Running Time: 35 min
Release Date: April 21, 2017Subtitle:
Welcome, my colleagues from gIDE around the globe. I am Dr. Robert Silva from ImplantePerio Group Brazil. And I’d like to thank you for joining me in this presentation. I hope that this can add some value to your clinical practice. And today, my topic will be corticotomy-assisted orthodontics. Of course that being a periodontist, I will be not discussing too much about the orthodontical aspects of the therapy, but rather being focused on how periodontal procedures can aid in helping orthodontics to proceed their treatment. Well, in regular orthodontic therapy, we know that can help many of our patients improving the quality of their occlusion. However, it’s also true that one issue related to orthodontics, especially in adults, is the treatment time required to fulfill the therapy. That is, in fact, one of the reasons why many, many adult patients give up the opportunity of going for orthodontics. So this is a problem. However, when they decide going into orthodontics, they might also have some drawbacks related to the treatment itself. One of those is related to the possibility of creating gingival recessions. And that is because during the process of the tooth movement through the bone, sometimes we put the tooth outside the bone housing. That will create the dehiscence and fenestrations that will increase the likelihood of developing gingival recessions. And that can be simple gingival recessions, such as this single gingival recession in the lower anterior tooth. Or it can be multiple gingival recessions, both in the upper and the lower jaw. Another important aspect is the possibility of creating root resorption. And that is related to the strain for the force that is applied during the tooth movement. Of course, that will decrease the functional aspect of that tooth. So those are general problems related to conventional orthodontics. To overcome all those drawbacks, we can use the corticotomy-assisted orthodontic, which basically is a small cut through the cortical bone, both in the buccal and the palatal aspect of every single tooth that has to be orthodontically moved. And that will eliminate the tension related to the cortical bone during the tooth movement. Performing this procedure in a much, much faster way. It was introduced by COL in 1959 and then was renamed by professors Wilcko, the brothers Wilcko, by Wilckodontics. And today, we know this procedure as perodontal accelerated osteogenic orthodontics. The advantages of the corticotomy-assisted orthodontics are related in the screen. Which are a shorter treatment time, which can be three to four times, as opposed to the conventional therapy. We can simultaneously treat during the procedure the dehiscence and fenestration, so we are going to increase the overall bone width. We can also simultaneously treat gingival recessions by wood coverage when they are present. And because of the increase overall of bone width, we can appreciate much better stability in the post-therapy phase, and decrease the chances of root resorption because we need less strains of the orthodontic appliance to move teeth. And as you are going to see in a moment, everything happens because of the RAP phenomenon that I will be explaining in a few moments. Of course, there are disadvantages that we have to include another surgery or a surgery to the procedure that might not be necessary during the conventional orthodontics. And that would add some morbidity to the patient and some cost related to the biomaterial and the peridontal surgery itself. So how the procedure is performed? So, number one, the orthodontist will apply the brackets and the wire to the patient at least one week before the surgical phase is initiated. And of course, at that moment the orthodontist will contact the periodontist or the surgeon who will perform the procedure to discuss exactly what he requires in terms of the corticotomy. So it’s very important to understand that it’s the orthodontist who really performs the treatment planning of the patient. He has to determine their areas that the surgeon will perform the corticotomy. So for the person who is going to do the surgery, it’s very, very important to have digital imaging so that we can understand exactly the anatomy of the roots in such a way that we do not perform any kind of problems, such as cutting the roots, or touching the roots of the patient during the cuts. So after that, we will get the patient to our office to do the surgery. And of course, for the surgery we must ask the orthodontist to remove the wire, so that makes it a little bit easier for performing the procedure. And we should perform, at this moment, a full thickness flap, Both in the buccal and the palatal aspect of those teeth that are about to be orthodontically moved. In the lingual aspect, however, especially in the upper jaw, we should not touch the papillas or it’s indicated not to touch the papillas to decrease the chances of developing some kind of recession or loss of the papilla inter-papillary tissue between teeth. For that, we performed this horizontal incision parallel to the gingival margins, at least two to three millimeters distant from the gingival margin. At this moment we will perform the corticotomy, which is the procedure itself, the main aspect of the surgery. And that is realized in such a way that we are going to cut in a shallow way, not deep, up to one to 1.5 millimeters through the cortical bone until we get to the medullary spade around every single tooth that is going to be moved orthodontically. And that is performed in the buccal and the lingual or palatal aspect. In the apical area of the cuts, we must connect those vertical cuts around those teeth, but always being protective to the root tips. So this horizontal cut is made, like 2 to 3 millimeters apical to the apex of the teeth. So it’s very important to have always in hand the CT scan of the patient, or the perioptical x-ray so that we can really understand that situation. So the corticotomy can be performed either using a conventional bur, which is the normal way of doing it. But definitely a much better way of doing this is using the piezoelectric surgery, which provides a much better view of the cutting, which is very