ORIGINAL ARTICLE
New Surgical Technique and Distraction Osteogenesis for Ankylosed Dental Movement Ivo Agabiti, MD, DDS,* Paolo Capparè, MD, OMS,† Enrico Felice Gherlone, MD, DDS,† Carmen Mortellaro, MD, DDS,‡ Giovanni B. Bruschi, MD, MS§ and Roberto Crespi, MD, MS† Abstract: Dental ankylosis often presents a significant vertical alveolar defect that is an esthetic problem for prosthetic rehabilitation. Moreover, surgical-orthodontic treatment by corticotomies and distraction devices provides special attention to avoid the loss of blood supply to the segment; furthermore, gingival recessions may appear because the gingival tissues cannot proliferate as fast as the immediate repositioning of the tooth. This case report presents a surgical technique for buccal, palatal, and vertical movements, and examines the effects of a tooth/ arch-borne tooth distractor appliance, for the alignment of ankylosed teeth. The slow movements of tooth and bone block and fine cut simplifies orthodontic treatment in patients and makes it possible to achieve complex movements in a relatively short period. The reported dislocation procedure allows a use of buccal-lingual vertical osteotomy with horizontal osteotomy to correct tooth positions via bony block movement maintaining gingival tissues in position. The used sonic saw have proven to be a valuable alternative to manual or rotating tools, oscillating saws, or piezoelectric units because it is faster and easier for surgical approach. Key Words: Dental ankylosis, distraction osteogenesis, vertical corticotomy, tooth-borne distractor, cementum, root fusion, sonic saw, distraction device (DD) (J Craniofac Surg 2014;25: 828–830)
A
nkylosis is the fusion of the cementum or dentin to the alveolar bone. It may be caused by genetic diseases or local conditions such as periapical infections, trauma, or previous surgical procedures.1–4 The diagnosis of ankylosis should be based on clinical and radiographic evidence. The clinical diagnosis of ankylosis can be made only when the affected tooth gives evidence of an inability to move with normal vertical dental alveolar growth, persisting shorter to the neighboring teeth. Radiologically, the lack of periodontal membrane supports the clinical diagnosis.5,6 From the *Pesaro, Italy (private practice); †Department of Dentistry, VitaSalute University and San Raffaele Hospital, Milan Italy; ‡Department of Health Sciences, A. Avogadro University of Eastern Piedmont, Alessandria, Italy; and §Private Practice, Rome, Italy. Received May 20, 2013. Accepted for publication January 7, 2014. Address correspondence and reprint requests to Roberto Crespi, MD, MS, Department of Dentistry, San Raffaele Scientific Institute, Via Olgettina 58, 20132 Milan, Italy; E-mail: [email protected] The authors report no conflicts of interest. Copyright © 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000737
828
The development of 3-dimensional imaging systems, such as computer-assisted tomography, offers an expectation of the ability to see small areas of cementum and root fusion.7 Because the diagnosis of ankylosis is made subsequent to the failure of vertical alveolar growth, a significant vertical alveolar defect was often present at the time of the clinical diagnosis. Such a vertical alveolar defect presents an esthetic problem for prosthetic rehabilitation. Distraction osteogenesis is a new modality to progressively stretch the bone and the soft-tissue envelope by means of distraction appliances anchored to the bone.8 Since 1996, when bone distraction was first used in vivo, many authors9–11 proposed the use of distraction osteogenesis devices in alignment of ankylosed teeth. At the same time, several reports12–16 have suggested the use of buccal-lingual vertical corticotomy with subapical horizontal osteotomy to correct tooth positions via bony block movement. Many researchers have moved an ankylosed tooth to its proper position right after the corticotomy of the alveolar bone of ankylosed teeth. The essential requirement in these osteotomies is to remove a small amount of bone so as not to further destroy the thin residual ridge. The recent introduction of the new sonic tools has further simplified this technique, allowing thin osteotomies in a faster way, with the best respect for soft tissues, having the same principle of piezoelectric devices. Furthermore, the small thickness of the blade surface reduces friction and minimizes bone overheating. However, such surgical procedure requires total repositioning of the separated bone, and it provides special attention to avoid the loss of blood supply to the segment; furthermore, gingival recessions may appear because the gingival tissues cannot proliferate as fast as the immediate repositioning of the tooth. To overcome these limitations, a surgical-orthodontic technique to maximize the rapidity of movement and prevent damage to the gingival tissues, maintaining 3 mm attached gingival band, was advisable. So, this case report presents a surgical technique for buccal, palatal, and vertical movements, and examines the effects of a tooth/arch-borne tooth distractor appliance, for the alignment of ankylosed teeth.
