The Saudi Dental Journal (2011) 23, 99–106
King Saud University
The Saudi Dental Journal www.ksu.edu.sa www.sciencedirect.com
CASE REPORT
Orthodontic treatment of an anterior openbite with the aid of corticotomy procedure: Case report Ali S. Aljhani a, Abdullah M. Aldrees
b,*
a
King Abdullah International Medical Research Centre, King Saud University for Health Sciences, Riyadh, Saudi Arabia b Department of Pediatric Dentistry and Orthodontics, College of Dentistry, King Saud University, P.O. Box 60169, Riyadh 11545, Saudi Arabia Received 11 October 2009; revised 16 January 2010; accepted 7 June 2010 Available online 26 October 2010
KEYWORDS Openbite treatment; Corticotomy
Abstract This case report illustrates the orthodontic treatment combined with the corticotomy technique in an adult patient to accelerate tooth movement and shorten the treatment time. The patient was a 22-year-old woman with an anterior open bite and flared and spaced upper and lower incisors. First, fixed orthodontic appliances (bidimensional edgewise brackets) were bonded, and a week later buccal and lingual corticotomy with alveolar augmentation procedure in the maxillary arch from the first molar to the contralateral first molar, and from canine to canine in the mandibular arch was performed. Orthodontic therapy proceeded with frequent activation of the appliances to retract the incisors every 2 weeks. The total treatment time was 5 months and no adverse effects were observed at the end of active treatment. The addition of the decortication procedure to the conventional orthodontic therapy decreased the duration of treatment significantly. Successful closure of the anterior open bite with adequate overbite and interdigitation of the teeth were achieved. ª 2010 King Saud University. Production and hosting by Elsevier B.V. All rights reserved.
1. Introduction * Corresponding author. Tel.: +966 1 4676057; fax: +966 1 4679017. E-mail address: [email protected] (A.M. Aldrees). 1013-9052 ª 2010 King Saud University. Production and hosting by Elsevier B.V. All rights reserved. Peer review under responsibility of King Saud University. doi:10.1016/j.sdentj.2010.10.005
Production and hosting by Elsevier
Orthodontic treatment has the ability to modify the dentofacial skeleton and affect facial esthetics. Currently many adult patients seek orthodontic treatment for their malocclusions. In a recent Medical Expenditure Panel Survey (MEPS), adults accounted for 23.1% of all orthodontic visits in 2004 (Guay et al., 2008). The percentage of adult active patients was reported to be around 20% of the total patients being treated in the orthodontic offices in the United States (Keim et al., 2008). Comprehensive orthodontic treatment for adults is considerably longer than for adolescent patients (Vig et al., 1990; Kocadereli, 2002), and treatment modifications have been suggested to reduce the treatment time. Ko¨le (1959) was the first to describe a technique
100 that involved a radicular corticotomy and supra-apical osteotomy to expedite tooth movement. He believed that by creating blocks of bone with vertical buccal and lingual corticotomy cuts and supra-apical horizontal osteotomy connecting cuts, segments of bone with the embedded teeth can be moved rapidly (Ko¨le, 1959). Anholm et al. (1986) reported the treatment of a non-extraction case with severe malocclusion in 11 months using corticotomy. Later, Suya (1991) suggested replacing the osteotomy cuts with horizontal corticotomy in a report of 395 adult Japanese patients treated with this modified procedure. In 1990, Gantes et al. (1990) have reported five orthodontic cases treated with corticotomy in which circumscribing corticotomy cuts both facially and lingually around the six upper anterior teeth were made. The upper first bicuspids were removed and the bone over the extraction sockets was removed both buccally and lingually (Gantes et al., 1990). Chung et al. (2001) also reported two cases in which blocks of medullary bone are moved block by block with orthopedic forces. Similarly, Hwang and Lee (2001) have performed the intrusion of unopposed molars by performing a corticotomy procedure and using magnets on two adult patients. Wilcko et al. (2001) modified the technique with the addition of alveolar augmentation with resorbable, alloplastic freezedried bone to increase the volume of alveolar bone, regenerate bone affected by dehiscence and fenestration, and avoid gingival recession. They explained that the movement does not result from repositioning of tooth-bone blocks, but rather from a cascade of transient localized reactions in the bony alveolar housing leading to bone healing (Wilcko et al., 2001). Since 2001, few cases treated with corticotomy were reported in the literature. Germec et al. (2006) reported the treatment of an adult patient with a modified corticotomy technique, in which the lingual vertical and subapical horizontal cuts were eliminated; was combined with orthodontic therapy for the retraction of the lower anterior teeth after the extraction of four premolars. The use of the corticotomy technique with skeletal anchorage devices in the treatment of adults was reported by Iino et al. (2006), Moon et al. (2007), and Chung et al. (2009). For the intrusion of overerupted molars in adults, selective alveolar corticotomy with a modified full-coverage maxillary splint treatment was used by Oliveira et al. (2008). In a preliminary study, Fischer has compared the movement of impacted canines after surgical exposure using conventional surgical technique with their contralateral canines exposed using a corticotomy-assisted technique, and he concluded that corticotomy-assisted surgical technique reduced the orthodontic treatment time by 28–33% (Fischer, 2007). The aim of this report is to present in detail the efficient and rapid orthodontic treatment of anterior open bite malocclusion with the use of the decortication technique and to discuss the surgical and the orthodontic steps involved.
