PubMed Scopus (62) Google Scholar Mucin is a characteristic of many cases of focal mucinosis but is not present in myxomas. The alcian blue staining of hyaluronic acid is the predominant characteristic of oral focal mucinosis but is not characteristic of odontogenic myxomas.6Gabay E. Akrish S. Machtei E.E. Oral focal mucinosis associated with cervical external root resorption: a case report.Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010; 110: e75-e78Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar The consensus for treatment of oral focal mucinosis is complete surgical excision of the lesion.1Tomich C.E. Oral focal mucinosis. A clinicopathologic and histochemical study of eight cases.Oral Surg Oral Med Oral Pathol. 1974; 38: 714-724Abstract Full Text PDF PubMed Scopus (62) Google Scholar, 8Soares de Lima A.A. Naval Machado M.A. Martins W.D. Trindade Gregio A.M. Dirschnabel A.J. Folador Mattioli T.M. et al.Oral focal mucinosis.Quintessence Int. 2008; 39: 611-615PubMed Google Scholar Recurrence of oral focal mucinosis has not been reported in the literature (Table).7Lee J.G. Allen G. Moore L. Gue S. Oral focal mucinosis in an adolescent: a case report.Aust Dent J. 2012; 57: 90-92Crossref PubMed Scopus (16) Google ScholarTableReports of oral focal mucinosis in the literatureAuthorYearLocationAge (y)SexDurationRecurrence after surgical excisionTomich1Tomich C.E. Oral focal mucinosis. A clinicopathologic and histochemical study of eight cases.Oral Surg Oral Med Oral Pathol. 1974; 38: 714-724Abstract Full Text PDF PubMed Scopus (62) Google Scholar1974Palate40F5-10 yNoMandibular gingiva31F1 yNoMandibular gingiva16MNANoBuccal mucosaNAF1 yNoTip of tongue45M2 moNoMandibular alveolar mucosa28MNANoAnterior hard palate22F4 moNoAnterior hard palate19F4 moNoSaito et al4Saito I. Ide F. Enomoto T. Kudo I. Oral focal mucinosis.J Oral Maxillofac Surg. 1985; 43: 372-374Abstract Full Text PDF PubMed Scopus (18) Google Scholar1985Gingiva35M3 moNAGingiva50FNANABuchner et al2Buchner A. Merrell P.W. Leider A.S. Hansen L.S. Oral focal mucinosis.Int J Oral Maxillofac Surg. 1990; 19: 337-340Abstract Full Text PDF PubMed Scopus (30) Google Scholar1990Gingiva18F9 moNoGingiva30M5 yNoGingiva32F1 mNoGingiva22F1 yNoGingiva53FNANoGingiva16FNANoGingiva43MNANoGingiva41FNANoGingiva37F3 yNoGingiva46M1 yNoMandibular retromolar area46M3 yNoAlveolar mucosa61FNANoAlveolar mucosa37FNANoHard palate38F1 yNoTongue50M2 moNoGnepp et al14Gnepp D.R. Vogler C. Sotelo-Avila C. Kielmovitch I.H. Focal mucinosis of the upper aerodigestive tract in children.Hum Pathol. 1990; 21: 856-858Abstract Full Text PDF PubMed Scopus (23) Google Scholar1990Hard palate4FNANoSoda et al3Soda G. Baiocchini A. Bosco D. Nardoni S. Melis M. Oral focal mucinosis of the tongue.Pathol Oncol Res. 1998; 4: 304-307Crossref PubMed Scopus (24) Google Scholar1998Tongue68M3 yNAEtges et al10Etges A. Sobral A.P.V. Santos J.N. Silva M.J.A. Araujo V.C. Mucinose oral focal: estudo clínico, histo-patológico e histoquímico.RPG Rev Pos Grad. 2000; 7: 140-144Google Scholar2000Gingiva40F3 moNAGingiva43M8 yNAIezzi et al5Iezzi G. Rubini C. Fioroni M. Piattelli A. Oral focal mucinosis of the gingiva: case report.J Periodontol. 2001; 72: 1100-1102Crossref PubMed Scopus (20) Google Scholar2001Gingiva48M8 moNoAldred et al11Aldred M.J. Talacko A.A. Ruljancich K. Story R.D. Newland S. Chen S.T. et al.Oral focal mucinosis: report of 15 cases and review of the literature.Pathology. 2003; 35: 393-396Crossref PubMed Scopus (33) Google Scholar2003Lip38FNANoLip74MNANoGingiva30F1 moNoGingiva16F4 moNoGingiva49M10 yNoGingiva31F6 moNoGingiva52M1 yNoGingiva40F4 moNoGingiva37F3 moNoGingiva35F1 yNAGingiva33F1 yNAGingiva68M1 yNABuccal mucosa56FNANAMouth60F1 yNATongue55M3 moNoTalacko et al15Talacko A.A. Lacy M.F. Besly W.J. Aldred M.J. Oral focal mucinosis: report of two cases with ulceration.Pathology. 