precise cutting. Less bleeding during the procedure because of the huge amount of irrigation that comes out and really cleans the area. It’s protective to the soft tissues and they only cut through the bone. And much less traumatic to the patient. So I recommend or it’s recommended to use the piezoelectric insert to do it in a very good way. So this is a small video demonstrating the procedure itself. So you can see here that the flap is very wide. And because we must have full visibility of the area to be treated. And the piezo insert will cut in a very precise way the area in between each individual tooth that has to be moved orthodontically. You can appreciate as well that the depth of the cut is no more than one to 1.5 millimeters. It’s only to really get through the cortical bone and penetrate a little bit in the medullary space. And again, in the apical area, we can connect those vertical cuts by horizontal cuts, protecting the roots of the tip of the teeth around 3 millimeters, 2 to 3 millimeters. And this is a view of the palatal area that also has to be raised. Again, with the collar around the neck of the teeth in such a way that we can protect the soft tissues, in terms of not providing the chance of developing any kind of mucogingival problem in that area. So after the corticotomy is performed, now it’s time to add the bone graft in part of the procedure. And that will help the treatment of the dehiscences that will take place during the orthodontic movement, or already existing. So basically what we do is to apply a layer of biomaterial. We like to use xenograft, bovine bone, because it has all of the good characteristics of a grafting material. And they don’t reabsorb so easily or so fast, in such a way that will maintain the volume of the originated bone through the time. And it’s very important to perform this procedure because after the healing of the bone, what happens is that this new layer of bone formation will protect the roots of the teeth in terms of not developing dehiscences and fenestrations. And this new volume of bone can also be associated with the post-op stability of the orthodontic procedure. So after the graft material is applied, we have to protect these graft materials with collagen membrane. And in this case that you are seeing, I also placed a fibrin membrane taken off from the patient’s blood to improve the healing of the soft tissues. And then, of course we are going to provide general sutures and post-op recommendations to the patient. We send the patient home with all those recommendations and he would look for the orthodontist about one week later to wire those brackets and initiate the orthodontic movement. It’s very important that the orthodontics be aware and also the patient to be co-operative to follow the instruction, which is to activate the wire every two weeks because during the process of the corticotomy and the RAP phenomena that we will explain in a moment, the window of opportunity of moving the teeth in a very, very fast way is related to four to six months. After this period of four to six months, the velocity of the treatment comes back to the normal pace and the treatment is finished on a regular basis. But during these four to six months where the RAP is taking place, we’re going to have a tremendous movement in a much, much faster way. So the mechanism of the corticotomy-assisted orthodontics is related to the RAP phenomenon. That stands for Regional Acceleratory Phenomenon. And what that means is that because we perform the cuts through the bone, that creates a regional transient osteopenia, which is related to the cut itself. And that triggers the wound healing process related to the bone healing in such a way that the bone metabolism will be activated up to 50 times more, as opposed to the regular physiologic bone turnover with an increase of the cellular content, growth factors and vessels at that area. Another important feature associated with the RAP phenomenon is the dematerialization of the cortical plates. Which is very interesting because, by having though that non-mineralized organic matrix around the tooth or the teeth that are to be orthodontically moved, during the movement of the teeth what happens is that the soft layer of the bone will follow the tooth movement and will not develop further fenestration and dehiscence in that area. So that will protect the existing bone and will help the graft to take place in that area. And the window opportunity, again, of this procedure relies on four to six months. So we must always tell the patient and orthodontist to comply in terms of activating the wire every two weeks. And then, that will also help the maintenance of this RAP phenomenon. So this is a young female patient whose major concern is static related to not exposing the incisal edges of the upper teeth at rest. She has a dental class 3 malocclusion with anterior open bite, she only touches the posterior teeth, as you can see in the lower images. She has a mid-line deviation to the right and several gingival recessions, especially in the upper posterior teeth. The occlusal view of the upper jaw shows a very constricted arch, and that has to be taken into consideration in the treatment. So how is the procedure itself? In this case, since the patient has gingival recessions, as we can see in the screen, we decided to perform at the same moment of the corticotomy also the treatment of the gingival recession. So for doing that, we decided to use these oblique incisions from the base of the papillas so we elevated a full thickness flap until we could have full visibility of the area to be treated. Then we did the papilla despitalizations as part of the root-covered procedure. And then the corticotomy was performed using the piezoelectric surgery. The orthodontist in this case suggested me to perform this procedure in both sides of the maxilla from this patient from lateral to the last molar. So that’s what I did. So after the flap was elevated, the piezoelectric insert was positioned. And a cut through the cortical bone until the medullary spades, around every one of those teeth in the buccal and in the palatal aspect. In the buccal, as part of the treatment, because you can notice the presence of the dehiscence and fenestrations, we