2. Case report A 22-year-old African woman presented with a chief complaint of: ‘‘I hate my open bite’’. She had no relevant medical history and she presented with several restorations, extractions of third molars, and excellent oral hygiene. Pre-treatment facial photographs showed a straight profile with protrusive and competent lips and acute nasolabial angle. The patient had an Angle Class I malocclusion on a mild skel-
A.S. Aljhani, A.M. Aldrees etal Class III relationship with a 0 mm overjet and 6 mm open bite extending from the right second premolar to the left second premolar. The upper and lower arches were malaligned with moderate spacing, and an evident tongue thrust habit accentuating the bimaxillary flaring and protrusion of the incisors (Figs. 1–9). The patient showed a genuine interest to have the orthodontic treatment completed as soon as possible. 2.1. Treatment plan The suggested treatment plan involved comprehensive orthodontic treatment with fixed appliances to align the upper and lower teeth, close the anterior spaces, retract the proclined incisors, and close the anterior open bite. Corticotomy procedure was planned to expedite the tooth movement. One week before the surgery, preadjusted edgewise orthodontic fixed appliances were placed (bidimensional appliances: 0.018 · 0.025-in. slot brackets for the incisors, 0.022 · 0.028-in. for the canines and the posterior teeth), and 0.016-in. NiTi archwires were inserted for leveling and alignment. 2.2. Surgical procedure Following the technique described by Wilcko et al. (2001), full thickness flap was reflected sharply both facially and lingually around all erupted teeth from first molar to first molar in the maxillary arch, and between the canines in the mandibular arch under local anesthesia (Fig. 10). Each flap was released with a sulcular incision and with papillary preservation technique when possible. The lingual interdental papilla between the maxillary central incisors was not reflected, and no vertical releasing incisions were used. Cuts in the alveolus that penetrate the entire thickness of the cortical plate and penetrate just barely into the medullary bone were performed both buccally and lingually around all the teeth in both arches. Vertical decortication cuts were made between the roots of the teeth and they were stopped 2–3 mm shy of the alveolar crest. Horizontal scalloped corticotomy cuts were used to connect the vertical cuts along with perforations in the cortical plate. Bone grafting mixture OraGraft demineralized cortical particulate (LifeNet Health Inc., Virginia Beach, VA, USA) was then applied to the activated cortical plates. Flaps were returned to their pre-surgical positions and sutured with interrupted loop sutures. Non-resorbable sutures (Gore-tex, CV-5, RT-16, from W.L. Gore & Associates Inc., Medical Products Division, Flagstaff, AZ, USA) were used and the sutures were left for 14 days before they were removed. Patient was kept under antibiotic for 10 days following the surgery. 2.3. Treatment progress At the suture removal appointment, 0.016 · 0.022-in. NiTi archwire was inserted in the upper arch and 0.016-in. stainless steel was inserted in the lower arch with 150 g NiTi coil springs attached from the mandibular first molars to the canines for retraction and powerchain to derotate the lower first premolars (Fig. 11A–C). Four weeks later, continuous powerchian was inserted in the upper arch and a 0.016 · 0.016-in. stainless steel archwire with closing loops was inserted in the lower arch for incisors retraction (Fig. 11D–F). Class III box elastics (3/16 in., 4 oz) were prescribed to be worn full-time. Archwires were activated
Orthodontic treatment of an anterior openbitewith the aid of corticotomy procedure: Case report
Figures 1–9
101
Pre-treatment extraoral, intraoral photographs and panoramic radiograph.
every 2 weeks, and 4 weeks later 0.016 · 0.022-in. stainless steel archwire was inserted in the upper arch, and in the lower 0.016-in. stainless steel with helices was inserted (Fig. 11G– I). Powerchains were replaced every 2 weeks, and then finishing upper and lower 0.016 · 0.022-in. stainless steel archwires
were inserted and vertical anterior and posterior elastics were used (Fig. 11J–L). The total active treatment period was only 5 months. Then, preadjusted edgewise appliance were removed, upper and lower lingual retainers were bonded and removable upper circum-
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A.S. Aljhani, A.M. Aldrees
Figure 10 (A, C) Maxillary corticotomy of the buccal and palatal sides of alveolar bone with the grafting mixture covering the decorticated bone. (B, D) Flaps returned to their pre-surgical positions and sutured with interrupted loop sutures.
Figure 11
Intraoral photographs at 2 weeks (A–C), 6 weeks (D–F), 10 weeks (G–I), and 4 months (J–L) after the corticotomy procedure.
ferential and lower Hawley retainers were inserted to be worn full time. Post-treatment evaluation of the patient revealed good preservation of the interdental papillae with no gingival recession. Post-treatment OPG shows good parallelism of the roots, no significant reduction in the radiographic height of the cres-
tal bone and nor radiographic evidence of any significant apical root resorption. Treatment objectives were achieved and the teeth are in good interdigitation with adequate overbite (Figs. 12–20). Final lateral cephalometric radiograph’s analysis show an acceptable dental compensation achieved for the underlying skeletal Class III discrepancy (Fig. 21).
Orthodontic treatment of an anterior openbitewith the aid of corticotomy procedure: Case report
Figures 12–20
103
Post-treatment extraoral, intraoral photographs and panoramic radiograph.