CLINICAL REPORT A 21-year-old male patient presented with a severely ankylosed left maxillary central incisor (tooth 21), displaced 5 mm apically relative to the adjacent central incisor. The clinical diagnosis of ankylosis was confirmed by the inability of the tooth to respond to orthodontic forces (Figs. 1A–D). The patient had a history of trauma to this tooth. At age 11, he had avulsed the tooth and his general dentist replanted it within 30 minutes of the accident. Cone-beam tomography revealed areas of cementum and root fusion and buccal position of the root (Figs. 1B, C). Bands with direct-bond brackets were applied to the malpositioned incisors to align the upper dental arch, excluding the ankylosed incisor, and to create sufficient interradicular distance in
The Journal of Craniofacial Surgery • Volume 25, Number 3, May 2014
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery • Volume 25, Number 3, May 2014
New Distraction Osteogenesis
The transporting nut and the guide tube were paralleled and aligned. Finally, the main threaded rod was inserted in the transporting nut passing through the crimpable guide tube. The pieces can also be attached extraorally and inserted as one piece. The DD was applied to the mobile tooth-bone segment using the archwire as the anchorage unit. The distraction procedure began after a 7-day latency period. It was activated 2 times a day for 0.5 mm distraction rate per day for a period of 12 days. When the infrapositioned tooth reached the level of its neighbor, distraction was stopped, the DD removed, and a bonded-type bracket positioned. For the healing of the bone segment, a passive archwire remained for 6 weeks. Bone formation after distraction was evaluated by cone-beam tomography after 6 months from intervention (Fig. 2).
DISCUSSION FIGURE 1. Preoperative intraoral view (A); preoperative CT-scan view (B, C); placement of brackets (D); incision (E); corticotomies are performed by a sonic saw (F, G, H, I); suture (L); immediate postoperative CT view (M, N, O); placement of distraction device (P).
the projected region of the osteotomy (Fig. 1D). After the alignment of the upper dentition, and before distraction, conventional osteotomy procedures were carried out. The surgeon administered local anesthesia by infiltration into the labial vestibule (articain 4% plus epinephrine 1/100,000; Ubistesin, 3M/ESPE, Seefeld, Austria). A partial-thickness horizontal incision was made in the keratinized gingiva from the right to the left maxillary canine maintaining 3 mm attached coronal gingival tissues (Fig. 1E). Vertical release incisions extending up into the unattached tissue were made at both ends. The partial-thickness flap was reflected to expose the anterior maxilla up to the piriform aperture.13 Starting at the vertical incisions, 2 separate subperiosteal tunnels were elevated inferiorly. One tunnel was to the mesial of tooth 21 and the other was to the distal. The tunnels were placed to expose the interdental bone on both sides of tooth 21 to the crest of the ridge. The mesial and distal cuts were made from the crest of the alveolar ridge, and a horizontal cut was made to connect the distal vertical cuts. These cuts were made as deeply into the bone as to cut from buccal to palatal cortical bone avoiding to damage palatal soft tissues. An angled shaft sonic saw (Sonosurgery; Komet-Brasseler GmbH, Germany) was used to perform the osteotomies, achieving a depth of 11 mm; in this way, the bone ridge was split and at the same time the impacted tooth was longitudinally halved (Figs. 1F, I). These tools exploit the orbital motion of the sonic air-scaler, with 5-times slower frequency vibrations than ultrasound devices (approximately 6 vs. 30 kHz); the 3 surgical tips with straight and angled shapes that move on 3 different space planes due to their exclusive orbital mechanism allow to approach any district of the mouth to perform thinner (0.25 mm) as well as deeper (10–11 mm) osteotomies, making them less traumatic and safer at the same time. Care was taken to ensure that the palatal and buccal attached gingival tissues were maintained because these tissues were critical to providing the blood supply to the segment in healing process. The alveolar segment was mobilized with the help of an osteotome. The partial-thickness flap was then closed and sutured without repositioning the mobilized segment.12,17,18,19 One day after surgical procedure, the distraction device (DD) was applied to the ankylosed tooth. The threaded transporting nut was inserted and ligated to the bracket of the ankylosed tooth. Then, the crimpable guide tube was crimped to the 0.017 0.025 inch stainless steel archwire.
