The Saudi Dental Journal (2011) 23, 99–106

King Saud University

The Saudi Dental Journal

www.ksu.edu.sawww.sciencedirect.com

CASE REPORT

Orthodontic treatment of an anterior openbite

with the aid of corticotomy procedure: Case report

Ali S. Aljhani a, Abdullah M. Aldrees b,*

a King Abdullah International Medical Research Centre, King Saud University for Health Sciences,Riyadh, Saudi Arabiab Department of Pediatric Dentistry and Orthodontics, College of Dentistry, King Saud University, P.O. Box 60169,Riyadh 11545, Saudi Arabia

Received 11 October 2009; revised 16 January 2010; accepted 7 June 2010Available online 26 October 2010

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KEYWORDS

Openbite treatment;

Corticotomy

Corresponding author. T

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-mail address: amaldrees@k

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Abstract This case report illustrates the orthodontic treatment combined with the corticotomy

technique in an adult patient to accelerate tooth movement and shorten the treatment time. The

patient was a 22-year-old woman with an anterior open bite and flared and spaced upper and lower

incisors. First, fixed orthodontic appliances (bidimensional edgewise brackets) were bonded, and a

week later buccal and lingual corticotomy with alveolar augmentation procedure in the maxillary

arch from the first molar to the contralateral first molar, and from canine to canine in the mandib-

ular arch was performed. Orthodontic therapy proceeded with frequent activation of the appliances

to retract the incisors every 2 weeks. The total treatment time was 5 months and no adverse effects

were observed at the end of active treatment. The addition of the decortication procedure to the

conventional orthodontic therapy decreased the duration of treatment significantly. Successful clo-

sure of the anterior open bite with adequate overbite and interdigitation of the teeth were achieved.ª 2010 King Saud University. Production and hosting by Elsevier B.V. All rights reserved.

6 1 4676057; fax: +966 1

(A.M. Aldrees).

y. Production and hosting by

Saud University.

lsevier

1. Introduction

Orthodontic treatment has the ability to modify the dentofacialskeleton and affect facial esthetics. Currently many adult pa-tients seek orthodontic treatment for their malocclusions. In

a recent Medical Expenditure Panel Survey (MEPS), adults ac-counted for 23.1% of all orthodontic visits in 2004 (Guay et al.,2008). The percentage of adult active patients was reported to

be around 20% of the total patients being treated in the ortho-dontic offices in the United States (Keim et al., 2008). Compre-hensive orthodontic treatment for adults is considerably longerthan for adolescent patients (Vig et al., 1990; Kocadereli, 2002),

and treatment modifications have been suggested to reduce thetreatment time. Kole (1959) was the first to describe a technique

100 A.S. Aljhani, A.M. Aldrees

that involved a radicular corticotomy and supra-apical osteot-

omy to expedite tooth movement. He believed that by creatingblocks of bone with vertical buccal and lingual corticotomycuts and supra-apical horizontal osteotomy connecting cuts,segments of bone with the embedded teeth can be moved rap-

idly (Kole, 1959). Anholm et al. (1986) reported the treatmentof a non-extraction case with severe malocclusion in 11 monthsusing corticotomy. Later, Suya (1991) suggested replacing the

osteotomy cuts with horizontal corticotomy in a report of395 adult Japanese patients treated with this modified proce-dure. In 1990, Gantes et al. (1990) have reported five orthodon-

tic cases treated with corticotomy in which circumscribingcorticotomy cuts both facially and lingually around the sixupper anterior teeth were made. The upper first bicuspids were

removed and the bone over the extraction sockets was removedboth buccally and lingually (Gantes et al., 1990). Chung et al.(2001) also reported two cases in which blocks of medullarybone are moved block by block with orthopedic forces. Simi-

larly, Hwang and Lee (2001) have performed the intrusion ofunopposed molars by performing a corticotomy procedureand using magnets on two adult patients.