3. Discussion The comprehensive orthodontic treatment of this adult patient who presented with an anterior open bite was completed in 5 months which is significantly less than the routine duration that conventional orthodontic treatment of similar cases re-
quires. The addition of the corticotomy procedure has been reported to shorten the conventional orthodontic treatment time (Ko¨le, 1959; Anholm et al., 1986; Gantes et al., 1990; Suya, 1991; Chung et al., 2001; Hwang and Lee, 2001; Wilcko et al., 2001), and it was claimed that teeth can be moved 2–3 times further in 1/3 to 1/4 the time required for traditional
104
A.S. Aljhani, A.M. Aldrees
Figure 21 Final lateral cephalometric radiograph with a table illustrating analysis results. *Connor and Moshiri (1985). **Anderson et al. (2000).
orthodontic therapy (Wilcko et al., 2001, 2003, 2008). The current report confirms previously published findings and supports this treatment option for an overall shorter treatment times. The concept of corticotomy as introduced by Ko¨le (1959) relied on creating blocks of bone with the embedded teeth that can be moved rapidly with heavy forces. The same concept was followed by the others who reported corticotomy-facilitated orthodontic treatment of several cases (Anholm et al., 1986; Gantes et al., 1990; Suya, 1991; Chung et al., 2001). On the other hand, conventional orthodontic forces were advocated by Wilcko et al. (2001, 2003, 2008), who explained the rapid tooth movement as an illustration of regional acceleratory phenomenon (RAP). This process was first described by Frost (1983), who found that the surgical wounding of osseous tissues results in accelerated regional healing process (Frost, 1983, 1989a,b). It can expedite hard- and soft-tissue healing two- to ten-fold, and it leads to decreased regional bone density and accelerated bone turnover (Frost, 1983). This was reported to occur in intraoral cortical bone by others too (Goldie and King, 1984; Shih and Norrdin, 1985; Yaffe et al., 1994). Wilcko et al. (2008) showed that transient localized demineralization–remineralization in the bony alveolar housing occurs, and the demineralization of the alveolar bone over the root surfaces leaves the collagenous soft tissue matrix of the bone, which can be carried with the root surface and then remineralizes following the completion of the orthodontic treatment. Initially, the term ‘‘Accelerated Osteogenic Orthodontics’’ was used to describe the combined corticotomy-facilitated orthodontics and periodontal alveolar augmentation (Wilcko et al., 2001). Later, Wilcko et al. (2008) have modified it to be ‘‘Periodontally Accelerated Osteogenic Orthodontics’’ (PAOO) technique. In their case reports, Wilcko et al. (2008) have emphasized that after a 2-week post-operative waiting
period to permit demineralization, extraction spaces can be closed in 6–8 weeks with efficient orthodontic forces. That coincided with the technique employed in the treatment of the current case, in which major tooth movement occurred in the first 4 months with conventional forces. In a recent report comparing the alveolar bone reactions to osteotomy-assisted and corticotomy-assisted tooth movement, Lee et al. (2008) found evidence of regional accelerated phenomenon in the alveolar bone of the corticotomy-treated animals and distraction osteogenesis in the osteotomy-assisted tooth movement animals by microCT. This confirms by microimaging techniques the hypothesis of the difference in the healing processes involved in both procedures. Original corticotomy-facilitated orthodontic treatment involved buccal and lingual osteotomy cuts with orthopedic forces, and the use of alveolar augmentation with demineralized bone graft was advocated by Wilcko et al. (2001, 2003) to cover any fenestrations and dehiscences and to increase in the bony support for both the teeth and the overlying and soft tissues. Surface computed tomographic scans taken before and after the treatment showed a return of the layer of mineralized bone over the roots of the teeth and a general increase of the bone volume in the cases presented by Wilcko et al. (2001, 2003). The use of particulate autogenous bone graft harvested from the rami and exostosis of a case was reported by Nowzari et al. (2008), and no changes in the bone configuration were observed a year after the completion of treatment. More controlled studies are still required to investigate the value of the alveolar augmentation as a routine step in the decortication technique, and the effects of different grafting materials on the alveolar bone. While osteotomy cuts were recommended on both alveolar surfaces (buccal and lingual) (Ko¨le, 1959; Wilcko et al., 2001, 2003), two recently published case reports showed the results of selective corticotomy limited to the buc-
Orthodontic treatment of an anterior openbitewith the aid of corticotomy procedure: Case report cal and labial surfaces to reduce the operation time and post-operative patient discomfort, and avoid the risk of violating vital lingual anatomy (Germec et al., 2006; Nowzari et al., 2008). The current case was managed with both buccal and lingual cuts and efficient tooth movement was observed, however, elimination of the lingual cuts should be studied in future trials. Most of the recently published literature showed no adverse effects of the corticotomy on the periodontium (Germec et al., 2006; Iino et al., 2006; Nowzari et al., 2008; Oliveira et al., 2008; Wilcko et al., 2008). In this case, no reduction in the crest bone height, gingival recession, and apical root resorption were seen after the orthodontic treatment. The need for more frequent activation compared to conventional orthodontic treatment, the extra expenses for the periodontal surgery, and the post-operative discomfort were the disadvantages of this technique that the patient need to tolerate for a faster course of treatment. Anterior open bite is often accompanied with anterior tongue placement between the separated anterior teeth as a maneuver to close off the front of the mouth and form an anterior seal. However, forward resting posture of the tongue, due to the prolonged duration of this pressure, could affect tooth position and cause anterior open bite (Proffit et al., 2006). The exact etiological factors for the anterior open bite in the current case could not be determined, but successful closure of the open bite was achieved within a short period of time in spite of the accompanied tongue thrust. This indicates that the accelerated tooth movement brought by the corticotomy can overcome the lingual resistance to teeth retraction by the tongue. Increased stability provided by PAOO has been reported by Wilcko et al. (2008) and that was explained by the loss of tissue memory from high tissue turnover of the periodontium, and the increased thickness of the alveolar cortices from the augmentation grafting. It is possible that more stability of the correction achieved in this case is expected due to the reasons illustrated previously. Since most of what we know about the decortication procedures in orthodontics is based on case reports, more laboratory and clinical studies are needed to explain the mechanisms involved in this process at the molecular level, and to explore the long term effects of this procedure. 4. Conclusions Comprehensive orthodontic treatment with the aid of the decortication technique is an effective treatment option in adults to achieve a significant reduction in the treatment duration. In addition, with the combination of both periodontal surgery and orthodontic treatment, this option would be an excellent approach for managing preexisting periodontal problems through increasing the alveolar volume and reducing the likelihood of gingival recession. References Anderson, A.A., Anderson, A.C., Hornbuckle, A.C., Hornbuckle, K., 2000. Biological derivation of a range of cephalometric norms for children of African American descent (after Steiner). Am. J. Orthod. Dentofacial Orthop. 118 (1), 90–100. Anholm, M., Crites, D., Hoff, R., Rathbun, E., 1986. Corticotomyfacilitated orthodontics. Calif. Dent. Assoc. J. 7, 8–11.
