The Orthodontist's Role in 21st Century Periodontic ...030ecaa.netsolhost.com/WordPress/wp-content/uploads/2010/06/SI… · The Orthodontist’s Role in 21st Century Periodontic-Prosthodontic

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he Orthodontist’s Role in 21st Centuryeriodontic-Prosthodontic Therapyilliam L. Mihram and Neal C. Murphy

Often orthodontists can be of considerable assistance in periodontal and

prosthodontic treatment. The orthodontists’ principle periodontal objective

with so-called facilitative care is to reduce or prevent excessive periodontal

surgery by establishing a physiologic alveolar crestal topography. This can

be done by recognizing the effect of orthodontic tooth movement (OTM) on

the alveloar topography and engineering the desired contour with selective

force gradients in concert with minor periodontal surgery. With this syner-

gistic orchestration between specials the prosthetic foundation is more

stable, the esthetic contour of the gingiva is improved and, most important,

unnecessary removal of alveolar bone is avoided because pathologic con-

tours due to tooth malalignment are eliminated prior to osseous surgery.

Case studies are integrated herein with emerging 21st century concepts of

periodontal tissue engineering (Semin Orthod 2008;14:272-289.) © 2008

Elsevier Inc. All rights reserved.

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ften orthodontists can be of considerableassistance in periodontic and prosthodon-

ic treatment. Dental alignment of the archesan facilitate prosthodontic objectives, a strategyeferred to as “facilitative orthodontics.”

The latter is not done simply to facilitate aath of insertion of a prosthesis. The orthodon-

ists’ principle periodontal objective with facili-ative care is to reduce or prevent excessive pe-iodontic surgery by establishing a physiologiclveolar crestal topography.

However, the orthodontic perspective is of-en omitted from treatment planning in casesf periodontic-prosthodontic collaboration.his may be due to many factors both culturalnd professional. The periodontist, prosth-dontist, or general dentist may not be awaref what is possible from orthodontics, or the

Former Associate Clinical Professor of Periodontics and Orth-dontics, University of Southern California, Los Angeles, CA; Pri-ate Practice, Santa Ana, CA.

Address correspondence to William L. Mihram, DDS, MSD, 801ustin Ave., Suite 708, Santa Ana, CA 92705. Phone: (714)58-1137; E-mail: [email protected]

© 2008 Elsevier Inc. All rights reserved.1073-8746/08/1404-0$30.00/0

tdoi:10.1053/j.sodo.2008.07.005

72 Seminars in Orthodontics, Vol 14, No

rthodontist may simply decline participationn limited objective therapy. Also, on a mostundamental educational level, most orth-dontic graduate programs spend the majorityf the curriculum with adolescent therapy ando not have an understanding of the specialeeds of the periodontal and prosthodonticommunities.

Adding another specialist in a comprehensivereatment plan can also reduce case acceptanceecause of the increased cost. However, patientsho appreciate the difference between pricend value (utility/cost) and the nuanced intel-ectual distinctions among financial, biological,pportunity, time, and morbidity costs can beiscriminating enough to appreciate the profes-ional effort. Even where such considerationsre dismissed as impractical, too theoretical, orrcane, at the very least it is incumbent on thethical professional to ensure that patients de-line such care only after being fully informed ofll treatment alternatives.

This article will explain, against the back-round of special periodontal therapy and a casetudy method, what the orthodontist can providend where the orthodontist is an integral part of
he periodontic-prosthodontic treatment. Orth-
4 (December), 2008: pp 272-289

mailto:[email protected]

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273Periodontic-Prosthodontic Therapy

dontists who want to participate will be en-anced ethically, financially, and intellectually.oreover, and perhaps most importantly, the

rthodontist will find it professionally gratifyingo extend his or her professional skills into aroader therapeutic perspective.

istory of “Facilitative Orthodontics”

n 1923, Dr. Isador Hirschfeld, a periodontist,eported that the position of the teeth in theirpatial relation to the alveolar process can affecthe shape and location of the periodontium.1

n the 1950s many periodontists hypothesizedhat perhaps one could change abnormal,onphysiologic topography of the periodon-

ium by changing the alignment of the roots.n essence, the tooth would be used as a “han-le” to push or pull the healthy periodontiumo the new desired position or shape (within ahenotypic potential). With this insight ahole new type of periodontal treatment waseveloped in which the orthodontist couldarticipate.

