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146 ORTHODONTICS T A and Prci o Denfal Enhnmnt

1Proessor, Departmento Orthodontics andDentoacial Orthopedics,Sree Balaji Dental Collegeand Hospital, Chennai,Tamil Nadu, India.

CORRESPONDENCEDr A. Ari YezdaniDepartment oOrthodontics andDentoacial OrthopedicsSree Balaji Dental Collegeand Hospital

Velachery Main RoadNarayanapuramPallikaranai, Chennai600100Tamil NaduIndiaEmail:[email protected]

Accelerated orthodonticswith alveolar decortication andaugmentation: A case report

A. Ari Yezdani, MDS, FWFO1

This case report reiterates the act that selective alveolar decortication in

conjunction with periodontal alveolar augmentation with a bone grat indubitably

and ecaciously produces rapid orthodontic tooth movement. A 29-year-old

woman presented with a Class I malocclusion and increased bidentoalveolar

protrusion with increased spacing between the maxillary and mandibular

incisors. She readily agreed to selective alveolar decortication in conjunction

with periodontal alveolar augmentation with a bone grat when presented with

the proposal that her malocclusion could be corrected in one-third the treatmenttime required or conventional orthodontics. A preadjusted edgewise appliance

(Roth prescription, 0.022 0.028-inch slot) was placed prior to the surgical

procedure. One week later, ull-thickness labial and lingual faps were refected

in the maxillary and mandibular arches. The alveolar bone was selectively

decorticated and periodontally augmented with a bone grat. Starting 1 week

postsurgically, orthodontic adjustments were carried out every 2 weeks. From

bracketing to debracketing, the entire orthodontic treatment took 7 months. The

rapid orthodontic tooth movement was attributed to the regional acceleratory

phenomenon, triggered by selective alveolar decortication. The subsequent

periodontal alveolar augmentation with the bone grat repaired the bonydehiscences and enhanced the bone volume and dramatically improved the

patients sot tissue prole. OrthOdOntics (chic) 2012;13:146155.

Key words: alveolar decortication, periodontal alveolar augmentation,preadjusted edgewise appliance therapy, rapid orthodontic treatment

A

ccelerated osteogenic orthodontics (AOO) taps the innate potentialo living bone. It is a procedure wherein selective decortication o the

alveolar bone produces a transient burst in hard and sot tissue remod-eling by a process known as the regional acceleratory phenomenon (RAP).1,2The demineralization and remineralization phenomena triggers rapid toothmovement in concordance with ecient orthodontic treatment. This proce-dure is avored over the bony block movement advocated by Kole.3 Genersonet al achieved rapid tooth movement with the single-stage corticotomy-onlytechnique.4 Anholm et al,5 Gantes et al,6 and Suya7 reported rapid tooth move-ment with shortened treatment times with no adverse periodontal eectswith corticotomy-acilitated orthodontic treatment. The structural integrity othe periodontium is enhanced with periodontal alveolar augmentation with abone grat, thus producing an environment resistant to relapse.8 This causes anincrease in the thickness o the alveolar bone at the cephalometric landmarks


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A-point9 and B-point,10 which considerably improves lip posture. Any pre-existing alveolar enestrations over root prominences as well as the tell-talesigns o bony dehiscence ormation can be eectively addressed with thisprocedure. The amalgamation o these two techniquesselective alveolardecortication and periodontal alveolar augmentation, called AOOin con-

junction with ecient orthodontic biomechanics paved the way or rapidtooth movement with shortened treatment time.11

Goldie and King12 created osteoporotic conditions in rats and demonstrat-ed enhanced tooth movement and decreased root resorption. Sebaoun etal13 also demonstrated an increase in apposition and resorption o rat alveolarspongiosa adjacent to the corticotomy site. Bogoch et al demonstrated anincrease in apposition and resorption o rabbit tibia (long bone) spongiosaadjacent to the decortication site.14 These animal experiments lent urther cre-dence to this procedure.

To conrm the validity o these two time-tested procedures, selective alveo-lar decortication and periodontal alveolar augmentation with a bone grat wasperormed.

CASE REPORTDiagnosis and etiologyA 29-year-old woman presented with orward placement o the maxillary andmandibular anterior incisors with excessive spacing and gingival recession inrelation to the mandibular let central incisor.

Extraoral assessment. The patient had a mesoprosopic ace, convex pro-le, posterior divergence, incompetent lips, average clinical mandibular planeangle, and complete maxillary incisal display on smiling, with no signs o tem-poromandibular joint dysunction (Fig 1).