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Chung, K.R., Oh, M.Y., Ko, S.J., 2001. Corticotomy-assisted orthodontics. J. Clin. Orthod. 35 (5), 331–339. Chung, K.R., Kim, S.H., Lee, B.S., 2009. Speedy surgical-orthodontic treatment with temporary anchorage devices as an alternative to orthognathic surgery. Am. J. Orthod. Dentofacial Orthop. 135 (6), 787–798. Connor, A.M., Moshiri, F., 1985. Orthognathic surgery norms for American black patients. Am. J. Orthod. 87 (2), 119–134. Fischer, T.J., 2007. Orthodontic treatment acceleration with corticotomy-assisted exposure of palatally impacted canines. Angle Orthod. 77 (3), 417–420. Frost, H.M., 1983. The regional accelerated phenomenon: a review. Henry Ford Hosp. Med. J. 31 (1), 3–9. Frost, H.M., 1989a. The biology of fracture healing. An overview for clinicians. Part I. Clin. Orthop. Relat. Res. 248, 283–293. Frost, H.M., 1989b. The biology of fracture healing. An overview for clinicians. Part II. Clin. Orthop. Relat. Res. 248, 294–309. Gantes, B., Rathbun, E., Anholm, M., 1990. Effects on the periodontium following corticotomy-facilitated orthodontics. Case reports. J. Periodontol. 61 (4), 234–238. Germec, D., Giray, B., Kocadereli, I., Enacar, A., 2006. Lower incisor retraction with a modified corticotomy. Angle Orthod. 76 (5), 882– 890. Goldie, R.S., King, G.J., 1984. Root resorption and tooth movement in orthodontically treated, calcium-deficient, and lactating rats. Am. J. Orthod. 85 (5), 424–430. Guay, A.H., Brown, L.J., Wall, T., 2008. Orthodontic dental patients and expenditures––2004. Am. J. Orthod. Dentofacial Orthop. 134 (3), 337–343. Hwang, H.S., Lee, K.H., 2001. Intrusion of overerupted molars by corticotomy and magnets. Am. J. Orthod. Dentofacial Orthop. 120 (2), 209–216. Iino, S., Sakoda, S., Miyawaki, S., 2006. An adult bimaxillary protrusion treated with corticotomy-facilitated orthodontics and titanium miniplates. Angle Orthod. 76 (6), 1074–1082. Keim, R.G., Gottlieb, E.L., Nelson, A.H., Vogels III, D.S., 2008. JCO study of orthodontic diagnosis and treatment procedures. Part 1: Results and trends. J. Clin. Orthod. 42 (11), 625–640. Kocadereli, I., 2002. Changes in soft tissue profile after orthodontic treatment with and without extractions. Am. J. Orthod. Dentofacial Orthop. 122 (1), 67–72. Ko¨le, H., 1959. Surgical operations on the alveolar ridge to correct occlusal abnormalities. Oral Surg. Oral Med. Oral Pathol. 12 (5), 515–529 (concl.). Lee, W., Karapetyan, G., Moats, R., Yamashita, D.D., Moon, H.B., Ferguson, D.J., Yen, S., 2008. Corticotomy-/osteotomyassisted tooth movement microCTs differ. J. Dent. Res. 87 (9), 861–867. Moon, C.H., Wee, J.U., Lee, H.S., 2007. Intrusion of overerupted molars by corticotomy and orthodontic skeletal anchorage. Angle Orthod. 77 (6), 1119–1125. Nowzari, H., Yorita, F.K., Chang, H.C., 2008. Periodontally accelerated osteogenic orthodontics combined with autogenous bone grafting. Compend. Contin. Educ. Dent. 29 (4), 200–206. Oliveira, D.D., De Oliveira, B.F., De Araujo Brito, H.H., De Souza, M.M., Medeiros, P.J., 2008. Selective alveolar corticotomy to intrude overerupted molars. Am. J. Orthod. Dentofacial Orthop. 133 (6), 902–908. Proffit, W.R., Fields, H.W., Sarver, D.M., 2006. Contemporary Orthodontics. Mosby Inc., Saint Louis, pp. 153–154. Shih, M.S., Norrdin, R.W., 1985. Regional acceleration of remodeling during healing of bone defects in beagles of various ages. Bone 6 (5), 377–379. Suya, H., 1991. Corticotomy in orthodontics. In: Ho¨sl, E., Baldauf, A. (Eds.), Mechanical and Biological Basics in Orthodontic Therapy. Hu¨thig Buch Verlag, Heidelberg, Germany, pp. 207–226. Vig, P.S., Weintraub, J.A., Brown, C., Kowalski, C.J., 1990. The duration of orthodontic treatment with and without extractions: a
106 pilot study of five selected practices. Am. J. Orthod. Dentofacial Orthop. 97 (1), 45–51. Wilcko, W.M., Wilcko, T., Bouquot, J.E., Ferguson, D.J., 2001. Rapid orthodontics with alveolar reshaping: two case reports of decrowding. Int. J. Periodont. Restorative Dent. 21 (1), 9–19. Wilcko, W.M., Ferguson, D.J., Bouquot, J.E., Wilcko, M.T., 2003. Rapid orthodontic decrowding with alveolar augmentation: case report. World J. Orthodont. 4, 197–205.