One of the first reported uses of this novelpproach, published by Brown2 in 1973, was theeduction of mesial periodontal defects by up-ighting mesially inclined molars. Technicallyhe mesial tipping produces only a gingival orseudopocket if no periodontal attachment haseen lost. However, a pocket deeper than 3 mmroduces microecosystems that promote therowth of periodontal pathogens and subse-

igure 1. Uprighting the molar pulls the crestal alveorthodontic therapy thus eliminates unnecessary bonprighting. (Bottom, right) Soft tissue (arrow) and n

uent attachment loss. o

Mesial tipping is the first link in a pathologicausal chain, but in a multifactorial causal sys-em the tipping is best referred to as a risk factor.igure 1 shows the reduction of the pocket withprighting of a mandibular second molar doney the present author while in graduate school

n the early 1970s. If the pocket is eliminatedith surgery alone, excessive bone must be re-oved, which can adversely affect more anterior

eeth.

alient Periodontal Issuesn Orthodontics

brupt changes in bone topography, caused ei-her by malocclusion or periodontitis, are notollowed by the overlying gingiva; this discor-ance between soft tissue and subjacent bonereates pockets. Even in an infection-free denti-ion, arch length deficiencies cause this bonyistortion and pocket formation. An alternativeo uprighting molars, or leveling and aligningeeth in each arch, is to take away unnecessarilyreater amounts of supporting bone (and, byefinition, part of the healthy periodontal liga-ent) on the bicuspids and other teeth. Figureillustrates these two alternative treatment ap-

roaches. Bone removal usually has to be ex-ended and contoured over several teeth to sur-ically eliminate abrupt changes in form andreate a physiologic topography conductive toeriodontal health.

All periodontal patients scheduled for osse-

oronally and thus reduces the vertical osseous defect.moval for pocket elimination. (Bottom, left) Beforeone (osteoid).

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us resective surgery should be given the option

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274 Mihram and Murphy

o undergo some orthodontic care to obviate thehance of unnecessary alveolar bone removal.igure 3 illustrates how, as molars drift mesially,hey tip gingivally and a pseudopocket (gingivalocket without attachment loss) will form on theesial aspect since the crown drifts on a mesio-

pical trajectory. This promotes plaque reten-ion and results in attachment loss, deepeninghe pocket even further.

rthodontic Elimination of Gingival Pocketsaused by Dental Crowding

f the “piling up” of soft tissue on the mesial

igure 2. If orthodontic uprighting is not done ashown in the bottom image, then excessive amountsf bone must be removed during osseous surgery.one coronal to the red inferior line represents themount of bone that is removed by standard osseousesection when no orthodontic treatment is used topright the molar. The coronal and apical white linesepresent the cemento-enamel junction and alveolarsseous crest, respectively. (Color version of figure isvailable online.)

spect of the molar can be reversed by molar (

prighting, excessive osseous surgery can bevoided. Ingber3 extended the concept to thepico-coronal dimension, introducing the con-ept of “forced eruption” as a method of treat-ng one and two walled osseous defects (Fig 4).

e later reported in 1976 that forced eruptionould enhance clinical crown lengthening,resently a popular technique, which ad-resses important prosthetic concerns.4 Thisnhances both esthetic values and functionhile decreasing morbidity associated with the

nadequate crown mass that reduces prosthesisetention.

To create clinical crown lengthening with-ut orthodontic therapy, usually bone and softissue must be removed around two teeth me-ial and distal to the affected tooth, thus wors-ning their periodontal status and esthetic re-ult (Fig 5). By extruding the tooth first, bonend soft tissue attachment is affected on onlyhe crown-lengthened tooth and the estheticutcome is maintained. The bone and softissue follow the root of the treated tooth ando surgery is needed on the adjacent teeth.

igure 3. (A) Note the deep vertical bony defect on theesial of the tilted molar. (B) Note how much healthy

lveolar bone had to be removed in this case because theatient did not elect orthodontic uprighting beforeomprehensive prosthodontic-periodontal therapy withacilitative orthodontic care. The excessive surgical mor-idity of this case could have been reduced with orth-dontic molar uprighting and selective decortication.
Color version of figure is available online.)

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hus, only one tooth is involved in surgery andot four to five.