In this case report, the slow movements of tooth and bone block and fine cut simplifies orthodontic treatment in patients and makes it possible to achieve complex movements in a relatively short period. The reported dislocation procedure allows a use of buccal-lingual vertical osteotomy with horizontal osteotomy to correct tooth positions via bony block movement maintaining gingival tissues in position. Although osteodistraction is a good treatment modality for the subjects with ankylosed teeth, existing appliances could be bulky and difficult to apply in dental regions. Indeed, Kinzinger et al20 used a bone-borne distractor, which was bulky and difficult to apply. This distractor is attached to the bone by miniscrews, and this may create some surgical complications such as the perforation of the roots of adjacent teeth. The necessity of a second operation for the removal of these distractors appears to be another disadvantage. On the other hand, the miniature tooth-borne distractor is not attached to the bone but to the tooth itself and the archwire, which makes it so easy to apply and remove. Alcan21 treated 2 cases with vertically malpositioned incisors, using the DD, and this device was evaluated and compared with the distraction appliances used before in the literature. In conclusion, it was found to be efficient with its small dimensions, ease of application and removal, and ease of activation, with patient tolerance. Isaacson et al22 moved an ankylosed central incisor using orthodontics, surgery, and distraction osteogenesis to bring both the incisal edge and the gingival margin of the clinical crown to the proper height in the arch relative to their antimeres. In another study done by Nocini et al,9 the authors proposed a customized distraction
FIGURE 2. Intraoral view at the end of distraction (A); CT views at the end of distraction (B, C, D); 6-month follow-up from the end of distraction, clinical view (E); 6-month follow-up at the end of distraction, CT views (F, G, H).
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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The Journal of Craniofacial Surgery • Volume 25, Number 3, May 2014
Agabiti et al
device for alveolar ridge augmentation and alignment of ankylosed teeth. Distraction was successfully performed in 3 clinical cases: 2 bone-implant segments and 1 bone-ankylosed tooth segment. All cases were clinically uneventful. According to these authors, the tooth distractor used in the present report is efficient, easy to use, and well tolerated by the patient. Because it uses both the tooth and the archwire as anchorage units, indications for the use of DD are restricted because a multibanded appliance where the DD can be fixed is mandatory. Moreover, in this report, a distraction protocol was followed where the rate was 0.5 mm per day and clinical observations of good gingival health and esthetics were recorded. Considering the contemporary distraction osteogenesis protocol,23 in which the distraction rhythm is twice a day and the distraction rate is 1 mm per day, this method seems to be slower, but the authors explain this by the need to maintain the vitality of the attached soft tissue. Although the vitality of the attached soft tissue is an important issue, the conventional distraction protocols still recommend a much faster rate. Moreover, the precision of the sonic saw allows a safe osteotomy around the root. The microinvasive osteotomy is fast, characterized by precision of cutting action and surgical control. Healing procedure following the use of the sonic saw is rapid, with minimal morbidity. Vercellotti et al24 reported monocortical tooth dislocation and ligament distraction technique combining 2 different dental movements that work separately but simultaneously on opposite root surfaces. On the root surface corresponding to the direction of movement, vertical and horizontal microsurgical corticotomies were performed around each tooth root with a piezosurgical microsaw to eliminate cortical bone resistance. During the osteogenic process that follows, application of normal orthodontic biomechanics achieves the final tooth movement. In previous studies, the osteotomies were usually performed by microoscillating saws20 for the vertical and horizontal cuts, and microsaws21 to have thinner cuts and to prevent bone loss. These microsaws allow the surgeon to produce interdental cuts even if the adjacent roots are very close. The adoption of piezoelectric tools has made the execution of osteotomies for the split-crest technique considerably safer and easier.24,25 Piezoelectric technology and relative ultrasonic tools for bone surgery that use modulated (pulsed) frequency have been developed and is actually widely used in surgical procedures for selective cutting of mineralized tissues for the assumption that soft-tissue structures such as nerves, blood vessels, and membranes are not damaged by a fortuitous contact with this vibrating tools; in fact, when soft tissues are detached from hard tissues, they do not oscillate at the same frequency of surgical tips and in this way they absorb rather than transmit vibrations, and therefore soft tissues cannot be damaged. In conclusion, orthodontic microsurgery is associated with minimal morbidity and offers a promising means of improving and simplifying orthodontic therapy in adult patients. In this case report, the new sonic saw has proven to be a valuable alternative to manual or rotating tools, oscillating saws, or piezoelectric units because it is faster and easier for surgical approach.