A.S. Aljhani, A.M. Aldrees Wilcko, M.T., Wilcko, W.M., Bissada, N.F., 2008. An evidence-based analysis of periodontally accelerated orthodontic and osteogenic techniques: a synthesis of scientific perspectives. Semin. Orthod. 14, 305–316. Yaffe, A., Fine, N., Binderman, I., 1994. Regional accelerated phenomenon in the mandible following mucoperiosteal flap surgery. J. Periodontol. 65 (1), 79–83.
King Saud University
The Saudi Dental Journal www.ksu.edu.sa www.sciencedirect.com
CASE REPORT
Orthodontic treatment of an anterior openbite with the aid of corticotomy procedure: Case report Ali S. Aljhani a, Abdullah M. Aldrees
b,*
a
King Abdullah International Medical Research Centre, King Saud University for Health Sciences, Riyadh, Saudi Arabia b Department of Pediatric Dentistry and Orthodontics, College of Dentistry, King Saud University, P.O. Box 60169, Riyadh 11545, Saudi Arabia Received 11 October 2009; revised 16 January 2010; accepted 7 June 2010 Available online 26 October 2010
KEYWORDS Openbite treatment; Corticotomy
Abstract This case report illustrates the orthodontic treatment combined with the corticotomy technique in an adult patient to accelerate tooth movement and shorten the treatment time. The patient was a 22-year-old woman with an anterior open bite and flared and spaced upper and lower incisors. First, fixed orthodontic appliances (bidimensional edgewise brackets) were bonded, and a week later buccal and lingual corticotomy with alveolar augmentation procedure in the maxillary arch from the first molar to the contralateral first molar, and from canine to canine in the mandibular arch was performed. Orthodontic therapy proceeded with frequent activation of the appliances to retract the incisors every 2 weeks. The total treatment time was 5 months and no adverse effects were observed at the end of active treatment. The addition of the decortication procedure to the conventional orthodontic therapy decreased the duration of treatment significantly. Successful closure of the anterior open bite with adequate overbite and interdigitation of the teeth were achieved. ª 2010 King Saud University. Production and hosting by Elsevier B.V. All rights reserved.
1. Introduction * Corresponding author. Tel.: +966 1 4676057; fax: +966 1 4679017. E-mail address: [email protected] (A.M. Aldrees). 1013-9052 ª 2010 King Saud University. Production and hosting by Elsevier B.V. All rights reserved. Peer review under responsibility of King Saud University. doi:10.1016/j.sdentj.2010.10.005
Production and hosting by Elsevier
Orthodontic treatment has the ability to modify the dentofacial skeleton and affect facial esthetics. Currently many adult patients seek orthodontic treatment for their malocclusions. In a recent Medical Expenditure Panel Survey (MEPS), adults accounted for 23.1% of all orthodontic visits in 2004 (Guay et al., 2008). The percentage of adult active patients was reported to be around 20% of the total patients being treated in the orthodontic offices in the United States (Keim et al., 2008). Comprehensive orthodontic treatment for adults is considerably longer than for adolescent patients (Vig et al., 1990; Kocadereli, 2002), and treatment modifications have been suggested to reduce the treatment time. Ko¨le (1959) was the first to describe a technique
100 that involved a radicular corticotomy and supra-apical osteotomy to expedite tooth movement. He believed that by creating blocks of bone with vertical buccal and lingual corticotomy cuts and supra-apical horizontal osteotomy connecting cuts, segments of bone with the embedded teeth can be moved rapidly (Ko¨le, 1959). Anholm et al. (1986) reported the treatment of a non-extraction case with severe malocclusion in 11 months using corticotomy. Later, Suya (1991) suggested replacing the osteotomy cuts with horizontal corticotomy in a report of 395 adult Japanese patients treated with this modified procedure. In 1990, Gantes et al. (1990) have reported five orthodontic cases treated with corticotomy in which circumscribing corticotomy cuts both facially and lingually around the six upper anterior teeth were made. The upper first bicuspids were removed and the bone over the extraction sockets was removed both buccally and lingually (Gantes et al., 1990). Chung et al. (2001) also reported two cases in which blocks of medullary bone are moved block by block with orthopedic forces. Similarly, Hwang and Lee (2001) have performed the intrusion of unopposed molars by performing a corticotomy procedure and using magnets on two adult patients. Wilcko et al. (2001) modified the technique with the addition of alveolar augmentation with resorbable, alloplastic freezedried bone to increase the volume of alveolar bone, regenerate bone affected by dehiscence and fenestration, and avoid gingival recession. They explained that the movement does not result from repositioning of tooth-bone blocks, but rather from a cascade of transient localized reactions in the bony alveolar housing leading to bone healing (Wilcko et al., 2001). Since 2001, few cases treated with corticotomy were reported in the literature. Germec et al. (2006) reported the treatment of an adult patient with a modified corticotomy technique, in which the lingual vertical and subapical horizontal cuts were eliminated; was combined with orthodontic therapy for the retraction of the lower anterior teeth after the extraction of four premolars. The use of the corticotomy technique with skeletal anchorage devices in the treatment of adults was reported by Iino et al. (2006), Moon et al. (2007), and Chung et al. (2009). For the intrusion of overerupted molars in adults, selective alveolar corticotomy with a modified full-coverage maxillary splint treatment was used by Oliveira et al. (2008). In a preliminary study, Fischer has compared the movement of impacted canines after surgical exposure using conventional surgical technique with their contralateral canines exposed using a corticotomy-assisted technique, and he concluded that corticotomy-assisted surgical technique reduced the orthodontic treatment time by 28–33% (Fischer, 2007). The aim of this report is to present in detail the efficient and rapid orthodontic treatment of anterior open bite malocclusion with the use of the decortication technique and to discuss the surgical and the orthodontic steps involved.