Intraoral assessment. Oral hygiene was satisactory, with gingival reces-sion and bony dehiscence in relation to the mandibular let central incisor.

The nonvital maxillary right central incisor was endodontically treated priorto orthodontic treatment, and there was no history o pernicious oral habits.The maxillary arch was U-shaped with severely proclined maxillary inci-

sors and excessive spacing in between them. The mandibular arch was alsoU-shaped with proclined mandibular incisors, mesiolingual rotation o themandibular let central incisor, mesiolabial rotation o mandibular let lateralincisor, and mesiolabial rotation o the mandibular right lateral incisor, withgingival recession in relation to the mandibular let central incisor.

Increased overjet and deep bite were both observed. The maxillary andmandibular dental midlines coincided with each other and the skeletal mid-lines. On both sides, the molar relationship was Class I. The canine relationshipwas also Class I, and the curve o Spee was 3.5 mm (see Fig 1).


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Accelerated orthodontics with alveolar decortication and augmentationCse Rp


Radiographic assessment. The panoramic radiograph conrmed the pres-ence o all permanent teeth and normal alveolar bone levels, except in rela-tionship to the mandibular let central incisor (Fig 2).

Cephalometric analysis (Table 1) revealed a skeletal Class I pattern, with anearly orthognathic maxilla and mandible. There was an average mandibularplane angle and severely proclined maxillary and mandibular incisors.

Fig 1 Pretreatment intra- and extraoral photographs.

Fig 2 Pretreatment (a)panoramic radio-graph and (b)lateral cephalogram.

a

b


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Treatment objectivesThe main treatment objectives were to improve the sot tissue prole, achievelip competence, and enhance smile esthetics. Since the maxilla and mandi-ble were almost orthognathic, greater emphasis was laid on the correctiono the increased bidentoalveolar protrusion, the excessive spacing present inthe maxillary incisors, and the moderate spacing present in the mandibular

incisors, in addition to the rotated mandibular anteriors and deep bite. A non-extraction approach was decided upon since adequate spacing was presentin the maxillary and mandibular arches. Correction o the bony dehiscence inrelation to the mandibular let central incisor was to be addressed with thebone grat. A composite resin veneer or the maxillary right central incisor,subsequent to completion o orthodontic treatment, was advised.

Treatment alternativesConventional orthodontics could have been perormed but it would have tak-en 1.6 years to nish. Instead, the patient opted or AOO, since she preerredto complete treatment within a short period o time.

Treatment progressPrior to the surgical procedure, preadjusted edgewise brackets (Roth pre-scription, 0.022 0.028-inch slot) were bonded, complete with transpalatalanchorage. The patient underwent selective alveolar decortication and peri-odontal alveolar augmentation with Grabio Glascera bone grat (DorthomMedi Dents). Grabio Glascera is made up o bioactive, ceramic, composite,porous granules50% bioactive glass and 50% hydroxyapatite.

Clinical procedureOne week beore the AOO procedure, maxillary and mandibular 0.014-inchNi-Ti archwires were engaged rom second molar to second molar, with atranspalatal arch serving as an anchorage device.

Table 1 Cephalometric analysis

Variable Norm Pretreatment Posttreatment

SNA (degrees) 82 2 82.5 83

SNB (degrees) 80 2 78.5 80

ANB (degrees) 2 2 4 3

UI to NA (degrees) 22 46 22UI to NA (mm) 4 16 9.5

LI to NB (degrees) 25 41 34.5

LI to NB (mm) 4 13 10

Go-Gn-SN (degrees) 32 2 30 26.5

LI to A-Pog (mm) 1 2 9.5 8

UI to SN (degrees) 102 2 128.5 106.5

LI to MP (degrees) 90 2 108.5 103

N-Me (mm) 123 5 116.5 113.5

N-ANS (mm) 56 3 52.5 50

ANS-Me (mm) 70 5 65 65

E-plane (mm) 2 2 8 4


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Under local anesthesia, surgery was perormed on both the maxillary andmandibular arches. Labial and lingual sulcular incisions were made using a12-BP blade around all remaining maxillary and mandibular teeth. No verticalreleasing incisions were made. Flaps were refected beyond the apices o theteeth, with care taken not to disturb any o the neurovascular bundles exitingthe bone or the genioglossus attachment. The interdental papillae were re-fected with ull-thickness labial and lingual faps (Figs 3 and 4).