REFERENCES 1. Biederman W. The incidence and etiology of tooth ankylosis. Am J Orthod 1956;42:921–926 2. Biederman W. Etiology and treatment of tooth ankylosis. Am J Orthod 1962;49:670–684
830
3. Rubin PL, Weissman EJ, Bisk F. Experimental tooth ankylosis in the monkey. Angle Orthod 1984;54:67–72 4. Yilmaz RS, Darling A, Levers BG. Experimental tooth ankylosis and horizontal tooth movement in the pig. Arch Oral Biol 1981;26:41–47 5. Anderson L, Blomlof L, Lindskog S, et al. Tooth ankylosis. Clinical, radiographic and histological assessments. Int J Oral Surg 1984;13:423–431 6. Pilo R, Littner MM, Marshak B, et al. Case reports. Severe infraocclusion ankylosis, report of three cases. J Dent Child 1989;56:144–146 7. Elefteriadis JN, Athanasiou AE. Evaluation of impacted canines by means of computerized tomography. Int J Adult Orthod Orthognath Surg 1996;11:257–264 8. Guerrero CA, Bell WH, Contasti GI, et al. Intraoral mandibular distraction osteogenesis. Semin Orthod 1999;5:35–40 9. Nocini PF, Santis DD, Ferrari F, et al. A customized distraction device for alveolar ridge augmentation and alignment of ankylosed teeth. Int J Oral Maxillofac Implants 2004;19:133–144 10. Chang HY, Chang YL, Chen HL. Treatment of a severely ankylosed central incisor and a missing lateral incisor by distraction osteogenesis and orthodontic treatment. Am J Orthod Dentofacial Orthop 2010;138:829–838 11. Ohkubo K, Susami T, Mori Y, et al. Treatment of ankylosed maxillary central incisors by single-tooth dento-osseous osteotomy and alveolar bone distraction. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;111:561–567 12. Medeiros PJ, Bezera AR. Treatment of an ankylosed central incisor by single-tooth dento-osseous osteotomy. Am J Orthod Dentofacial Orthop 1997;112:496–501 13. Patrıkıou A, Katsavrias EG. Repositioning ankylosed maxillary canines by segmental osteotomy. J Clin Orthod 1995;29:625–628 14. Kole H. Surgical operations on the alveolar ridge to correct occlusal abnormalities. Oral Surg Oral Med Oral Pathol 1959;12:515–529 15. Anholm JM, Crites DA, Hoff R, et al. Corticotomy-facilitated orthodontics. Calif Dent Assoc J 1986;14:7–11 16. Gantes B, Rathbun E, Anholm M. Effects on the periodontium following corticotomy-facilitated orthodontics. Case reports. J Periodontol 1990;61:234–238 17. Langer B, Langer L. The superimposed flap: modification of the surgical technique for implant insertion. Int J Periodont Rest Dent 1990;10:208–215 18. Burk JL, Provencher RF, McKean TW. Small segment and one tooth osteotomies to correct dentoalveolar deformities. J Oral Surg 1977;35:452–460 19. Martin RJ, Goupil MT, Goldschmidt M. Single implant segmental osteotomy: case report. Int J Maxillofac Implants 1998;13:710–712 20. Kinzinger GS, Janicke S, Riediger D, et al. Orthodontic fine adjustment after vertical callus distraction of an ankylosed incisor using the floating bone concept. Am J Orthod Dentofacial Orthop 2003;124:582–590 21. Alcan T. A miniature tooth-borne distractor for the alignment of ankylosed teeth. Angle Orthod 2006;76:77–83 22. Isaacson RJ, Strauss RA, Bridges-Poquis A, et al. Moving an ankylosed central incisor using orthodontics, surgery and distraction osteogenesis: case report. Angle Orthod 2001;71:411–418 23. Kuriakose MA, Shnayder Y, DeLacure MD. Reconstruction of segmental mandibular defects by distraction osteogenesis for mandibular reconstruction. Head Neck 2003;25:816–824 24. Vercellotti T, Podesta’ A. Orthodontic microsurgery: a new surgically guided technique for dental movement. Int J Periodontics Restorative Dent 2007;27:325–331 25. Harder S, Wolfart S, Mehl C, et al. Performance of ultrasonic devices for bone surgery and associated intraosseous temperature development. Int J Oral Maxillofac Implants 2009;24:484–490
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
