Accelerated orthodontic treatment in a patient with reduced periodontal tissue. Case report

ABSTRACT

Orthodontic treatment in a patient that suffered periodontitis and as a result has a reduced periodontium often requires a combination of several surgical techniques as well as interdisciplinary treatments aimed at achieving optimum results.

Objective

To present a treatment with accelerated orthodontics in a patient with severe malocclusion, periodontitis and reduced periodontium to achieve orthodontic treatment success in lesser time and with minimum alteration of periodontal tissues.

Methodology

41 year old female patient, dolichofacial, with a skeletal class II malocclusion, molar class II, canine class II, spacing, convex profile, incompetent lips, gummy smile, and advanced periodontal loss. Initial orthodonticperiodontal treatment was followed by corticotomy. Periodontal treatment consisted in root planning and scaling as well as oral hygiene instructions. 0.018-slot Roth prescription fixed appliances were placed in both arches without extractions.

Results

At the end of treatment esthetic, occlusal and functional results were achieved.

Conclusions

Periodontally compromised patients can be successfully treated by correcting malocclusion when an interdisciplinary approach is used.

RESUMEN

El tratamiento de ortodoncia en un paciente con periodontitis y periodonto reducido, generalmente requiere la combinación de distintas técnicas quirúrgicas y tratamientos interdisciplinarios con el fin de obtener resultados óptimos.

Objetivo

Presentar el tratamiento de ortodoncia acelerada en paciente con maloclusión severa, periodontitis y periodonto reducido para el éxito en el tratamiento ortodóncico, en un menor tiempo y con mínima alteración en los tejidos periodontales.

Metodología

Paciente femenina de 41 años de edad, dolicofacial, que presenta maloclusión clase II esquelética, clase II molar y clase II canina, diastemas, perfil convexo, incompetencia labial, sonrisa gingival y tejidos periodontales disminuidos. El tratamiento inicial tue ortodóntico-periodontal, seguido por corticotomías. El tratamiento periodontal consistió en raspado y alisado radicular e instrucciones de higiene. Colocación de aparatología fija prescripción Roth, slot .018 en ambas arcos sin extracciones.

Resultados

Al término del tratamiento se lograron resultados estéticos, oclusales y funcionales.

Conclusiones

Los pacientes comprometidos periodontalmente pueden tratarse satisfactoriamente corrigiendo la maloclusión cuando se utiliza un enfoque interdisciplinario.

INTRODUCTION

The need to speed up orthodontic treatment to fulfill the patient's expectations resulted in the combination of orthodontic treatment with a surgical procedure. Corticotomy was introduced as a supplementary technique for orthodontic therapy to achieve accelerated tooth movements with minimal surgical intervention. It reduces treatment time by eliminating the resistance offered by dense cortical bone to traditional orthodontic movement and decreases root resorption and damage to the periodontalligament.^1,2

Conventionally, periodontal therapy in adult patients with reduced periodontium and orthodontic involvement translates into prolonged treatments or may involve a financial commitment that the patient is not able to afford. Additionally treatment results are unpredictable because the bone behavior may vary, and cause a failure or a relative success which causes the patients to be reluctant to accept long-term treatments. An alternative to orthodontic treatment in patients with a reduced or a healthy periodontium is orthodontic microsurgery or corticotomy.^3,4

Corticotomy for orthodontic treatment may be considered as an intermediate therapy between orthognathic surgery and conventional orthodontics⁵ which is characterized by a biological mechanism based on the regional acceleration phenomenon or RAP by its acronym. In 1983, frost showed that harmful regional stimuli of sufficient magnitude may give rise to a sharply accelerated activity and reorganization in the bony and soft tissue. He called this cascade of physiological healing processes RAP. This phenomenon is characterized by an activation of the localized remodeling process which accelerates healing especially after surgery with damage to cortical bone. This surgical injury is a factor of reinforcement for the induction of RAP.⁶

The surgical techniques for accelerated orthodontics are divided into corticotomy or decortication and osteotomy. Corticotomy is a surgical technique in which only the cortical bone is cut, drilled, or mechanically altered until bone marrowis reached and remains intact. On the contrary, an osteotomy consists in performing surgical incisions through the cortical up until bone marrow and is usually the formation or separation of a new bone segment.⁷

The benefits of corticotomy in comparison with conventional orthodontics are:

• 1.

