- Branschofsky M.
- Beikler T.
- Schäfer R.
- Flemming T.F.
- Lang H.
Therefore, orthodontic treatment may be required to achieve tooth movement, reestablish functional dentition, and restore facial esthetics. Appropriate treatment planning in these patients should be conducted by a team comprising a periodontist, an oral surgeon, and an orthodontist.
,
- Gonen Z.B.
- Alkan A.
- Ekizer A.
- Kutuk N.
- Tasdemir Z.
Such approaches use both soft-tissue regeneration and periodontally accelerated osteogenic orthodontics (PAOO) to regenerate periodontal supporting structures.
- Mandelaris G.A.
- Richman C.
- Kao R.T.
This strategy enables the correction of osseous defects and a simultaneous increase in the amount of soft tissue that can be used for subsequent regenerative approaches.
- Lee J.W.
- Lee S.J.
- Lee C.K.
- Kim B.O.
with the goal of reporting on an appropriate treatment strategy that can ensure that the patient’s esthetic requirements are met in the course of reliably treating complex cases. The sequential periodontal and orthodontic treatment plans used to treat our patient consisted of 4 stages (Figure 1): initial periodontal therapy (stage 1), clear aligner–mediated elimination of traumatic occlusion (stage 2), subepithelial connective tissue graft (SCTG) and PAOO with bone grafting to augment soft and hard tissue (stage 3), and closure of the remaining space with clear aligners (stage 4).
Figure 1Schematic overview of the multidisciplinary sequential treatment approach used in this case. PAOO: Periodontally accelerated osteogenic orthodontics. SCTG: Subepithelial connective tissue graft.
Case Description
Figure 2Initial and final intraoral images and cephalometrics.Pretreatment intraoral photographs (A), lateral cephalogram (B), and panoramic radiograph (C).Posttreatment intraoral photographs (D), lateral cephalogram (E), and panoramic radiograph (F). G. Cephalometric tracings at pretreatment (black line) and posttreatment (red line) superimposed on the sella-nasion plane at sella. H. Cephalometric summary. FH: Frankfurt horizontal plane. LI: Long axis of the mandibular incisor. SN: Sella-nasion. MP: Mandibular plane. SNA: Angle between sella-nasion line and nasion-A point line. SNB: Angle between sella-nasion line and nasion-B point. UI: Long axis of the maxillary incisor.
Figure 3Traumatic occlusion was adjusted by means of using clear aligners (series 1) to rectify the anterior crossbite. A, B. Spacing in the mandibular arch, space between the mandibular canine and premolar, anterior crossbite. C, D. Normal overjet and overbite.
Figure 4Clinical images of subepithelial connective tissue graft (SCTG). A. Connective tissue was harvested from the palate area. B. The connective tissue graft was placed on the coronal part of the recessed area. C. Interrupted sutures were used to close the partial-thickness flap. D. A contemporaneous frenectomy was performed. E. Primary closure. SCTG improved the keratinized tissue width in this patient, from 1.5 mm before SCTG (F) to 4 mm at 3 months after SCTG (G).
Figure 5Full-thickness envelope flap reflection and circumferential corticotomy (A). Bone graft placement (B). Placement and fixation of a bioabsorbable collagen membrane (C). Primary closure (D).
Figure 6Clinical images from stage 1 (A), 3 months after subepithelial connective tissue graft (B), and 6 months after stage 2 (C). Three-dimensional cone-beam computed tomography images obtained at 3 months after subepithelial connective tissue graft (D) and at 6 months after stage 2 (E).
Figure 7A detailed overview of the location of the measurement plane for the selected tooth. Correlated planes were identified using 3 intersecting guidelines, with red, blue, and green corresponding to the axial, coronal, and sagittal planes, respectively. The location of the axial plane was adjusted by passing the red guideline through the cementoenamel junction of the selected tooth in both the sagittal and coronal views, after which the blue guideline was rotated until the intersecting line reached its shortest length (A). The green guideline was then rotated until it passed through the root apex and the midpoint of the incisal margin (B). The blue guideline was rotated until it passed through the root apex and the cusp (C). W = cd represents the buccal bone thickness at the middle between the cementoenamel junction and apex (D). H = eb represents buccal vertical bone level, corresponding to the distance from the labial aspect of the apex to the most coronal level of the alveolar bone at the labial cortical surface (E).
Figure 8The largest labiolingual section of the anterior teeth in the sagittal view. First row: before periodontally accelerated osteogenic orthodontics. Second row: 6 months after periodontally accelerated osteogenic orthodontics (red arrows show marked hard-tissue augmentation). GOBR: Guided orthodontic bone regeneration.
- Sun L.
- Yuan L.
- Wang B.
- Zhang L.
- Shen G.
- Fang B.
One examiner (L.S.), other than the provider, conducted all measurements.
Stage 1: initial periodontal treatment
- Tonetti M.S.
- Greenwell H.
- Kornman K.S.