New Surgical Technique and Distraction Osteogenesis for Ankylosed Dental Movement Ivo Agabiti, MD, DDS,* Paolo Capparè, MD, OMS,† Enrico Felice Gherlone, MD, DDS,† Carmen Mortellaro, MD, DDS,‡ Giovanni B. Bruschi, MD, MS§ and Roberto Crespi, MD, MS† Abstract: Dental ankylosis often presents a significant vertical alveolar defect that is an esthetic problem for prosthetic rehabilitation. Moreover, surgical-orthodontic treatment by corticotomies and distraction devices provides special attention to avoid the loss of blood supply to the segment; furthermore, gingival recessions may appear because the gingival tissues cannot proliferate as fast as the immediate repositioning of the tooth. This case report presents a surgical technique for buccal, palatal, and vertical movements, and examines the effects of a tooth/ arch-borne tooth distractor appliance, for the alignment of ankylosed teeth. The slow movements of tooth and bone block and fine cut simplifies orthodontic treatment in patients and makes it possible to achieve complex movements in a relatively short period. The reported dislocation procedure allows a use of buccal-lingual vertical osteotomy with horizontal osteotomy to correct tooth positions via bony block movement maintaining gingival tissues in position. The used sonic saw have proven to be a valuable alternative to manual or rotating tools, oscillating saws, or piezoelectric units because it is faster and easier for surgical approach. Key Words: Dental ankylosis, distraction osteogenesis, vertical corticotomy, tooth-borne distractor, cementum, root fusion, sonic saw, distraction device (DD) (J Craniofac Surg 2014;25: 828–830)
A
nkylosis is the fusion of the cementum or dentin to the alveolar bone. It may be caused by genetic diseases or local conditions such as periapical infections, trauma, or previous surgical procedures.1–4 The diagnosis of ankylosis should be based on clinical and radiographic evidence. The clinical diagnosis of ankylosis can be made only when the affected tooth gives evidence of an inability to move with normal vertical dental alveolar growth, persisting shorter to the neighboring teeth. Radiologically, the lack of periodontal membrane supports the clinical diagnosis.5,6 From the *Pesaro, Italy (private practice); †Department of Dentistry, VitaSalute University and San Raffaele Hospital, Milan Italy; ‡Department of Health Sciences, A. Avogadro University of Eastern Piedmont, Alessandria, Italy; and §Private Practice, Rome, Italy. Received May 20, 2013. Accepted for publication January 7, 2014. Address correspondence and reprint requests to Roberto Crespi, MD, MS, Department of Dentistry, San Raffaele Scientific Institute, Via Olgettina 58, 20132 Milan, Italy; E-mail: [email protected] The authors report no conflicts of interest. Copyright © 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000737
828
The development of 3-dimensional imaging systems, such as computer-assisted tomography, offers an expectation of the ability to see small areas of cementum and root fusion.7 Because the diagnosis of ankylosis is made subsequent to the failure of vertical alveolar growth, a significant vertical alveolar defect was often present at the time of the clinical diagnosis. Such a vertical alveolar defect presents an esthetic problem for prosthetic rehabilitation. Distraction osteogenesis is a new modality to progressively stretch the bone and the soft-tissue envelope by means of distraction appliances anchored to the bone.8 Since 1996, when bone distraction was first used in vivo, many authors9–11 proposed the use of distraction osteogenesis devices in alignment of ankylosed teeth. At the same time, several reports12–16 have suggested the use of buccal-lingual vertical corticotomy with subapical horizontal osteotomy to correct tooth positions via bony block movement. Many researchers have moved an ankylosed tooth to its proper position right after the corticotomy of the alveolar bone of ankylosed teeth. The essential requirement in these osteotomies is to remove a small amount of bone so as not to further destroy the thin residual ridge. The recent introduction of the new sonic tools has further simplified this technique, allowing thin osteotomies in a faster way, with the best respect for soft tissues, having the same principle of piezoelectric devices. Furthermore, the small thickness of the blade surface reduces friction and minimizes bone overheating. However, such surgical procedure requires total repositioning of the separated bone, and it provides special attention to avoid the loss of blood supply to the segment; furthermore, gingival recessions may appear because the gingival tissues cannot proliferate as fast as the immediate repositioning of the tooth. To overcome these limitations, a surgical-orthodontic technique to maximize the rapidity of movement and prevent damage to the gingival tissues, maintaining 3 mm attached gingival band, was advisable. So, this case report presents a surgical technique for buccal, palatal, and vertical movements, and examines the effects of a tooth/arch-borne tooth distractor appliance, for the alignment of ankylosed teeth.