In 1987, Pontoriero and coworkers5 reportedhat repeated gingival fiberotomies (minor inci-ion gingival fibers) can prevent the coronal dis-lacement of the gingiva and attachment appara-

us with the tooth during orthodontic extrusion; 2ears later Ingber6 reported on forced eruptions asmeans to improve cosmetic periodontal deformi-

ies (Fig 6). This author7 has combined Ingber’sechnique of extrusion for vertical defects withontoriero’s technique of repeated fiberotomies

igure 4. (A) Illustrations from Ingber’s definitiverticles (1974) illustrate the relationship between thelveolar crest attached to the root in a one-wallednfrabony defect (vertical or angular bone loss) andhe effect of facilitative extrusion. The interdiscipli-ary synergy between the periodontal and orthodon-

ic specialties has made this low morbidity treatmenteasible. (B) To eliminate the vertical defect (dottedine) the surgery must involve four more teeth (solidine) to blend the architecture.

o prevent coronal movement of the periodon- l

ium on a different aspect of the same tooth wherenormal periodontium presents. Without this crit-

cal modification, treatment can create iatrogenicingival pockets distally as mesial pockets are elim-nated by uprighting.

igure 5. (A) Crown lengthening with surgery only. Notehe inconsistent gingival margins (yellow arrow at c) on the

axillary central incisors in this schematic when only sur-ical apical positioning of the gingival margin is employedo lengthen the clinical crown. (B) The tooth is extrudedrst above (yellow arrow). Surgery is then done on onlyne tooth. (C) Surgical flap on adjacent teeth visualizinglveolar bone extruded with tooth root. Primary closure ofhe flap follows. (Color version of figure is available on-
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ase 1: Orthodontics as an Aid in Minimizingurgical Morbidity (Fig 7)he patient in Fig 7 presented with a vertical osse-us defect on the mesial aspect of the maxillary

ateral incisor. The tooth was orthodontically ex-ruded to bring the bone on the mesial defect to

igure 6. Leveling of the gingiva by extrusion of the lancisors, left (yellow) arrow, and consistent margins, righColor version of figure is available online.)

he normal level of the adjacent teeth as advised byngber. However, repeated fiberotomies were per-ormed only on the distal aspect, an intact peri-dontium, to prevent it from moving incisally, thusaximizing esthetics results. Unfortunately, many

eriodontists today still provide crown lengthen-

incisors. Note inconsistent gingival margins on lateraleen) arrow, after facilitative orthodontic management.

Figure 7. Extrusion with partial fiberotomies toeliminate mesial osseous defect and produce a nor-mal level of the periodontium. Alveolar bone comeswith the extruded surface of the tooth that has aninfrabony defect, left arrows (black). Partial fibe-rotomy on opposite proximal surface keeps bone atconsistent level, arrows (red). (Color version of fig-

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ure is available online.)

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ng for prosthetic reasons with only osseous sur-ery that adversely affects four more teeth as washown in Fig 5a. This is because many periodontistsave not been trained to proficiency in orthodontic

echniques or have not been influenced by an orth-dontist who is familiar with periorthodontic theory.he progressive orthodontist can help end this aca-emic deficiency simply by communicating basicooth root movement–bone response concepts.

ase 2: Orthodontics as an Aid in Correctingiological Width Violations

he patient in case 2 presented to the periodon-al office for a fifth opinion regarding her gin-ival recession and inflammation. That she hadhree sets of crowns placed, all causing biologi-al width impingement and further recessionFig 8). The four previous periodontists recom-ended more surgical crown lengthening to cor-

ect the biological width impingement, which ofourse would only cause more recession. A combi-ation of Pontoriero’s extrusion with fiberotomies

o correct the biological width violation and Ing-er’s cosmetic extrusion was recommended to

evel gingival margins.

The first photograph shows the gingival re-ession and biological width violation on theatient’s left maxillary lateral and central in-isors (numbers 7 and 8). Extrusion with fibe-otomies was first performed to correct theiological width violation. Then the teeth wereurther extruded to bring the gingival mar-ins, coronally, level with tooth numbers 9 and0. The next photograph shows the correction ofhe biological width problem and leveling of theingival margins with provisional crowns (Fig 8).

ase 3: Orthodontics as an Aid in Improvingmplant Sites (Fig 9)

his patient presented to Salama (H) andalama (M), the former a dually certified pe-iodontists and prosthodontist, the latter a du-lly certified periodontists and orthodontist.8

heir article described a very creative methodf tooth extrusion for implant site develop-ent in a compromised alveolus. The method

pplies Ingber’s forced eruption idea to in-rease the dimensions of the local alveolus.

In this case there is external and internal resorp-ion on the labial of the mandibular incisor giving

Figure 8. The right incisors were extruded with fibe-rotomies to correct biological width impingementfirst and then extruded further to level the gingival
margins. (Color version of figure is available online.)