The alveolar bone on the labial and lingual aspects o the anterior teeth tobe moved was decorticated with round perorations made with a long shanksurgical bur (Fig 5), accompanied with copious saline irrigation, penetrating

just into the medullary bone. The areas around the rst and second molarswere let untouched since they would serve as anchorage units.

Five milliliters o the patients blood was drawn and centriuged to obtainplatelet-rich plasma. Then, 1 mL o platelet-rich plasma, along with a ew dropso calcium gluconate, was then mixed well with the Grabio Glascera gran-ules. Periodontal alveolar augmentation (Fig 6) was done with Grabio Glascerabone grat to a thickness o 2 to 3 mm, and the ull-thickness faps were thenreturned to their original positions and sutured into place with one interruptedloop 3/0 suture interproximally (Fig 7). Postsurgically, amoxicillin (500 mg three

times a day or 1 week) and anti-infammatory drugs (three times a day or 1week) were given. Chlorhexidine mouthwash was also advised. Suture removalwas perormed 1 week postoperatively, and nonsteroidal anti-infammatorydrugs (NSAIDs) were asked to be discontinued until orthodontic treatment wascomplete. Orthodontic treatment was commenced 1 week ollowing surgery.Thereater, adjustments were made every 2 weeks until treatment was nished(Figs 8 to 10).

Treatment outcomeThe patient showed remarkable improvement in the correction o the in-creased bidentoalveolar protrusion, spacing, rotated mandibular incisors, anddeep bite in just 7 months. A Class I molar and canine relationship was also

Fig 4 Refection o the ull-thickness fap. (a)Mandibular rontal view. (b)Mandibular lingual view.

Fig 3 Refection o the ull thickness fap. (a)Maxillary rontal view. (b)Maxillary palatal view.

a b

a b


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achieved. This speedy treatment eect was most probably attributed to theRAP phenomenon. The alveolar enestrations and bony dehiscence, in rela-tion to mandibular let central incisor, were successully addressed with the

Fig 5 Perorations with a long shank surgical bur. (a and b)Maxillary right quadrant, (c)maxillarypalatal view, (d)mandibular rontal view.

Fig 6 Alveolar augmentation with bone grat. (a)Maxillary rontal view, (b)maxillary palatal view, and(c)mandibular anterior view.

Fig 7 Suturing. (a)Maxillary palatal view and (b)mandibular rontal view.

a b c

Fig 8 Aligning and leveling. Fig 9 Space closure.

Fig 10 Finishing and detailing. (a)Right, (b)rontal, and (c)let.

a b

a

a

b

b

c

c

d


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periodontal alveolar augmentation with the Grabio Glascera bone grat, whichprovided overall adequate alveolar bone volume. A pleasing acial prole result-ed, as evidenced by the end-o-treatment cephalometric analysis (see Table 1)(Figs 11 to 14).

Fig 11 Posttreatment intra- and extraoral photographs.

Fig 12 Posttreatment (a)panoramic radio-graph and (b)lateral cephalogram.

a

b


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Fg 13 Cephalometric superimposition. Black, pre-treatment; red; posttreatment.

Fg 14 Posttreatment extraoral view, withcomposite resin veneer complete or themaxillary right central incisor.

Discussion

This case validates the evidence-based use o AOO. The shortened treatmentduration with rapid orthodontic tooth movement that was observed could beattributed to the RAP phenomenon produced by the decortication procedure.

The cancellous portion o the alveolar bone gets induced into a more pliable,transient, reversible, demineralized state called osteopenia. Osteopenia is astate o calcium depletion, occurring because o two processesosteoclasis(surace resorption) and osteocytic osteolysis (osteon remodeling). This is acatabolic process, a resorption response resulting in decreased bone density,but with no change in alveolar bone volume.15 With demineralization, bonematrix transportation occurs and the remaining collagenous sot tissue matrixo the bone is transported with the root in the direction o movement.16

The demineralization is ollowed by the anabolic process, a ormation re-sponse wherein new bone is deposited and the osteoid matrix gets reminer-alized. As long as tooth movement continues, RAP is prolonged. When RAPdissipates, osteopenia disappears. The RAP commences a ew days ater sur-

gery, peaks between 1 and 2 months when catabolic and anabolic responsesare threeold higher, dissipates to a normal steady state by 11 weeks atersurgery, and takes approximately 6 to 24 months to resolve completely.17