CLINICAL REPORT A 21-year-old male patient presented with a severely ankylosed left maxillary central incisor (tooth 21), displaced 5 mm apically relative to the adjacent central incisor. The clinical diagnosis of ankylosis was confirmed by the inability of the tooth to respond to orthodontic forces (Figs. 1A–D). The patient had a history of trauma to this tooth. At age 11, he had avulsed the tooth and his general dentist replanted it within 30 minutes of the accident. Cone-beam tomography revealed areas of cementum and root fusion and buccal position of the root (Figs. 1B, C). Bands with direct-bond brackets were applied to the malpositioned incisors to align the upper dental arch, excluding the ankylosed incisor, and to create sufficient interradicular distance in
The Journal of Craniofacial Surgery • Volume 25, Number 3, May 2014
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery • Volume 25, Number 3, May 2014
New Distraction Osteogenesis
The transporting nut and the guide tube were paralleled and aligned. Finally, the main threaded rod was inserted in the transporting nut passing through the crimpable guide tube. The pieces can also be attached extraorally and inserted as one piece. The DD was applied to the mobile tooth-bone segment using the archwire as the anchorage unit. The distraction procedure began after a 7-day latency period. It was activated 2 times a day for 0.5 mm distraction rate per day for a period of 12 days. When the infrapositioned tooth reached the level of its neighbor, distraction was stopped, the DD removed, and a bonded-type bracket positioned. For the healing of the bone segment, a passive archwire remained for 6 weeks. Bone formation after distraction was evaluated by cone-beam tomography after 6 months from intervention (Fig. 2).
DISCUSSION FIGURE 1. Preoperative intraoral view (A); preoperative CT-scan view (B, C); placement of brackets (D); incision (E); corticotomies are performed by a sonic saw (F, G, H, I); suture (L); immediate postoperative CT view (M, N, O); placement of distraction device (P).
the projected region of the osteotomy (Fig. 1D). After the alignment of the upper dentition, and before distraction, conventional osteotomy procedures were carried out. The surgeon administered local anesthesia by infiltration into the labial vestibule (articain 4% plus epinephrine 1/100,000; Ubistesin, 3M/ESPE, Seefeld, Austria). A partial-thickness horizontal incision was made in the keratinized gingiva from the right to the left maxillary canine maintaining 3 mm attached coronal gingival tissues (Fig. 1E). Vertical release incisions extending up into the unattached tissue were made at both ends. The partial-thickness flap was reflected to expose the anterior maxilla up to the piriform aperture.13 Starting at the vertical incisions, 2 separate subperiosteal tunnels were elevated inferiorly. One tunnel was to the mesial of tooth 21 and the other was to the distal. The tunnels were placed to expose the interdental bone on both sides of tooth 21 to the crest of the ridge. The mesial and distal cuts were made from the crest of the alveolar ridge, and a horizontal cut was made to connect the distal vertical cuts. These cuts were made as deeply into the bone as to cut from buccal to palatal cortical bone avoiding to damage palatal soft tissues. An angled shaft sonic saw (Sonosurgery; Komet-Brasseler GmbH, Germany) was used to perform the osteotomies, achieving a depth of 11 mm; in this way, the bone ridge was split and at the same time the impacted tooth was longitudinally halved (Figs. 1F, I). These tools exploit the orbital motion of the sonic air-scaler, with 5-times slower frequency vibrations than ultrasound devices (approximately 6 vs. 30 kHz); the 3 surgical tips with straight and angled shapes that move on 3 different space planes due to their exclusive orbital mechanism allow to approach any district of the mouth to perform thinner (0.25 mm) as well as deeper (10–11 mm) osteotomies, making them less traumatic and safer at the same time. Care was taken to ensure that the palatal and buccal attached gingival tissues were maintained because these tissues were critical to providing the blood supply to the segment in healing process. The alveolar segment was mobilized with the help of an osteotome. The partial-thickness flap was then closed and sutured without repositioning the mobilized segment.12,17,18,19 One day after surgical procedure, the distraction device (DD) was applied to the ankylosed tooth. The threaded transporting nut was inserted and ligated to the bracket of the ankylosed tooth. Then, the crimpable guide tube was crimped to the 0.017 0.025 inch stainless steel archwire.