Figure 9. (A) Before extru-sion of the lateral incisor(#23). Note the location ofthe cervical caries (arrow) atthe osseous crest (dashedline) that would requirecrown lengthening and un-necessary bone removal with-out orthodontic extrusion.(B) Gingival margin 2nd alve-olus are extruded coronal toadjacent gingival margins.Radiograph does not demon-strate extruded alveolar bonebecause it is not fully calci-fied. (C) Final prostheses areseated and cemented to thar-moneous consistent gingivalmargins. (Color version of
figure is available online.)

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t a poor prognosis. If routine removal even withone grafting were done, there would be a labialefect. By extrusion of the tooth over 7 mm thereas sufficient, indeed an overabundance of hardnd soft tissue enough to place an implant (Fig 9).

Minor” Orthodontic Crowding as a “Major”eriodontal Problem

narrow interproximal space present due torch length or tooth size deficiencies may resultn a constriction of the interproximal bone. Theompromised bone resulting from a reducednterradicular distance can be a challenge foroth periodontists and prosthodontists. Thiseptal constriction is an iatrogenic compromisehen orthodontists reduce interproximal con-

acts to the point where excessively reducedstripped) proximal surfaces are dysfunctionalnd the gingival embrasure is moved apical tohe interproximal gingival margins. Extendinghe embrasure this far apically provides a fertileiche for microbial biofilm proliferation beyond

he reach of floss and scalers and compromisesost resistance by reducing the vasculature of

nterproximal alveolar bone and its vasculature.eptal bone mass is also reduced where rootsan migrate closer together due to interproxi-al caries or a local arch length deficiency

“slipped contact”). This deficiency may be trivi-lized or summarily dismissed by mechanicallyriented clinicians as a so-called minor orth-dontic or a simple “cosmetic” problem that canimply be covered up with a veneer or similarrosthesis.

igure 10. (A) Note the widened interproximal spac
odily distal-driving of the second molar with facilitative o
ase 4: Recognition of Crowding as aeriodontal Concern (Fig 10)

rthodontists must be aware of dental contactistortion from a biological and prosthodonticerspective not merely as an esthetic issue. A

ocal problem may not be insignificant to theeriodontist who has to regenerate bone sincenarrow septum does not lend itself to regen-

ration as predictably as well-endowed inter-roximal bone.

The narrowed space also makes prostheticestoration difficult, resulting in improper con-ours, tissue impingement, and food impaction.s the two adjacent cribriform plates of the

ooth sockets (radiographically lamina dura)ove closer together, there is a loss of medul-

ary bone and its blood supply. If the patient isusceptible to periodontitis, this impairedone can be lost very rapidly and the treatmentecomes complicated. Widening of the inter-roximal bone simply by orthodontic alignmentf the dental arch can greatly enhance local hostesistance and thus the prognosis of an infectedentition (Fig 10). This is an important fact toppreciate, since of all the components of mal-cclusion, arch length deficiency, not cross bitesr overbite/overjet deformities, is the most sig-ificant from a periodontic perspective. The

reatment of interproximal tissue constrictionnd contact point/embrasure distortions is therinciple periodontal reason to eliminate crowd-

ng. Interestingly, alveolus “deficiency” can beeen as an illusory and misleading term thatresupposes a popular but mythical “geneti-

etween arrows) and (B) healthier bone produced by
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ally fixed, small jaw/large teeth” fallacy. Therch displays “crowding” not because an im-utable arch length is deficient; the malleable

rch length is deficient because the teeth arerowded.

The small-jaw-large-teeth fallacy does not fitith the facts of alveolus ontogeny or guidedrch development through the transitionalentition. In instances where the clinician maye unfamiliar with alveolus ontogeny, the al-eolus is allowed to become deficient (de-ormed) by nonintervention. The eliminationf crowing by leveling and aligning, an alveo-

us development exercise, is for the periodon-ally sophisticated orthodontist who sees orth-dontic treatment as more than cosmetic, theost compelling periodontal rationale for

rthodontic therapy. For these reasons, evenimited orthodontic care is helpful to patientshen the option for more comprehensive care

s not possible.

he Importance of the Periodontal Tissueso Orthodontics

he importance of the periodontium to orth-dontic care is comparable to the importancef civil engineering to architecture. However,or many mechanically oriented orthodontistshe subjacent periodontium is often not con-idered sufficiently but merely as a distractionrom efficient biomechanics. This misunder-tanding or nonappreciation is in part due tohether this arena appropriately lies in theomains of periodontics or orthodontics. Thepinion of many periodontists, including theresent author, is that alveolus topographicalngineering is periodontics with an orthodon-ic component. It is essential that orthodonticducational entities develop more explicit in-truction in periodontology, alveolus develop-ent, and pathophysiology. Orthodontics is

onsidered to be much more than simply ansthetic domain.