During the initial periodontal treatment, a periodontal specialist (M.C.) performed scaling and root planing and provided oral hygiene instructions. A power toothbrush plus mouthrinse for interdental cleaning was introduced. Use of an interdental brush was forbidden in the esthetic area, to avoid unnecessary gingival recession. Inflammation was controlled, and there were no bleeding sites with probing depth equal to or greater than 4 mm (eFigure, B, available online at the end of this article).
Stage 2: clear aligner–based orthodontic treatment (series 1)
Clear aligners were used to adjust traumatic occlusion by means of rectifying the anterior crossbite of the patient. This first series of aligner treatments consisted of a series of 18 aligners designed to align, intrude, and retract the migrated mandibular incisors. The patient was directed to wear aligners continuously other than during eating or toothbrushing and to change aligners every 10 days. Once per month, we saw the patient to evaluate the aligner and periodontal tissue status.
Stage 3: soft- and hard-tissue augmentation
As the patient exhibited a thin periodontal phenotype and gingival recession, SCTG was conducted to improve recession, root coverage, and keratinized tissue width. Without such treatment, there was insufficient gingival coverage available for bone grafting. All surgical procedures were performed under local anesthesia. Papilla-sparing incisions were made during flap creation. After root surface demineralization by means of citric acid and tetracycline gel, a 1.5- through 2-mm thick connective tissue graft was transplanted stably from the maxillary left palate to the labial side of the mandibular anterior teeth.
- Wang B.
- Shen G.
- Fang B.
- Yu H.
- Wu Y.
- Sun L.
This increased alveolar volume, together with the more structurally complete periodontium, enabled us to mobilize teeth more safely and efficiently in this patient. A full-thickness envelope fap was reflected facially (Figure 5). Corticotomy was conducted using a piezoelectric surgical device (Piezosurgery, Silfragent) between the roots of the mandibular anterior teeth, extending from 2 mm from the top of the alveolar ridge to the apical area, with a depth of less than 3 mm within the bone. Transverse cortical osteotomy was performed in an area less than 5 mm from the apical area. After corticotomy, reconstituted deproteinized bovine bone (Bio-Oss, Geistlich Biomaterials) was combined with blood obtained from the surgical area before placement in the recipient site. Next, a bioabsorbable collagen membrane (Bio-Guide, Geistlich Biomaterials) was placed over the grafted material. An FS-2 needle and 4-0 absorbable sutures (Biosyn, Covidien) were then used for suturing, penetrating the periosteum at the coronal aspect toward the periosteal releasing incision and passing through the membrane to produce a simple surgeon’s knot. A combination of vertical mattress and sling sutures was used for primary closure. The postoperative instructions to the patient were identical to those after SCTG.
Stage 4: clear aligner–based orthodontic treatment (series 2)
At 2-weeks after the corticotomy, active orthodontic treatment was resumed. The second clear aligner series was used to close the remaining space in the maxillary and mandibular arches. The patient was directed to change each of the 24 aligners after 7 days over a 6-month treatment period. After treatment, the patient indicated that he was satisfied with the treatment outcome and was given an appropriate thermoplastic retainer for retention. Every 3 months during the treatment period, the patient underwent periodontal maintenance.
Clinical outcomes
Discussion
- Shen X.
- Shi J.
- Xu L.
- Jiao J.
- Lu R.F.
- Meng H.X.
Anterior crossbite is always associated with a number of complications, including gingival recession of the mandibular incisors, incisal wear, and tooth migration.
- Seehra J.
- Fleming P.S.
- DiBiase A.T.
Many aspects of occlusion can contribute to abnormal migration of teeth, and more than 1 of those factors may be present in an individual patient. Pathologic tooth migration (PTM) is tooth displacement that results from imbalanced tooth-retention force.
- Jepsen K.
- Jaeger A.
- Jepsen S.
Soft-tissue forces of the tongue, cheeks, and lips are known to cause tooth movement and, in some situations, PTM.
Periodontitis can also drive PTM, and, in these cases, orthodontic realignment can complement periodontal management.
- Kruk H.
- Bensaid X.
- Chevalier G.
- Cherkaoui S.
- Fontanel F.
- Danan M.
In our case, we observed PTM in both the maxillary and mandibular anterior teeth regions, along with gingival recession and excessive space. Normal forces exerted on teeth with reduced periodontal tissue also can cause secondary occlusal trauma. In a case such as this, a combined periodontal-orthodontic approach to treating secondary occlusal trauma can ensure proper rehabilitation of periodontal, occlusal, and esthetic parameters.
- Thierens L.A.M.
- Van de Velde T.
- De Pauw G.A.M.
- Branschofsky M.
- Beikler T.
- Schäfer R.
- Flemming T.F.
- Lang H.
Occlusal trauma can aggravate this condition and result in further loss of attachment, thus making it challenging to provide the orthodontic treatment necessary to achieve an appropriate occlusal relationship. When malocclusion drives infrabony defect progression, conducting periodontal surgery before correcting the malocclusion can result in an uncertain postoperative prognosis and may hamper long-term dental stability. Therefore, we ensured that orthodontic treatment took precedence over periodontal surgery in this patient to correct his anterior crossbite. With the occlusal trauma abrogated, we were able to improve the odds of good surgical outcomes.