This accelerated and intense regional healing response was utilized to cor-rect the bidentoalveolar protrusion and deep bite and rapidly close the wideexisting spaces between the maxillary and mandibular incisors in just 7 months.Selective alveolar decortication is a physiologically driven process. Uninter-rupted vascular supply to surgical areas is critical in maintaining the vitalityo hard and sot tissues. The perorations made were as eective as the alter-native circumscribed corticotomy cuts, since these perorations provided thenecessary bleeding points and communications with the soter inner medullarybone. These communications then act as pathways through which new blood


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154 oRTHoDonTics T A and Prci o Denfal Enhnmnt

vessels and pluripotential cells migrate rom the medullary bone into the corti-cal plates. Then, these very pluripotential cells remove old bone and createnew bone and make the cortical plates more vital and responsive to the orceso tooth movement. Bone luxation is contraindicated because it could lead tointrapulpal and intraosseous morbidity and can jeopardize the integrity o theneurovascular bundle exiting the apices o the teeth, resulting in devitalization.

Higher susceptibility to root resorption in adults is due to the periodontal

ligament becoming less vascular, aplastic, and narrower; the bone becomingmore dense, avascular, and aplastic; and the cementum becoming wider.18 Evi-dence suggests an association between orthodontic root resorption and thepresence and removal o necrotic hyalinized periodontal ligament tissue.19 Inthe AOO procedure, though, root resorption is minimized due to bone matrixtransportation.

It has been reported that patients with thinner mandibular cortices are atincreased risk or dental relapse subsequent to decrowding.20 In adults, bonydehiscence ormation over the roots ater traditional orthodontic therapy re-solves only partially during retention.21 The AOO procedure with the GrabioGlascera bone grat signicantly improved the structural integrity o the peri-odontium, provided additional support or the roots o the teeth and perioral

musculature, and also repaired the bony dehiscence in relation to the man-dibular let central incisor. An added advantage to the periodontal health asa result o this procedure is that due to the shortened treatment times, rela-tively benign commensal bacterial biolms have less time to assume qualita-tive changes and convert to destructive cytotoxic (periodontopathic) potentialcompared with that seen when xed appliances are worn or 2 to 3 years.

Tooth movements were accomplished in 2 weeks with AOO procedure, ascompared with conventional orthodontics in 6- to 8-weeks interval, and theorthodontic adjustments were perormed every 2 weeks with the applicationo normal orthodontic orces.

RAP might be the contributing actor to the increased mobility o the teethdue to increased osteoclastic activity along the periodontal ligament surace

ollowing surgery.22

The patient was given xed lingual retainers or reten-tion, which creates an environment that osters alveolar remineralization. Bonemorphogenetic protein infuences the primitive uncommitted stem cells to be-come more specic cell types in bone morphogenesis.23 Following cessationo active tooth movement, the growth protein component in the sot tissuematrix o the bone stimulates an increase in the osteoblastic activity, resultingin remineralization o the sot tissue matrix.24 It has been reported that duringretention, clinical outcomes o periodontal AOO patients improved and didnot relapse.25 In essence, the AOO procedure is in vivo tissue engineering,highlighting the ability to morph bone with orthodontic tooth movement, peri-odontal bone activation, and alveolar augmentation.26

conclusion

In this case, treatment with conventional orthodontics would have taken 1.6years to complete, but with the implementation o AOO, the teeth were movedthree to our times aster, or a treatment duration o 7 months. This causeda dramatic reduction in the bacterial actors, with a consequent decrease inincidence o caries and inection.

The procedure had also caused an increase in the alveolar bone volume,which provided or an intact periodontium and an adequate zone o gingivalattachment and interdental papillae with redressal o the gingival recession.There was no loss o tooth vitality nor apical root resorption, and parallelism


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o the roots was well maintained. AOO is indispensable or those patients whodesire the benets o orthodontic treatment in a short period o time and isinveritably a useul adjunct in any orthodontists armamentarium.

ReFeRences

1. Frost HM. The biology o racture healing:An overview or clinicians. Part I. ClinOrthop Relat Res 1989;248:283293.

2. Frost HM. The biology o racture healing:An overview or clinicians. Part II. ClinOrthop Relat Res 1989;248:294309.

3. Kole H. Surgical operations o the alveolarridge to correct occlusal abnormalities.Oral Surg Oral Med Oral Pathol 1959;12:515529.

4. Generson RM, Porter JM, Zell A, StratigosGT. Combined surgical and orthodonticmanagement o anterior open bite usingcorticotomy. J Oral Surg 1978;34:216219.