2. Case report A 22-year-old African woman presented with a chief complaint of: ‘‘I hate my open bite’’. She had no relevant medical history and she presented with several restorations, extractions of third molars, and excellent oral hygiene. Pre-treatment facial photographs showed a straight profile with protrusive and competent lips and acute nasolabial angle. The patient had an Angle Class I malocclusion on a mild skel-
A.S. Aljhani, A.M. Aldrees etal Class III relationship with a 0 mm overjet and 6 mm open bite extending from the right second premolar to the left second premolar. The upper and lower arches were malaligned with moderate spacing, and an evident tongue thrust habit accentuating the bimaxillary flaring and protrusion of the incisors (Figs. 1–9). The patient showed a genuine interest to have the orthodontic treatment completed as soon as possible. 2.1. Treatment plan The suggested treatment plan involved comprehensive orthodontic treatment with fixed appliances to align the upper and lower teeth, close the anterior spaces, retract the proclined incisors, and close the anterior open bite. Corticotomy procedure was planned to expedite the tooth movement. One week before the surgery, preadjusted edgewise orthodontic fixed appliances were placed (bidimensional appliances: 0.018 · 0.025-in. slot brackets for the incisors, 0.022 · 0.028-in. for the canines and the posterior teeth), and 0.016-in. NiTi archwires were inserted for leveling and alignment. 2.2. Surgical procedure Following the technique described by Wilcko et al. (2001), full thickness flap was reflected sharply both facially and lingually around all erupted teeth from first molar to first molar in the maxillary arch, and between the canines in the mandibular arch under local anesthesia (Fig. 10). Each flap was released with a sulcular incision and with papillary preservation technique when possible. The lingual interdental papilla between the maxillary central incisors was not reflected, and no vertical releasing incisions were used. Cuts in the alveolus that penetrate the entire thickness of the cortical plate and penetrate just barely into the medullary bone were performed both buccally and lingually around all the teeth in both arches. Vertical decortication cuts were made between the roots of the teeth and they were stopped 2–3 mm shy of the alveolar crest. Horizontal scalloped corticotomy cuts were used to connect the vertical cuts along with perforations in the cortical plate. Bone grafting mixture OraGraft demineralized cortical particulate (LifeNet Health Inc., Virginia Beach, VA, USA) was then applied to the activated cortical plates. Flaps were returned to their pre-surgical positions and sutured with interrupted loop sutures. Non-resorbable sutures (Gore-tex, CV-5, RT-16, from W.L. Gore & Associates Inc., Medical Products Division, Flagstaff, AZ, USA) were used and the sutures were left for 14 days before they were removed. Patient was kept under antibiotic for 10 days following the surgery. 2.3. Treatment progress At the suture removal appointment, 0.016 · 0.022-in. NiTi archwire was inserted in the upper arch and 0.016-in. stainless steel was inserted in the lower arch with 150 g NiTi coil springs attached from the mandibular first molars to the canines for retraction and powerchain to derotate the lower first premolars (Fig. 11A–C). Four weeks later, continuous powerchian was inserted in the upper arch and a 0.016 · 0.016-in. stainless steel archwire with closing loops was inserted in the lower arch for incisors retraction (Fig. 11D–F). Class III box elastics (3/16 in., 4 oz) were prescribed to be worn full-time. Archwires were activated
Orthodontic treatment of an anterior openbitewith the aid of corticotomy procedure: Case report
Figures 1–9
101
Pre-treatment extraoral, intraoral photographs and panoramic radiograph.
every 2 weeks, and 4 weeks later 0.016 · 0.022-in. stainless steel archwire was inserted in the upper arch, and in the lower 0.016-in. stainless steel with helices was inserted (Fig. 11G– I). Powerchains were replaced every 2 weeks, and then finishing upper and lower 0.016 · 0.022-in. stainless steel archwires
were inserted and vertical anterior and posterior elastics were used (Fig. 11J–L). The total active treatment period was only 5 months. Then, preadjusted edgewise appliance were removed, upper and lower lingual retainers were bonded and removable upper circum-
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Figure 10 (A, C) Maxillary corticotomy of the buccal and palatal sides of alveolar bone with the grafting mixture covering the decorticated bone. (B, D) Flaps returned to their pre-surgical positions and sutured with interrupted loop sutures.
Figure 11
Intraoral photographs at 2 weeks (A–C), 6 weeks (D–F), 10 weeks (G–I), and 4 months (J–L) after the corticotomy procedure.
ferential and lower Hawley retainers were inserted to be worn full time. Post-treatment evaluation of the patient revealed good preservation of the interdental papillae with no gingival recession. Post-treatment OPG shows good parallelism of the roots, no significant reduction in the radiographic height of the cres-
tal bone and nor radiographic evidence of any significant apical root resorption. Treatment objectives were achieved and the teeth are in good interdigitation with adequate overbite (Figs. 12–20). Final lateral cephalometric radiograph’s analysis show an acceptable dental compensation achieved for the underlying skeletal Class III discrepancy (Fig. 21).
Orthodontic treatment of an anterior openbitewith the aid of corticotomy procedure: Case report
Figures 12–20
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Post-treatment extraoral, intraoral photographs and panoramic radiograph.