  Wider application in the treatment of malocclusions (reduction of the limits of dental movement and less need for extractions).

• 2.

  Decrease in treatment time.

• 3.

  Increase in alveolar volume and more maintenance of the periodontal structures (correction of preexisting bone fenestrations and dehiscences, with the use of bone grafts).

• 4.

  Alveolar remodeling for the improvement of the patient's profile when required.

• 5.

  Simultaneous use with other procedures (impacted teeth).⁸

MATERIALS AND METHODS

Case report

Female patient of 41 years of age, systemically sane referred of the Department of Periodontics DEPeI of FO UNAM with diagnosis of widespread severe chronic periodontitis. The reason for the query is «I want to see if I can do without my teeth». There was a clinical assessment (Figure 1) and requested diagnostic aids including study models (Figure 2), panoramic X-ray and lateral skull (Figure 3).

Figure 1.

Pre-treatment photographs.

Figure 2.

Initial models.

Figure 3.

Initial radiographs.

DIAGNOSIS

Female patient, 41 years of age, dolichofacial, convex profile, skeletal class II, bilateral molar and canine class II, proclination and protrusion of upper incisors, spacing, lip incompetence, gingival smile, and periodontal involvement.

TREATMENT PLAN

Orthodontic treatment with accelerated corticotomy, no extractions and 0.018” Roth fixed appliances was suggested.

Interconsultation with the Department of Periodontics was conducted and conventional phase I periodontal treatment that included personal plaque control, elimination of calculus, dental polishing, root scaling and planning of the periodontally involved teeth and extractions of dental organs number 18 and 28 was carried out. Once periodontal reassessment was performed the surgery was scheduled.

Corticotomy was then performed with a piezoelectric scalpel in D.O. #17-27 and two weeks later, it was performed in the lower arch, in dental organs #37-47 (Figure 4). Prior to the corticotomy 0.018” Roth fixed appliances were placed in the lower teeth.

• •

  Phase I: alignment and leveling. 0.012” NiTi to 0.016” SS

• •

  Phase II: coordination 2nd and 3rd order movements. 0.016” x 0.016” NiTi to 0.016” x .022” NiTi

• •

  Phase III: consolidation and stabilization. 0.016” x 0.022”SS

• •

  Retention.

Figure 4.

Corticotomies.

TREATMENT

In accordance with the arch sequence established in the treatment plan, orthodontic treatment was carried out. For space closure open coils, elastic thread and closed and intermediate elastic chains were used. Contraction loops and ¼” medium class II elastics were also used (Figure 5). Treatment time was 41 months and finally labial upper and lower fixed retainers were placed and lingual with 0.014” SS wire (Figure 6).

Figure 5.

Treatment.

Figure 6.

Fixed retainers.

RESULTS

At the end of the treatment, aesthetic, functional and occlusal results were achieved (Figures 7 to 10). The patient did not refer any TMJ symptomatology. Emphasis was made on the importance of continuing follow-up appointments at the Department of Periodontics to ensure periodontal health and orthodontic treatment stability with the necessary care of the retainers.

Figure 7.

Final photographs.

Figure 8.

Final radiographs.

Figure 9.

Final models and superimposition.

Figure 10.

Initial and final photographs.

DISCUSSION

Vercellotti in 2007 suggested piezoelectric corticotomy.^4,9 In 2009 Dibart published a less invasive transmucosal corticotomy technique called Piezocision.¹⁰ The authors mentioned a 60 to 70% treatment time reduction in comparison with traditional orthodontics. It is a physiological treatment based on the regional acceleration phenomenon and the maintenance of an adequate blood supply which is essential. This procedure is an alternative for adult patients with reduced periodontium and/or young patients with a complete periodontium.¹¹

CONCLUSIONS

Periodontally compromised patients can be treated successfully correcting their malocclusion when an interdisciplinary approach is used. The corticotomy procedure in this case reduced orthodontic treatment time with minimal trauma to the tissues despite the fact that the periodontium was reduced. The results obtained this case indicate that there are no adverse effects in the periodontium and this is clinically evident. Corticotomies provided efficiency and stability in orthodontic movements thus significantly avoiding root resorption.