5. Anholm M, Crites D, Ho R, Rathbun E.

Corticotomy-acilitated orthodontics. JCali Dent Assoc 1986;7:811.

6. Gantes B, Rathbun E, Anholm M. Eectson the periodontium ollowing corticoto-my-acilitated orthodontics. Case reports.J Periodontol 1990;61:234238.

7. Suya H. Corticotomy in orthodontics. In:Hosl E, Baldau A (eds). Mechanical andBiological Basics in Orthodontic Therapy.Heidelberg, Germany: Hutlig Buch, 1991:207226.

8. Wilcko MW, Ferguson DJ, Bouquot JE,et al. Rapid orthodontic decrowding withalveolar augmentation: A case report.

World J Orthod 2003;4:197205.9. Machado IM, Ferguson DJ, Wilcko WM,et al. Reabsorcion radicular. Despues deltratamiento ortodoncico con o sin corti-cotomia alveolar. Rev Ven Ort 2002;19:647653.

10. Haji SS. The infuence o accelerated osteo-genic response on mandibular decrowding[thesis]. St Louis: St Louis University, 2000.

11. Wilcko MW, Wilcko MT, Bouquot JE,Ferguson DJ. Rapid orthodontics withalveolar reshaping: Two case reports odecrowding. Int J Periodontics RestorativeDent 2001;21:919.

12. Goldie RS, King GJ. Root resorption

and tooth movement in orthodonticallytreated, calcium-decient, and lactatingrats. Am J Orthod 1984;85:424430.

13. Sebaoun JD, Ferguson DJ, Wilcko MT, etal. Corticotomie. Alveolaire et traitementsorthodontiques rapides. Orthod Fr 2007;78:217225.

14. Bogoch E, Gschwend N, Rahn B, MoranE, Perren S. Healing o cancellous boneosteotomy in rabbitsPart I: Regulationo bone volume and the regional accel-eratory phenomenon in normal bone. JOrthop Res 1993;11:285291.

15. Ferguson DJ, Wilcko WM, Wilcko TM. Ac-celerating orthodontics by altering alveo-lar bone density. Good Pract 2001;2:24.

16. Wilcko TM, Wilcko MW, Bissada NF. Anevidence-based analysis o periodontallyaccelerated orthodontic and osteogenictechniques: A synthesis o scientic per-spectives. Semin Orthod 2008;14:305316.

17. Yae A, Fine N, Binderman I. Regionalaccelerated phenomenon in the mandibleollowing mucoperiosteal fap surgery.J Periodontol 1994;65:7983.

18. Brezniak N, Wasserstein A. Root resorp-tion ater orthodontic treatment: Part 2.

Literature review. Am J Orthod Dentoa-cial Orthop 1993;103:138146.

19. Rygh R, Brudvik P. The histologicalresponses o the periodontal ligament tohorizontal orthodontic loads. In: Berkov-itz BKB, Moxham BJ, Newman HN (eds).The Periodontal Ligament in Health andDisease. London: Mosby-Wole, 1995:250254.

20. Rothe LE, Bollen RM, Herring SW, et al.Trabecular and cortical bone as risk ac-tors or orthodontic relapse. Am J OrthodDentoacial Or thop 2006;130:476484.

21. Fuhrmann R. Three-dimensional evalu-

ation o periodontal remodeling duringorthodontic treatment. Semin Orthod2002;8:2328.

22. Peier JS. The reaction o alveolar boneto fap procedures in man. J Periodontol1965;3:135140.

23. Fiorellini J, Nevins M. Repair and regen-eration o oral tissues: The molecular ap-proach. Postgrad Dent Series 1996;3:310.

24. Nyman S, Karring T, Bergenholtz G. Boneregeneration in alveolar bone dehis-cences produced by jiggling orces.J Periodontal Res 1982;17:316322.

25. Wilcko TM, Wilcko WM, Marquez MG,et al. The contributions o periodontics

to orthodontic therapy. In: Dibart S (ed).Practical Advanced Periodontal Surgery.Ames, Iowa: Wiley Blackwell, 2007:2350.

26. Murphy NC. In vivo tissue engineeringor orthodontists: A modest rst step. In:Davidovitch Z, Mah J, Suthanarak S (eds).Biological Mechanisms o Tooth Erup-tion, Resorption, and Movement. Boston:Harvard Society or the Advancement oOrthodontics, 2006:385410.


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