2004; 36: 582-583Crossref PubMed Scopus (16) Google Scholar2004Buccal mucosa63FNANAGingiva24MNANASoares de Lima et al8Soares de Lima A.A. Naval Machado M.A. Martins W.D. Trindade Gregio A.M. Dirschnabel A.J. Folador Mattioli T.M. et al.Oral focal mucinosis.Quintessence Int. 2008; 39: 611-615PubMed Google Scholar2008Gingiva36F4 moNoGabay et al6Gabay E. Akrish S. Machtei E.E. Oral focal mucinosis associated with cervical external root resorption: a case report.Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010; 110: e75-e78Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar2010Gingiva44F3 yNAMadhusudhan et al9Madhusudhan A.S. Nagarajappa D.A.S. Manjunatha B.S. Swati Saawarn Charan Babu Oral focal mucinosis: report of two cases.Rev Odonto Cienc. 2010; 25: 310-313Google Scholar2010Hard palate50M2 moNoGingiva26F3 moNoLee et al7Lee J.G. Allen G. Moore L. Gue S. Oral focal mucinosis in an adolescent: a case report.Aust Dent J. 2012; 57: 90-92Crossref PubMed Scopus (16) Google Scholar2012Gingiva17FNANAF, Female; M, male; NA, not available. Open table in a new tab F, Female; M, male; NA, not available. Our patient underwent surgically assisted RME for the correction of a transverse maxillary deficiency.17Altug-Atac A.T. Atac M.S. Kurt G. Karasud H.A. Changes in nasal structures following orthopaedic and surgically assisted rapid maxillary expansion.Int J Oral Maxillofac Surg. 2010; 39: 129-135Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar, 18Phillips C. Medland W.H. Fields Jr., H.W. Proffit W.R. White Jr., R.P. Stability of surgical maxillary expansion.Int J Adult Orthod Orthognath Surg. 1992; 7: 139-146PubMed Google Scholar The complications of surgically assisted RME described in the literature include bone defects, tooth mobility, external root resorption, smaller interproximal papillae, and gingival recession.19Koudstaal M.J. Poort L.J. van der Wal K.G. Wolvius E.B. Prahl-Andersen B. Schulten A.J. Surgically assisted rapid maxillary expansion (SARME): a review of the literature.Int J Oral Maxillofac Surg. 2005; 34: 709-714Abstract Full Text Full Text PDF PubMed Scopus (193) Google Scholar, 20Suri L. Taneja P. Surgically assisted rapid palatal expansion: a literature review.Am J Orthod Dentofacial Orthop. 2008; 133: 290-302Abstract Full Text Full Text PDF PubMed Scopus (217) Google Scholar, 21Cureton S.L. Cuenin M. Surgically assisted rapid palatal expansion: orthodontic preparation for clinical success.Am J Orthod Dentofacial Orthop. 1999; 116: 46-59Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar, 22Lanigan D.T. Mintz S.M. Complications of surgically assisted rapid palatal expansion: review of the literature and report of a case.J Oral Maxillofac Surg. 2002; 60: 104-110Abstract Full Text Full Text PDF PubMed Scopus (87) Google Scholar, 23Chuah C. Mehra P. Bilateral lingual anesthesia following surgically assisted rapid palatal expansion: report of a case.J Oral Maxillofac Surg. 2005; 63: 416-418Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar Nevertheless, surgically assisted RME appears to have few deleterious effects on the periodontium when evaluated clinically.24Gauthier C. Voyer R. Paquette M. Rompre P. Papadakis A. Periodontal effects of surgically assisted rapid palatal expansion evaluated clinically and with cone-beam computerized tomography: 6-month preliminary results.Am J Orthod Dentofacial Orthop. 2011; 139: S117-S128Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar The surgical technique used for this patient was the subtotal LeFort I osteotomy described by Bell and Jacobs,13Bell W.H. Jacobs J.D. Surgical-orthodontic correction of horizontal maxillary deficiency.J Oral Surg. 1979; 37: 897-902PubMed Google Scholar which allows a lower level of force to be applied to the facial structures and the cranial base compared with more conservative techniques, since separation of the pterygomaxillary junction appears to be an additional measure to protect the cranial base from undesirable side effects.25Holberg C. Steinhauser S. Rudzki I. Surgically assisted rapid maxillary expansion: midfacial and cranial stress distribution.Am J Orthod Dentofacial Orthop. 