ase 5: The Use of Implant Supportednchorage with Selective Decortication (Fig 11)

rthodontic therapy can be greatly facilitatednd enhanced with the use of prosthetic im-lants. The patient in Fig 11 presented with annterior open bite and pathological migration
flaring) of the maxillary teeth. Endosseous im- a
lants in the molar areas can be used as anchor-ge to retract the maxillary teeth. Furthermorehe anterior distorted alveolar architecture cane reengineered with periodontally acceleratedsteogenic orthodontic augmentation (PAOO)urgery to produce regional acceleratory phe-omenon (RAP), which results in a vast increase

n osteoblast and osteoclast activity. Clinicallyhis is manifest as a “softening” of the healing

igure 11. (A) Note the excessive overjet. (B) Pros-hetic implants in the molar areas were used as an-horage to move the maxillary teeth distally. (C) Notehe reduced overjet. (Color version of figure is avail-ble online.)

lveolus bone.

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igure 12. (A) Note the vertical maxillary excess and open bite. The treatment plan avoided consideration ofrthognathic surgery positing the dentoalveolar complex (periodontium and alveolar bone) as a reactive organeparate from the subjacent skeletal maxilla. Thus, the morbidity of orthognathic surgery is considered excessiven relation to the patient’s sensibilities and chief complaint. (B) Note vertical impaction of posterior dentitionith orthodontic temporary anchorage devices. The alveolus and periodontal structures (dentoalveolar com-lex) allows the alveolus to be molded as a separate “organ” using the teeth as “handles” to reshape the alveolar
one. Thus, reference to the “maxilla” in this sense is a misnomer. (Color version of figure is available online.)

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Selective Alveolar Decortications versus“Old-Fashioned Corticotomy”

eriodontally accelerated orthodontic toothovement combined simultaneously with osteo-

enic surgery can vastly improve the orthodonticutcome. The “new approach,” however, is oftenonfused with an old 19th and 20th centuryrocedure called corticotomy. Corticotomy wasften a highly morbid, hospital-based procedureictating surgical cuts made entirely through theuccal and lingual alveolar process periapically.he latter risked the devitalization of teeth asell as alveolar necrosis. Moreover some sur-eons made such deep bony cuts interproximallyhat the orthodontist considered it regional or-hognathic surgery. Since this unrefined tech-ique lacked an evidence base and had a highorbidity, it justifiably enjoyed rather little pop-

lar support.

Tissue Engineering for the OrthodonticSpecialty

o address the need for surgical orthopedics
f the alveolus, a new, refined, and evidence- t
ased technique is a much more gentle surgi-al procedure in which the periodontist uses a2 round bur to place small superficial holesust barely through the cortical plate on theuccal and/or lingual sides of the alveolarrocess. This is done for the explicit purposef engineering a therapeutic physiology, noto reposition or juxtapose bony parts. Thisoint is paramount because the purposefulnd permanent alteration of alveolar form to aovel design is achieved through a combina-

ion of somatic cell therapy (bone regenera-ion) and gene therapy (alteration of geneticxpression). It warrants reiteration that mod-rn selective alveolar decortication is not in-pired, designed, or intended to move bonyarts. Tissue engineering principles inherent

n the PAOO protocol and periodontal regen-rative science have delivered an entirely newimension in dentofacial orthopedics. More-ver, the superficial scarification necessary tolicit a commensurate degree of “optimal re-ponse” is so benign that a practical and pre-ictable alternative to hospitalization is now in

re 13. The patient’s normal attached gingiva hasn apically repositioned (arrows) before extrusion tovide esthetic zone of attached gingiva without reces-, which can occur with laser surgery directly into theosa. (Color version of figure is available online.)

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an now legitimately add the term “tissue en-ineering” to the specialty lexicon.

ase 6: Treatment of an Anterior Open BiteFigs 12, 13, 14)his, patient presented with occlusal contactn unilateral second molars and severe gener-lized gingival and bony dehiscences. Bonyehiscence and fenestrations can be visualizedith cone beam volumetric computerized to-ography (CBVCT), in the initial records

igure 14. (A) Before: Note anterior open bite and gingival recession improved. (Color version of figure

igure 15. Before: Note cross bite on right side withaxillary arch too small for mandibular arch. The

atient also has pockets and gingival recession. (

Figs 20, 21). If dehiscences or fenestrationsre present in adults it would be wise to useAOO before arch expansion. If thin alveolarone is present and facial features permit it,icuspid extractions can be justified. If, how-ver, thick alveolar bone is evident in the coneeam computerized images, lower incisor pro-lination may be attempted with relative peri-dontal impunity.