also perform the other part of the procedure, which is the bone grafting. So by us, was placed on top of those roots, completely covering all the dehiscence and fenestration defects. And that was covered with a collagen membrane to immobilize the graft material. And that was covered with a layer of fibrin membrane taken from the patient’s blood, which was centrifuged in the LPRF protocol. And then, we covered the area with the advancement of the flaps covering completely the graft material and the roots of the patient that were previously exposed. Of course that we do that in the buccal first. And after it’s sutured, we go to the palatal aspect. And we do this incision again parallel to the gingival margin, 2 to 3 millimeters distance from the gingival margin. And we perform the cut. The elevation of the flap in this area is a little bit more difficult and challenging because of the thickness of the pallet area. But pretty much you can perform a wider incision. And that will help you to further elevate the flap and then you will be able to see better the area, and then cut through this much thicker bone. But without any problem. And in this area, because the bone is so thick, of course it’s obvious that we don’t need to put any graft material in this area. And again, we suture the area in a very gentle way and this bend of soft tissue around the neck of those posterior palatal teeth will prevent any kind of problems in terms of soft tissue loss in the interproximal area. We do that in one side of the maxilla, then we go to the other side of the maxilla. It’s interesting to note that the time of the procedure, the length of the surgical procedure, is not so extended. It seems to be a very extended procedure but it’s a very quick procedure because it’s so easy to cut through the bone that it doesn’t add too much time for a regular peridontal surgery. And most patients will tell that the post-op morbidity is much less than what they expected. As a matter of fact, most of the patients complained much more from the activation of the wire, as opposed to the surgical phase itself. And then we can see the follow-up of that patient. In your left, you can see the previous image before we started the treatment. And you can follow the dates over there. And one week later, the procedure– only one week later, the procedure, you can already appreciate how the arch was widened in a very, very predictable and fast way. And that will further augmented or expended in one month, only one month after the procedure. So in one month of treatment, you can almost completely widen the arch as much as the orthodontist need to that patient. So after about four months of treatment you can see the change in the patient’s occlusion. It’s a dramatic change, of course. The patient now has occlusion almost normalized in this very short period. So that explains and shows in a very good way that the treatment is very, very quick using this methodology in a very safe way. Most of the orthodontics that I know and when I showed these kind of cases, and I ask them how long they think they would treat such a case in a conventional way. And the general answer that I get is between two years and three years. So between two to three years is the general treatment time that a patient like this is treated. In only four months, in this case, we almost finished the treatment movement. And we’re still within that window of opportunity that I mentioned, that is maintained every two weeks by activating the wires. And that will uphold and will sustain the RAP phenomenon. In this patient, only a couple of months later, the fine tuning of the orthodontics was realized. And this is the moment that we can, or the orthodontist can direct it, the bracket, this patient. So we can see that the orthodontic treatment is finished. And this is some images comparing the before and after of the orthodontic phase. Seven months, maybe, or eight months maybe in those cases. It’s almost like this, finished. Completely finished the treatment. In this case, because the patient was still not happy with the exposure of the upper teeth during rest. So our colleague, Dr. Oswaldo Scoppin de Andrade, he performed some [INAUDIBLE] veneers from canine to canine to increase a little bit the length of the teeth of the patient. As a matter of fact, I think this provided a much better looking to the patient’s quality of smile, as you can see here in those pictures. And this is of some views after the finalization of the cosmetic phase of the treatment, performed by my colleague, Dr. Oswaldo. And again, a pre and post-op comparison of how the patient came and how the patient went out of treatment, in which we can observe that in a very short period of time, the occlusion, the malocclusion was corrected, the functional aspect of the treatment was fulfilled, the aesthetically aspect, also we’re taking care of, not only related to the form, but also associated with the gingival recession. In this case, complete gingival root coverage. And both sides using one single procedure in this patient. And here you can observe the improvement of the patient’s smile. I was happy with the outcome, Doctor Oswaldo was very happy with the outcome. Dr. Masias, which is my partner orthodontist, he also was very happy with this procedure. And most importantly, the patient was very satisfied with the quality of her smile in a short period of time. We have been following this patient in the last two to three years, and it’s very, very stable without any kind of relapse so far. So let’s see another patient. The major complaint of this patient is related to aesthetics. And that is associated with, according to the patient, to the very protruded anterior upper teeth. We can see here in a closer view that the shape of the upper incisor edges are pretty much printed in the lower lip because of this inclination. It’s a very buccally position of her teeth. And intraorally, we can see that the patient has a class 2 malocclusion with a very big horizontal over-jaw of eight millimeters. Crowding of the interior lower teeth. No overbite. Again, arch constriction, both of the upper and the lower jaws. And a little bit of mid-line discrepancy. So after the diagnostic phase and discussion between myself and the