2007; 132: 776-782Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar, 26Anttila A. Finne K. Keski-Nisula K. Somppi M. Panula K. Peltomaki T. Feasibility and long-term stability of surgically assisted rapid maxillary expansion with lateral osteotomy.Eur J Orthod. 2004; 26: 391-395Crossref PubMed Scopus (81) Google Scholar, 27Byloff F.K. Mossaz C.F. Skeletal and dental changes following surgically assisted rapid palatal expansion.Eur J Orthod. 2004; 26: 403-409Crossref PubMed Scopus (109) Google Scholar, 28Chung C.H. Woo A. Zagarinsky J. Vanarsdall R.L. Fonseca R.J. Maxillary sagittal and vertical displacement induced by surgically assisted rapid palatal expansion.Am J Orthod Dentofacial Orthop. 2001; 120: 144-148Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar, 29Epker B.N. Fish L.C. The surgical-orthodontic correction of Class III skeletal open-bite.Am J Orthod. 1978; 73: 601-618Abstract Full Text PDF PubMed Scopus (26) Google Scholar, 30Krey K.F. Walter F. Dannhauer K.H. Changes in arch form following surgically-assisted rapid maxillary expansion (SRME).J Orofac Orthop. 2008; 69: 177-188Crossref PubMed Scopus (6) Google Scholar After the device is expanded, an opening forms in the midpalatal suture, which is monitored clinically and radiographically. The device is first expanded 5 days after surgery. The period before the device is expanded is called the latency period and is characterized by the infiltration of osteoblasts, but this period is too short to allow bone healing.20Suri L. Taneja P. Surgically assisted rapid palatal expansion: a literature review.Am J Orthod Dentofacial Orthop. 2008; 133: 290-302Abstract Full Text Full Text PDF PubMed Scopus (217) Google Scholar During this latency period, highly disorganized connective tissues form, which are later replaced by immature osseous tissues.31Sannomiya E.K. Macedo M.M. Siqueira D.F. Goldenberg F.C. Bommarito S. Evaluation of optical density of the midpalatal suture 3 months after surgically assisted rapid maxillary expansion.Dentomaxillofac Radiol. 2007; 36: 97-101Crossref PubMed Scopus (22) Google Scholar The anterior region of the palate has the broadest opening and is the last region to complete remodeling. Bone formation occurs along the edges of the palatine bone and continues toward the midline starting in the posterior region of the suture.32Gurgel Jde A. Malmstrom M.F. Pinzan-Vercelino C.R. Ossification of the midpalatal suture after surgically assisted rapid maxillary expansion.Eur J Orthod. 2012; 34: 39-43Crossref PubMed Scopus (17) Google Scholar, 33Angeletti P. Pereira M.D. Gomes H.C. Hino C.T. Ferreira L.M. Effect of low-level laser therapy (GaAlAs) on bone regeneration in midpalatal anterior suture after surgically assisted rapid maxillary expansion.Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010; 109: e38-e46Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar Six months after surgically assisted RME, bone formation is completing in the midpalatal suture between the maxillary central incisors. During this time, gingival tissues must be clinically healthy. In this patient, the appearance of the oral focal mucinosis lesion near the midpalatal suture might have been due to the production of hyaluronic acid by fibroblasts stimulated by the trauma from surgically assisted RME. A rare case with a potential association between oral focal mucinosis and surgically assisted RME was described. This case illustrates that oral focal mucinosis should be considered in the differential diagnosis of soft-tissue lesions in adult and adolescent patients who undergo surgically assisted RME. Oral focal mucinosis might be associated with surgically assisted RME because of the trauma inherent in the surgical procedure and its corresponding healing process.
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