- Verrusio C.
- Iorio-Siciliano V.
- Blasi A.
- Leuci S.
- Adamo D.
- Nicolò M.
Clear aligners are effective in moving teeth at a relatively low cost, over a relatively short period, while also allowing orthodontic management of crowding, spacing, and arch size. Relative to traditional fixed appliances, patients treated with clear aligners exhibit better periodontal health.
- Lu H.
- Tang H.
- Zhou T.
- Kang N.
As such, the use of these clear aligners may be a valuable treatment option for patients with PTM, as they are compatible with oral hygiene maintenance and esthetic needs.
- Lee J.W.
- Lee S.J.
- Lee C.K.
- Kim B.O.
However, these aligners always have serious undercuts given the gingival recession in patients with PTM. These undercuts not only make it difficult to wear and remove aligners but also exert a significant force on the migrated teeth. In our case, we checked and adjusted the margin of the clear aligners to avoid serious undercuts during the orthodontic treatment process, such that the orthodontic force used was light and better periodontal surgery outcomes could be achieved.
- Wilcko M.T.
- Wilcko W.M.
- Murphy K.G.
- et al.
Clinicians can select between hard- and soft-tissue augmentation protocols on the basis of projected tooth movement as well as existing soft- and hard-tissue architecture in surgically facilitated orthodontic cases.
Papilla-sparing incisions seem to induce less tissue response after flap surgery than sulcular incisions in oral surgery.
- Fickl S.
- Fischer K.R.
- Negri B.
- et al.
There may be certain advantages associated with the use of a pouch design and tension-free wound closure, which facilitate soft-tissue regeneration, allowing for more extensive bone augmentation while also facilitating contemporaneous correction of vertical and horizontal defects in the labial aspect of the mandibular anterior area.
- Ma Z.
- Zheng J.
- Yang C.
- Xie Q.
- Liu X.
- Abdelrehem A.
- Makki L.
- Ferguson D.J.
- Wilcko M.T.
- et al.
- Brugnami F.
- Caiazzo A.
- Mehra P.
Demineralization of a thin layer of bone over the root prominence after corticotomy surgery can optimize the response to the applied orthodontic forces. When this is combined with alveolar augmentation, the outcome is no longer dependent solely on original alveolar volume and osseous dehiscence, and fenestrations can be corrected over vital root surfaces, as substantiated by computed tomographic and histologic evaluations.
- Wilcko M.T.
- Wilcko W.M.
- Murphy K.G.
- et al.
- Schlegel A.K.
- Donath K.K.
It should be noted that Intrusion and constriction usually are not deemed to be high risk factors for recession if the root torque is controlled during intrusion. Retracting proclined incisors can improve tissue thickness and the presence of labial bone, and the tissue also will migrate coronally with retraction. Directionality of tooth movement has a considerable effect on the outcomes. As far as we observed in our case, the retroclination of the mandibular anterior teeth is the most recommended indication.
Conclusions
- Jiang Q.
- Li J.
- Mei L.
- et al.
Our patient had a congenital weak buccal plate, and the situation was worsened by periodontitis. Subsequently, traumatic occlusion arose owing to insufficient periodontal support, leading to anterior proclination. Thus, for retention, we had to focus on periodontal maintenance and prevention of occlusal trauma.
Although there are limitations to our case report, it illustrates that gingival soft-tissue transplantation together with PAOO may be a valuable approach for treating patients with a thin periodontal phenotype and who lack a buccal plate, provided that CBCT and clinical findings justify such an approach. However, future research will be necessary to assess the reliability and stability of outcomes associated with such a treatment strategy in similar patients over the longer term.
Biography
Dr. M. Chen is the department head, Department of Periodontology, Shanghai Stomatological Hospital, Fudan University, Shanghai, China.
Dr. X. Chen is an attending physician, Department of Periodontology, Shanghai Stomatological Hospital, Fudan University, Shanghai, China.
Dr. Sun is an attending physician, Department of Periodontology, Shanghai Stomatological Hospital, Fudan University, Shanghai, China.
Dr. Liu is a professor, Department of Orthodontics, Shanghai Stomatological Hospital, Fudan University, Shanghai, China.
Article Info
Publication History
Published online: February 28, 2022
Publication stage
In Press Corrected Proof
Footnotes
Disclosures. None of the authors reported any disclosures.
Dr. M. Chen and Dr. X. Chen contributed equally to this article.
This work was supported by grant 2020CXTDB04 from the Clinical Innovation Foundation of Shanghai Stomatological Hospital and grants 201840291, 20204Y049, and 20204Y0493 from the Science Foundation of Shanghai Municipal Commission of Health and Family Planning.
The authors would like to thank Dr. Zhu Jing for the initial periodontal treatment, Professor Wang Liming for periodontal surgery advice, and Professor Zhang Lei for collaboration in case management.
Identification
DOI: https://doi.org/10.1016/j.adaj.2021.11.004
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© 2022 American Dental Association.
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