orthodontist, the patient was bracketed, as you can see here for one week before the surgery. Then, at the day of the surgery, again, she was debracketed. And the same procedure was performed exactly the same way. So a full thickness flap elevation. A wide full flap elevation in order to completely see the area that I would cut the bone. Exposing also the apical area. We can see here that after the flap elevation, we can appreciate the presence of the dehiscense and fenestration defect that, simultaneously, were treated by the same protocol, which is application of a layer of biomaterial, completely covering the exposed roots, so treatment of the fenestration and dehiscenses. And the biomaterial was covered with a resolvable barrier membrane, which was protected by a layer of LPRF fibrin membrane to improve the healing of the soft tissues. The flap was commonly advanced, as you can see there. And after the area was sutured, then we moved it to the palatal area and extended horizontal incision distant from the gingival margin two to three millimeters. And exposed the area and the cuts were made. And again, no graft material was applied in the palatal area because the bone is very thick. Then, the suture was performed. That was done in one side of the maxilla, and in the other side of the maxilla. And again, I was advised or guided by the orthodontist who told me exactly where that I could cut the bone in the precise areas. So this is the moment or exactly moment before the treatment. And one week later. So the occlusal shots of the patients show a very, very nice, again, widening of the arch in only one week. So here is the front and lateral views reflective of this one week period. This is almost one month of healing. 2.5 months as you can already see that the soft tissues are completely healed without any kind of scar. And teeth are pretty much being moved in a very, very good way. So after eight months of treatment, we had a completely correction of the malocclusion of the patient, and the mid-line is already corrected in this period of time. So again, when we ask orthodontists how much time they would require to treat these cases, the number that I always listen from them, because I’m not an orthodontist, is between two to three years. So in only eight months we could observe that we could really finish the case in a very, very quick way. So in the lateral view, you can appreciate that in the course of those eight months, we have a completely correction of the inclination of the anterior teeth of the patient, which was her major concern. And also correcting the occlusal aspect of that patient. In the occlusal view, again, a very impressive widening of the arch which would help to create a space to deinclinate the anterior teeth, and find the proper position of the arches to find a very good matching of the upper and the lower jaw in a very good occlusion. And after directing of the patient, we have a very, very nice finishing of the case in which the patient is very, very happy with her occlusal aspects, the functional aspect. And most importantly, the aesthetic area. And this is the patient before and after the treatment, that we can observe a very nice improvement, especially in the patient’s major concern, which was the aesthetics of the anterior region of her mouth. And the satisfaction of the smile, proves the concept that this treatment can aid the patients in a very good way. So what are the indications of this procedure? Basically, corticotomy can be performed in any kind of orthodontic movement. Especially for adults and in using challenging orthodontic movement. So in those kind of situations, the corticotomy can pretty much help the patients in a very, very good way. And it’s also very well indicated to the correction of more moderate to severe malocclusions. However, there are some contraindications to this procedure that are listed in your screen. Which are active periodontal disease. We should not perform these when the soft tissues are not properly healed, or when we have inter-proximal bone loss, which would lead to a severe gingival recession and in papillary loss of the interproximal tissues. Which is, of course, an important drawback. So it’s very important to treat very periodontally sound patients to be safe. When there are endodontic issues or lesions, periodontal, endodontic lesions, or when the prognoses of their own the or don’t the treatment is not so good. So whenever we have endodontic issues, it’s very interesting and important to refer this patient to the endodontist so that this issue can be taken care of. Also, when the patient has a history of prolonged corticoid use, and current use of bisphosphonates or non-steroidal anti-inflammatory drugs that collectively can be associated with decreasing the bone metabolism. So to finish the procedure, there are several reviews and a very good body of literature, not randomized clinical trials, but a lot of clinical evidence suggesting that this procedure is quite effective and safe. With the major benefit which is reducing the treatment time of the patient, associated with the possibility of concomitant treatment of bone dehiscences and fenestrations, which in turn will aid the long stability of the treatment, not without any kind of relapse. And also, the treatment of gingival recessions. And I would suggest or recommend strongly that if you are to use this kind of procedure, that the piezoelectric device is used to create a much, much better environment to work with, without the morbidity that might be associated. And in this publication, where this procedure was described exactly the way I just mentioned to you, we can see in the CT scans that we are always going to see the augmentation of the buccolingual dimension of the ridge because of the grafting procedure. And again, that might be very important to the long stability, or long term, or medium term stability of the orthodontic treatment, such as was demonstrated in this case. A series where at least 2.5 years of follow-up was observed in these cases. With that, I hope that this very short presentation may have introduced this new concept or this possibility for you to help your patients. And with that, I would like to thank for your attention and hope to see you soon.