We appreciate the comments about our case report (Valladares-Neto J, Evangelista K, Torres HM, Pithon MM, Silva MAGS. A 22-year follow-up of the nonsurgical expansion of maxillary and mandibular arches in a young adult: are the outcomes stable, relapsed, or unstable with aging? Am J Orthod Dentofacial Orthop 2016;150:521-32). We thank you for the comments and for allowing us to clarify some of the issues raised.
Drs Monte and Nouer made a remarkable observation about the use of tomographic parameters to diagnose the rigidity of the sutures to predict the possibility of disruption of this suture in a borderline expansion treatment. However, the use of tomographic images in orthodontics became popular after cone-beam computed tomography advances, and our patient was treated in the early 1990s when the information related to suture maturation was available only in 2-dimensional images and histologic findings. We respect their opinions about taking tomographic images in cases that require maxillary expansion, and a study by Angelieri et al supports this affirmation. However, that study presented a cross-sectional design, and the resulting classification of midpalatal suture rigidity (A-E) still must to be tested in a clinical study with maxillary expansion needs. This certainly will contribute to evidenced-based practice. The study limitation was also highlighted by Angelieri et al because of the absence of histologic parameters and a gold standard to certify the ossification percentage of the suture. Furthermore, we are convinced that a fused palatine bone in some young adults can be expanded without surgery. So, the treatment decision should be based not only in image parameters, but also in a careful clinical evaluation.
About the second comment related to the retention phase, we want to reinforce that the posterior intercuspation was finished in good relation and was preserved in the long term. The alignment and leveling of the teeth were aspects to be followed, once the constricted arches were expanded in this adult patient. This condition was defended as a responsible approach to instability. The patient had a limited arch constriction, and this reinforced the tendency of expansion instability superimposed on the natural constriction with aging. However, tooth alignment remained good, which can be explained by the retainer—one of which is still used today.