Buccal and lingual flaps were reflected andhe stippling in the bone was done with a #2

al recession. (B) After: Anterior open bite closed andailable online.)

igure 16. After: Cross bite and midline corrected.ockets removed and mucogingival defects improved.

ingiv

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ound bur from first molar to first molar inoth arches to orchestrate a new and novelherapeutic alveolar ontogeny not possibleith either periodontal surgery or orthodontic

herapy alone. Graft material was then placedn the labial aspects of a decorticated alveolarortex and selectively on the lingual aspects ofhe alveolus where more so-called alveolusexpansion” was needed. The patient alsoad gingival recession on most of her teeth.herefore, soft connective tissue grafting was

is

eeded from first molar to first molar. The bonerafting material consisted of demineralizedreeze-dried bone allograft (DFDBA; also com-

only referred to as demineralized bone matrixDBM] in medical orthopedics) and “extended”ith a bovine-derived mineralized inorganic xeno-raft (Osteograft/N-300; CeraMed Dental, LLC,akewood, CO 80228). Palatal donor tissue wasliminated in favor of an acellular freeze-drieduman dermis (Alloderm; Life Cell Corporation,ranchburg, NJ 08876).

ure 17. (A) Before treatment photographs. Notetients flattened lower facial profile. Although bicus-

extraction may be unavoidable in teens, this con-nital absence demonstrates possible developmentalest since the development of the adult face is unpre-table. Consequently untoward and unforeseeable fa-l profile flattening can occur but happily is nowersible with outpatient periodontally accelerated os-genic orthodontic augmentation (PAOO). (B) Noteanterior horizontal overjet. (Color version of figure

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This allograft soft tissue was then placed overhe bone grafts and the flaps were coronallyepositioned superficial to the allograft to treatecession, fortify the soft tissue-dense attachedingiva, and provide a more stable dentogingivalunction at a more coronal level (Fig 14). The

igure 18. (A) Before periodontally accelerated osteeeks. Note the midline shift and thin periodontium (xtraction therapy. (B) Full thickness mucogingival flust through the cortical plate with a #2 round burccelerate OTM and enhance stability, the patient’s creeze-dried allograft (also known as demineralized birection of desired tooth movement without affecteparate operative “organ.” (E) Due to the preservatio
as little discomfort. (Color version of figure is available o
nterior open bite was easily closed in 7 monthsith no ancillary orthognathic surgery. Wilckond coworkers9,10 contend that these results areore stable than orthognathic surgery and Mur-

hy11 has explained the stability in terms ofltered phenotype.

ic orthodontic augmentation (PAOO) surgery at 2lled washboard effect), which often indicates bicuspidreflected. (C) Selective alveolar decortication (SAD)ates a therapeutic reversible regional osteopenia toobjective for selecting PAOO. (D) A demineralizedmatrix or DBM) widens the alveolus process in thehe subjacent maxilla. The alveolus is considered athe interproximal tissues and primary closure, there

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ase 7: Dental Crossbite (Figs 15, 16)he patient in case 7, a 57-year-old Hispanic fe-ale (Fig 15) presented with a presumptive max-

llary and manifest alveolus transverse deficiencyAngle Class III skeletal pattern), a dental archhat was “too small” relative to the mandibularrch homologue. A surgically assisted rapid palatal

igure 20. Orthodontic microimplant (TAD) acts asbsolute anchorage to move the molars distally asoiled spring moves premolar mesially to open previ-us orthodontic extraction site and enhance flattened

ower facial profile. (Color version of figure is avail-
ble online.) a
xpansion was initially thought to be necessary toreat her with conventional orthodontics. How-ver, because the patient was in her fifth decade ofife, the osteogenic potential of the alveolus waseemed inadequate a priori so that buccal gingival

igure 19. (A) Note the bony dehiscence top (greenrrow) and fenestrations bottom (blue arrows). (B)one grafting to change the B point labially whilending stability, preventing gingival soft tissue dehis-

ence, and providing an alternative to bicuspid extrac-on therapy as lower facial profile is enhanced. (C)rimary closure with primary intention healing en-res minimal postoperative discomfort that often ac-

ompanies open surgical wounds and healing by sec-ndary intention. (Color version of figure is availablenline.)