3. Discussion The comprehensive orthodontic treatment of this adult patient who presented with an anterior open bite was completed in 5 months which is significantly less than the routine duration that conventional orthodontic treatment of similar cases re-
quires. The addition of the corticotomy procedure has been reported to shorten the conventional orthodontic treatment time (Ko¨le, 1959; Anholm et al., 1986; Gantes et al., 1990; Suya, 1991; Chung et al., 2001; Hwang and Lee, 2001; Wilcko et al., 2001), and it was claimed that teeth can be moved 2–3 times further in 1/3 to 1/4 the time required for traditional
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Figure 21 Final lateral cephalometric radiograph with a table illustrating analysis results. *Connor and Moshiri (1985). **Anderson et al. (2000).
orthodontic therapy (Wilcko et al., 2001, 2003, 2008). The current report confirms previously published findings and supports this treatment option for an overall shorter treatment times. The concept of corticotomy as introduced by Ko¨le (1959) relied on creating blocks of bone with the embedded teeth that can be moved rapidly with heavy forces. The same concept was followed by the others who reported corticotomy-facilitated orthodontic treatment of several cases (Anholm et al., 1986; Gantes et al., 1990; Suya, 1991; Chung et al., 2001). On the other hand, conventional orthodontic forces were advocated by Wilcko et al. (2001, 2003, 2008), who explained the rapid tooth movement as an illustration of regional acceleratory phenomenon (RAP). This process was first described by Frost (1983), who found that the surgical wounding of osseous tissues results in accelerated regional healing process (Frost, 1983, 1989a,b). It can expedite hard- and soft-tissue healing two- to ten-fold, and it leads to decreased regional bone density and accelerated bone turnover (Frost, 1983). This was reported to occur in intraoral cortical bone by others too (Goldie and King, 1984; Shih and Norrdin, 1985; Yaffe et al., 1994). Wilcko et al. (2008) showed that transient localized demineralization–remineralization in the bony alveolar housing occurs, and the demineralization of the alveolar bone over the root surfaces leaves the collagenous soft tissue matrix of the bone, which can be carried with the root surface and then remineralizes following the completion of the orthodontic treatment. Initially, the term ‘‘Accelerated Osteogenic Orthodontics’’ was used to describe the combined corticotomy-facilitated orthodontics and periodontal alveolar augmentation (Wilcko et al., 2001). Later, Wilcko et al. (2008) have modified it to be ‘‘Periodontally Accelerated Osteogenic Orthodontics’’ (PAOO) technique. In their case reports, Wilcko et al. (2008) have emphasized that after a 2-week post-operative waiting
period to permit demineralization, extraction spaces can be closed in 6–8 weeks with efficient orthodontic forces. That coincided with the technique employed in the treatment of the current case, in which major tooth movement occurred in the first 4 months with conventional forces. In a recent report comparing the alveolar bone reactions to osteotomy-assisted and corticotomy-assisted tooth movement, Lee et al. (2008) found evidence of regional accelerated phenomenon in the alveolar bone of the corticotomy-treated animals and distraction osteogenesis in the osteotomy-assisted tooth movement animals by microCT. This confirms by microimaging techniques the hypothesis of the difference in the healing processes involved in both procedures. Original corticotomy-facilitated orthodontic treatment involved buccal and lingual osteotomy cuts with orthopedic forces, and the use of alveolar augmentation with demineralized bone graft was advocated by Wilcko et al. (2001, 2003) to cover any fenestrations and dehiscences and to increase in the bony support for both the teeth and the overlying and soft tissues. Surface computed tomographic scans taken before and after the treatment showed a return of the layer of mineralized bone over the roots of the teeth and a general increase of the bone volume in the cases presented by Wilcko et al. (2001, 2003). The use of particulate autogenous bone graft harvested from the rami and exostosis of a case was reported by Nowzari et al. (2008), and no changes in the bone configuration were observed a year after the completion of treatment. More controlled studies are still required to investigate the value of the alveolar augmentation as a routine step in the decortication technique, and the effects of different grafting materials on the alveolar bone. While osteotomy cuts were recommended on both alveolar surfaces (buccal and lingual) (Ko¨le, 1959; Wilcko et al., 2001, 2003), two recently published case reports showed the results of selective corticotomy limited to the buc-
Orthodontic treatment of an anterior openbitewith the aid of corticotomy procedure: Case report cal and labial surfaces to reduce the operation time and post-operative patient discomfort, and avoid the risk of violating vital lingual anatomy (Germec et al., 2006; Nowzari et al., 2008). The current case was managed with both buccal and lingual cuts and efficient tooth movement was observed, however, elimination of the lingual cuts should be studied in future trials. Most of the recently published literature showed no adverse effects of the corticotomy on the periodontium (Germec et al., 2006; Iino et al., 2006; Nowzari et al., 2008; Oliveira et al., 2008; Wilcko et al., 2008). In this case, no reduction in the crest bone height, gingival recession, and apical root resorption were seen after the orthodontic treatment. The need for more frequent activation compared to conventional orthodontic treatment, the extra expenses for the periodontal surgery, and the post-operative discomfort were the disadvantages of this technique that the patient need to tolerate for a faster course of treatment. Anterior open bite is often accompanied with anterior tongue placement between the separated anterior teeth as a maneuver to close off the front of the mouth and form an anterior seal. However, forward resting posture of the tongue, due to the prolonged duration of this pressure, could affect tooth position and cause anterior open bite (Proffit et al., 2006). The exact etiological factors for the anterior open bite in the current case could not be determined, but successful closure of the open bite was achieved within a short period of time in spite of the accompanied tongue thrust. This indicates that the accelerated tooth movement brought by the corticotomy can overcome the lingual resistance to teeth retraction by the tongue. Increased stability provided by PAOO has been reported by Wilcko et al. (2008) and that was explained by the loss of tissue memory from high tissue turnover of the periodontium, and the increased thickness of the alveolar cortices from the augmentation grafting. It is possible that more stability of the correction achieved in this case is expected due to the reasons illustrated previously. Since most of what we know about the decortication procedures in orthodontics is based on case reports, more laboratory and clinical studies are needed to explain the mechanisms involved in this process at the molecular level, and to explore the long term effects of this procedure. 4. Conclusions Comprehensive orthodontic treatment with the aid of the decortication technique is an effective treatment option in adults to achieve a significant reduction in the treatment duration. In addition, with the combination of both periodontal surgery and orthodontic treatment, this option would be an excellent approach for managing preexisting periodontal problems through increasing the alveolar volume and reducing the likelihood of gingival recession. References Anderson, A.A., Anderson, A.C., Hornbuckle, A.C., Hornbuckle, K., 2000. Biological derivation of a range of cephalometric norms for children of African American descent (after Steiner). Am. J. Orthod. Dentofacial Orthop. 118 (1), 90–100. Anholm, M., Crites, D., Hoff, R., Rathbun, E., 1986. Corticotomyfacilitated orthodontics. Calif. Dent. Assoc. J. 7, 8–11.