In this case report, the slow movements of tooth and bone block and fine cut simplifies orthodontic treatment in patients and makes it possible to achieve complex movements in a relatively short period. The reported dislocation procedure allows a use of buccal-lingual vertical osteotomy with horizontal osteotomy to correct tooth positions via bony block movement maintaining gingival tissues in position. Although osteodistraction is a good treatment modality for the subjects with ankylosed teeth, existing appliances could be bulky and difficult to apply in dental regions. Indeed, Kinzinger et al20 used a bone-borne distractor, which was bulky and difficult to apply. This distractor is attached to the bone by miniscrews, and this may create some surgical complications such as the perforation of the roots of adjacent teeth. The necessity of a second operation for the removal of these distractors appears to be another disadvantage. On the other hand, the miniature tooth-borne distractor is not attached to the bone but to the tooth itself and the archwire, which makes it so easy to apply and remove. Alcan21 treated 2 cases with vertically malpositioned incisors, using the DD, and this device was evaluated and compared with the distraction appliances used before in the literature. In conclusion, it was found to be efficient with its small dimensions, ease of application and removal, and ease of activation, with patient tolerance. Isaacson et al22 moved an ankylosed central incisor using orthodontics, surgery, and distraction osteogenesis to bring both the incisal edge and the gingival margin of the clinical crown to the proper height in the arch relative to their antimeres. In another study done by Nocini et al,9 the authors proposed a customized distraction
FIGURE 2. Intraoral view at the end of distraction (A); CT views at the end of distraction (B, C, D); 6-month follow-up from the end of distraction, clinical view (E); 6-month follow-up at the end of distraction, CT views (F, G, H).
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
829
The Journal of Craniofacial Surgery • Volume 25, Number 3, May 2014
Agabiti et al
device for alveolar ridge augmentation and alignment of ankylosed teeth. Distraction was successfully performed in 3 clinical cases: 2 bone-implant segments and 1 bone-ankylosed tooth segment. All cases were clinically uneventful. According to these authors, the tooth distractor used in the present report is efficient, easy to use, and well tolerated by the patient. Because it uses both the tooth and the archwire as anchorage units, indications for the use of DD are restricted because a multibanded appliance where the DD can be fixed is mandatory. Moreover, in this report, a distraction protocol was followed where the rate was 0.5 mm per day and clinical observations of good gingival health and esthetics were recorded. Considering the contemporary distraction osteogenesis protocol,23 in which the distraction rhythm is twice a day and the distraction rate is 1 mm per day, this method seems to be slower, but the authors explain this by the need to maintain the vitality of the attached soft tissue. Although the vitality of the attached soft tissue is an important issue, the conventional distraction protocols still recommend a much faster rate. Moreover, the precision of the sonic saw allows a safe osteotomy around the root. The microinvasive osteotomy is fast, characterized by precision of cutting action and surgical control. Healing procedure following the use of the sonic saw is rapid, with minimal morbidity. Vercellotti et al24 reported monocortical tooth dislocation and ligament distraction technique combining 2 different dental movements that work separately but simultaneously on opposite root surfaces. On the root surface corresponding to the direction of movement, vertical and horizontal microsurgical corticotomies were performed around each tooth root with a piezosurgical microsaw to eliminate cortical bone resistance. During the osteogenic process that follows, application of normal orthodontic biomechanics achieves the final tooth movement. In previous studies, the osteotomies were usually performed by microoscillating saws20 for the vertical and horizontal cuts, and microsaws21 to have thinner cuts and to prevent bone loss. These microsaws allow the surgeon to produce interdental cuts even if the adjacent roots are very close. The adoption of piezoelectric tools has made the execution of osteotomies for the split-crest technique considerably safer and easier.24,25 Piezoelectric technology and relative ultrasonic tools for bone surgery that use modulated (pulsed) frequency have been developed and is actually widely used in surgical procedures for selective cutting of mineralized tissues for the assumption that soft-tissue structures such as nerves, blood vessels, and membranes are not damaged by a fortuitous contact with this vibrating tools; in fact, when soft tissues are detached from hard tissues, they do not oscillate at the same frequency of surgical tips and in this way they absorb rather than transmit vibrations, and therefore soft tissues cannot be damaged. In conclusion, orthodontic microsurgery is associated with minimal morbidity and offers a promising means of improving and simplifying orthodontic therapy in adult patients. In this case report, the new sonic saw has proven to be a valuable alternative to manual or rotating tools, oscillating saws, or piezoelectric units because it is faster and easier for surgical approach.