igure 21. Final orthodontic treatment and prepros-hetic treatment with nearly ideal overjet/overbiteelationship. Murphy (2006)11 refers to this as anpigenetically engineered alternative regional pheno-ype (facilitative orthodontics). Note thickness of

andibular gingiva and cervical position despite mildarginal gingivitis. (Color version of figure is avail-

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ecession and generalized bony dehiscence pre-luded rapid palatal expansion (RPE) of any kind.he patient also had generalized gingival reces-

ion and periodontal pockets in the posterior areasf her dentition. An asymmetric Angle Class IIIkeletal malocclusion created a posterior cross biten the right side and an end-to-end incisal rela-ionship. The dental midline was deviated and the

axillary and mandibular skeletal midlines wereot coincident as evident in Fig 15.

The alveolar process of the mandibular incisorsas extremely thin on both the buccal and lingualspects. To correct these dento-skeletal deformi-ies, periodontally selective decortication surgeryas performed with DFDBA grafts in all areas of

he maxillary alveolus so that the maxilla dentalrch could be expanded. Periodontal surgeryas also performed in the mandibular anteriorlveolus from bicuspid to bicuspid to “thicken”he alveolar process by augmenting the facial-ingual dimension with bone and dense connec-ive tissue on both the buccal and lingual as-ects. Connective tissue grafts of Alloderm werelaced from first molar to first molar on the

abial aspects of the maxillary and mandibulareeth and on the lingual aspect of the mandib-lar anterior teeth. One can compare beforend after photographs in Figs 15 and 16. Theotal treatment time in fixed appliances was 7

onths. This treatment outcome was consideredptimal since it was essential for efficient prosth-

igure 22. Bony dehiscences and fenestrations cane discovered by cone beam volumetric computerizedomography in the initial records. These radiographsre similar to CT scans but have better resolution. Ifehiscences or fenestrations are present in adults itould be wise to use periodontally accelerated osteo-enic orthodontic augmentation before dental archxpansion to ensure that the alveolus form can ac-ommodate dental arch expansion. (Color version of

Tgure is available online.)

dontic rehabilitation. The short treatment timeas also optimal from a periodontal perspectiveecause it minimized a concomitant bacterial

oad that becomes increasingly pathogenic withime.

ase 8: Camouflage of Severe Skeletalysplasia (Fig 17)

his patient presented with a mild Angle Class IIkeletal relationship and a severe anterior over-et (Fig 17). All four of her second bicuspideeth were congenitally missing. Since the pa-ient had declined orthognathic surgery, herrevious orthodontist had decided to leave theilateral atrophic edentulous space in the max-

llary second bicuspid areas untreated to ensureetter lip support. The previous orthodontistonsidered that anterior teeth could not be pro-lined with conventional biomechanics withoutausing gingival recession. Others contend thathe lower incisor should not be moved too farabial to B point, or more than 2 to 4 mmnterior to the cephalometric line joining A-Po.owever, these traditional clinical guidelines

re being questioned as the result of emergingeriodontal standards, information presented inhis article, and other recent orthodontic re-earch.12

The original treatment plan resulted in annterior open bite with no anterior guidance inxcursive mandibular movements. The latter sit-ation requires for correction a combination ofstandard orthodontic biomechanical protocol,one grafting for implant site development, andugmentation of maxillary and mandibular an-erior alveolus. This would then be followed bymplant placement and both functional and cos-

etic dental restoration.The orthodontic brackets were placed and

rchwires activated 2 weeks before periodontal-rthodontic surgery. It was decided to open allecond bicuspid dental spaces to 7 mm for im-lant site development. Bone grafting was per-ormed on the labial alveolus to augment thedentulous second bicuspid areas. In Fig 19 notehe bony dehiscences on the mandibular anterioreeth. Crown lengthening via osseous resectionlaced the periodontium at the correct relation-hip to the cemento-enamel junction. Perforationn the cortical plate was done at this first surgery.
he maxillary anterior teeth were proclined

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lightly to improve lip support and to develophe implant site at the edentulous maxillary sec-nd bicuspid areas. Due to the fact that noecorticating perforations were done (andence there was no decalcification elicited)

or the patient’s left mandibular molars (toothumbers 18 and 19), they provided relative an-horage for midline correction and incisor pro-raction.