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Chung, K.R., Oh, M.Y., Ko, S.J., 2001. Corticotomy-assisted orthodontics. J. Clin. Orthod. 35 (5), 331–339. Chung, K.R., Kim, S.H., Lee, B.S., 2009. Speedy surgical-orthodontic treatment with temporary anchorage devices as an alternative to orthognathic surgery. Am. J. Orthod. Dentofacial Orthop. 135 (6), 787–798. Connor, A.M., Moshiri, F., 1985. Orthognathic surgery norms for American black patients. Am. J. Orthod. 87 (2), 119–134. Fischer, T.J., 2007. Orthodontic treatment acceleration with corticotomy-assisted exposure of palatally impacted canines. Angle Orthod. 77 (3), 417–420. Frost, H.M., 1983. The regional accelerated phenomenon: a review. Henry Ford Hosp. Med. J. 31 (1), 3–9. Frost, H.M., 1989a. The biology of fracture healing. An overview for clinicians. Part I. Clin. Orthop. Relat. Res. 248, 283–293. Frost, H.M., 1989b. The biology of fracture healing. An overview for clinicians. Part II. Clin. Orthop. Relat. Res. 248, 294–309. Gantes, B., Rathbun, E., Anholm, M., 1990. Effects on the periodontium following corticotomy-facilitated orthodontics. Case reports. J. Periodontol. 61 (4), 234–238. Germec, D., Giray, B., Kocadereli, I., Enacar, A., 2006. Lower incisor retraction with a modified corticotomy. Angle Orthod. 76 (5), 882– 890. Goldie, R.S., King, G.J., 1984. Root resorption and tooth movement in orthodontically treated, calcium-deficient, and lactating rats. Am. J. Orthod. 85 (5), 424–430. Guay, A.H., Brown, L.J., Wall, T., 2008. Orthodontic dental patients and expenditures––2004. Am. J. Orthod. Dentofacial Orthop. 134 (3), 337–343. Hwang, H.S., Lee, K.H., 2001. Intrusion of overerupted molars by corticotomy and magnets. Am. J. Orthod. Dentofacial Orthop. 120 (2), 209–216. Iino, S., Sakoda, S., Miyawaki, S., 2006. An adult bimaxillary protrusion treated with corticotomy-facilitated orthodontics and titanium miniplates. Angle Orthod. 76 (6), 1074–1082. Keim, R.G., Gottlieb, E.L., Nelson, A.H., Vogels III, D.S., 2008. JCO study of orthodontic diagnosis and treatment procedures. Part 1: Results and trends. J. Clin. Orthod. 42 (11), 625–640. Kocadereli, I., 2002. Changes in soft tissue profile after orthodontic treatment with and without extractions. Am. J. Orthod. Dentofacial Orthop. 122 (1), 67–72. Ko¨le, H., 1959. Surgical operations on the alveolar ridge to correct occlusal abnormalities. Oral Surg. Oral Med. Oral Pathol. 12 (5), 515–529 (concl.). Lee, W., Karapetyan, G., Moats, R., Yamashita, D.D., Moon, H.B., Ferguson, D.J., Yen, S., 2008. Corticotomy-/osteotomyassisted tooth movement microCTs differ. J. Dent. Res. 87 (9), 861–867. Moon, C.H., Wee, J.U., Lee, H.S., 2007. Intrusion of overerupted molars by corticotomy and orthodontic skeletal anchorage. Angle Orthod. 77 (6), 1119–1125. Nowzari, H., Yorita, F.K., Chang, H.C., 2008. Periodontally accelerated osteogenic orthodontics combined with autogenous bone grafting. Compend. Contin. Educ. Dent. 29 (4), 200–206. Oliveira, D.D., De Oliveira, B.F., De Araujo Brito, H.H., De Souza, M.M., Medeiros, P.J., 2008. Selective alveolar corticotomy to intrude overerupted molars. Am. J. Orthod. Dentofacial Orthop. 133 (6), 902–908. Proffit, W.R., Fields, H.W., Sarver, D.M., 2006. Contemporary Orthodontics. Mosby Inc., Saint Louis, pp. 153–154. Shih, M.S., Norrdin, R.W., 1985. Regional acceleration of remodeling during healing of bone defects in beagles of various ages. Bone 6 (5), 377–379. Suya, H., 1991. Corticotomy in orthodontics. In: Ho¨sl, E., Baldauf, A. (Eds.), Mechanical and Biological Basics in Orthodontic Therapy. Hu¨thig Buch Verlag, Heidelberg, Germany, pp. 207–226. Vig, P.S., Weintraub, J.A., Brown, C., Kowalski, C.J., 1990. The duration of orthodontic treatment with and without extractions: a
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