REFERENCES 1. Biederman W. The incidence and etiology of tooth ankylosis. Am J Orthod 1956;42:921–926 2. Biederman W. Etiology and treatment of tooth ankylosis. Am J Orthod 1962;49:670–684
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3. Rubin PL, Weissman EJ, Bisk F. Experimental tooth ankylosis in the monkey. Angle Orthod 1984;54:67–72 4. Yilmaz RS, Darling A, Levers BG. Experimental tooth ankylosis and horizontal tooth movement in the pig. Arch Oral Biol 1981;26:41–47 5. Anderson L, Blomlof L, Lindskog S, et al. Tooth ankylosis. Clinical, radiographic and histological assessments. Int J Oral Surg 1984;13:423–431 6. Pilo R, Littner MM, Marshak B, et al. Case reports. Severe infraocclusion ankylosis, report of three cases. J Dent Child 1989;56:144–146 7. Elefteriadis JN, Athanasiou AE. Evaluation of impacted canines by means of computerized tomography. Int J Adult Orthod Orthognath Surg 1996;11:257–264 8. Guerrero CA, Bell WH, Contasti GI, et al. Intraoral mandibular distraction osteogenesis. Semin Orthod 1999;5:35–40 9. Nocini PF, Santis DD, Ferrari F, et al. A customized distraction device for alveolar ridge augmentation and alignment of ankylosed teeth. Int J Oral Maxillofac Implants 2004;19:133–144 10. Chang HY, Chang YL, Chen HL. Treatment of a severely ankylosed central incisor and a missing lateral incisor by distraction osteogenesis and orthodontic treatment. Am J Orthod Dentofacial Orthop 2010;138:829–838 11. Ohkubo K, Susami T, Mori Y, et al. Treatment of ankylosed maxillary central incisors by single-tooth dento-osseous osteotomy and alveolar bone distraction. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;111:561–567 12. Medeiros PJ, Bezera AR. Treatment of an ankylosed central incisor by single-tooth dento-osseous osteotomy. Am J Orthod Dentofacial Orthop 1997;112:496–501 13. Patrıkıou A, Katsavrias EG. Repositioning ankylosed maxillary canines by segmental osteotomy. J Clin Orthod 1995;29:625–628 14. Kole H. Surgical operations on the alveolar ridge to correct occlusal abnormalities. Oral Surg Oral Med Oral Pathol 1959;12:515–529 15. Anholm JM, Crites DA, Hoff R, et al. Corticotomy-facilitated orthodontics. Calif Dent Assoc J 1986;14:7–11 16. Gantes B, Rathbun E, Anholm M. Effects on the periodontium following corticotomy-facilitated orthodontics. Case reports. J Periodontol 1990;61:234–238 17. Langer B, Langer L. The superimposed flap: modification of the surgical technique for implant insertion. Int J Periodont Rest Dent 1990;10:208–215 18. Burk JL, Provencher RF, McKean TW. Small segment and one tooth osteotomies to correct dentoalveolar deformities. J Oral Surg 1977;35:452–460 19. Martin RJ, Goupil MT, Goldschmidt M. Single implant segmental osteotomy: case report. Int J Maxillofac Implants 1998;13:710–712 20. Kinzinger GS, Janicke S, Riediger D, et al. Orthodontic fine adjustment after vertical callus distraction of an ankylosed incisor using the floating bone concept. Am J Orthod Dentofacial Orthop 2003;124:582–590 21. Alcan T. A miniature tooth-borne distractor for the alignment of ankylosed teeth. Angle Orthod 2006;76:77–83 22. Isaacson RJ, Strauss RA, Bridges-Poquis A, et al. Moving an ankylosed central incisor using orthodontics, surgery and distraction osteogenesis: case report. Angle Orthod 2001;71:411–418 23. Kuriakose MA, Shnayder Y, DeLacure MD. Reconstruction of segmental mandibular defects by distraction osteogenesis for mandibular reconstruction. Head Neck 2003;25:816–824 24. Vercellotti T, Podesta’ A. Orthodontic microsurgery: a new surgically guided technique for dental movement. Int J Periodontics Restorative Dent 2007;27:325–331 25. Harder S, Wolfart S, Mehl C, et al. Performance of ultrasonic devices for bone surgery and associated intraosseous temperature development. Int J Oral Maxillofac Implants 2009;24:484–490
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