Several months passed to accomplish thebove results and decalcification of the RAP dis-

igure 23. Cone beam volumetric computerized tomoas seen in Fig 19A) that allow the orthodontist to treoreover, the quantity and quality of the bone can d

redictability of side effects. Without this new imagingnvestigating whether or not a true dehiscence is presncision, the surgery is faster and produces less disco

ipated significantly approximately 6 months af- r

er surgery. Selective decortication surgery andone grafting was then performed on the pa-ient’s mandibular left posterior alveolus to ac-elerate distalization of the molars, using thenterior dentition as the relative anchorage. Anrthodontic microimplant was also placed in theetromolar area distal to the mandibular leftecond molar to provide absolute anchorageFig 20). After 4 to 5 weeks of healing and toothovement, prosthetic implants were placed in

he four bicuspid areas. Note the preprosthetic

hy can uncover alveolar and periodontal bony defectsth much less risk to patients than previously thought.mine if extraction therapy is possible with a greaternology, part of the surgical protocol is “exploratory”y imaging the alveolus topography before the initial

t to the patient.

grapat wietertech

ent. B

esults in Fig 21. Prosthetic treatment will be

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1

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one to establish an esthetic and functionallyhysiologic mutually protected occlusion. Seeigures 22 and 23 show the advantages of CBCT.

onclusions

ince sophisticated treatment requires excellentommunication, the interdisciplinary treatmentescribed required treatment coordination be-

ween well-informed clinicians in a variety ofelds. Although these procedures may seemaunting at first, repeated interdisciplinary col-

aboration results in very efficient protocols andxecution that patients appreciate and benefitrom. This author has, since the 1970s, enjoyedhe fellowship and professional collaboration ofrthodontists in a fruitful career13 and sustainedrofessional enthusiasm with other colleagues.14,15

opefully this spirit of interdisciplinary collabora-ion (as demonstrated in Figure 18) will inspireeaders to engage in their own interdisciplinaryollaboration, and advance the frontiers of therthodontic specialty’s scientific basis well into the1st century.

eferences1. Hirschfeld I: A study of skulls in the American museum

of natural history in relation to periodontal disease. JDent Res 5:2-41, 1923

2. Brown IS: The effect of orthodontic therapy on certaintypes of periodontal defects: 1. Clinical findings. J Peri-odontol 44:742-56, 1973

3. Ingber JS: Forced eruption. Part I. A method of treatingisolated one and two wall infrabony osseous defects-ratio-
nale and a case report. J Periodontol 45:199-206, 1974
4. Ingber JS: Forced eruption. Part II. A method of treatingno restorable teeth-Periodontal and restorative consid-erations. J Periodontol 47:203-16, 1976

5. Pontoriero R, Celenza F, Ricci G, et al: Rapid extrusionwith fiber resection: a combined orthodontic-periodon-tic treatment modality. Int J Periodontics RestorativeDent 5:31-43, 1987

6. Ingber JS: Forced eruption: alteration of soft tissue cos-metic deformities. Int J Periodontics Restorative Dent9:416-425, 1989

7. Mihram WL: The tilted molar; a prosthetic and peri-odontal dilemma. Oral Health 81:11-15, 1991

8. Salama H, Salama M: The role of orthodontic extrusiveremodeling in the enhancement of soft and hard tissueprofiles prior to implant placement. Int J PeriodonticsRestorative Dent 4:313-333, 1993

9. Wilcko MW, Wilcko MT, Bouquot JE, et al: Rapid orth-odontics with alveolar reshaping: two case reports ofdecrowding. Int J Periodontics Restorative Dent 1:9-19,2001

0. Wilcko WM, Ferguson DJ, Bouquot JE, et al: Rapid orth-odontic decrowding with alveolar augmentation: casereport. World J Orthod 4:197-205, 2003

1. Murphy NC: In vivo tissue engineering for orthodontists:a modest first step, in Davidovitch Z, Mah J, SuthanarakS (eds): Biological Mechanisms for Tooth Eruption, Re-sorption and Movement. Boston, Harvard Society for theAdvancement of Orthodontics, 2006:385-410

2. Djeu G, Hayes C, Zawaideh S: Correlation between man-dibular central incisor proclination and gingival reces-sion during fixed appliance therapy. Angle Orthod 72:238-245, 2002

3. Mihram WL: Dynamic biologic transformation of theperiodontium: a clinical report. J Prosthet Dent 78:337-3405, 1997

4. Roblee RD: Interdisciplinary Dentofacial Therapy: AComprehensive Approach to Optimal Patient Care. Chi-cago, Quintessence Publishing, 1994

5. Kokich V: Managing complex orthodontic problems: theuse of implants for anchorage. Semin Orthod 2:153-160,
1996

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