Wilcko et al. (2001) modified the technique with the additionof alveolar augmentation with resorbable, alloplastic freeze-dried bone to increase the volume of alveolar bone, regenerate

bone affected by dehiscence and fenestration, and avoid gingi-val recession. They explained that the movement does not resultfrom repositioning of tooth-bone blocks, but rather from a cas-cade of transient localized reactions in the bony alveolar hous-

ing leading to bone healing (Wilcko et al., 2001). Since 2001,few cases treated with corticotomy were reported in the litera-ture. Germec et al. (2006) reported the treatment of an adult pa-

tient with a modified corticotomy technique, in which thelingual vertical and subapical horizontal cuts were eliminated;was combined with orthodontic therapy for the retraction of

the lower anterior teeth after the extraction of four premolars.The use of the corticotomy technique with skeletal anchoragedevices in the treatment of adults was reported by Iino et al.

(2006), Moon et al. (2007), and Chung et al. (2009). For theintrusion of overerupted molars in adults, selective alveolarcorticotomy with a modified full-coverage maxillary splinttreatment was used by Oliveira et al. (2008). In a preliminary

study, Fischer has compared the movement of impacted ca-nines after surgical exposure using conventional surgical tech-nique with their contralateral canines exposed using a

corticotomy-assisted technique, and he concluded that corticot-omy-assisted surgical technique reduced the orthodontic treat-ment time by 28–33% (Fischer, 2007).

The aim of this report is to present in detail the efficient andrapid orthodontic treatment of anterior open bite malocclu-sion with the use of the decortication technique and to discuss

the surgical and the orthodontic steps involved.

2. Case report

A 22-year-old African woman presented with a chief complaintof: ‘‘I hate my open bite’’. She had no relevant medical historyand she presented with several restorations, extractions of

third molars, and excellent oral hygiene.Pre-treatment facial photographs showed a straight profile

with protrusive and competent lips and acute nasolabial angle.

The patient had an Angle Class I malocclusion on a mild skel-

etal Class III relationship with a 0 mm overjet and 6 mm open

bite extending from the right second premolar to the left sec-ond premolar. The upper and lower arches were malalignedwith moderate spacing, and an evident tongue thrust habitaccentuating the bimaxillary flaring and protrusion of the inci-

sors (Figs. 1–9). The patient showed a genuine interest to havethe orthodontic treatment completed as soon as possible.

2.1. Treatment plan

The suggested treatment plan involved comprehensive ortho-

dontic treatment with fixed appliances to align the upper andlower teeth, close the anterior spaces, retract the proclined inci-sors, and close the anterior open bite. Corticotomy procedure

was planned to expedite the tooth movement.One week before the surgery, preadjusted edgewise ortho-

dontic fixed appliances were placed (bidimensional appliances:0.018 · 0.025-in. slot brackets for the incisors, 0.022 · 0.028-in.

for the canines and the posterior teeth), and 0.016-in. NiTiarchwires were inserted for leveling and alignment.

2.2. Surgical procedure

Following the technique described by Wilcko et al. (2001), full

thickness flap was reflected sharply both facially and linguallyaround all erupted teeth from first molar to first molar in themaxillary arch, and between the canines in the mandibulararch under local anesthesia (Fig. 10). Each flap was released

with a sulcular incision and with papillary preservation tech-nique when possible. The lingual interdental papilla betweenthe maxillary central incisors was not reflected, and no vertical

releasing incisions were used. Cuts in the alveolus that pene-trate the entire thickness of the cortical plate and penetrate justbarely into the medullary bone were performed both buccally

and lingually around all the teeth in both arches. Verticaldecortication cuts were made between the roots of the teethand they were stopped 2–3 mm shy of the alveolar crest. Hor-

izontal scalloped corticotomy cuts were used to connect thevertical cuts along with perforations in the cortical plate. Bonegrafting mixture OraGraft� demineralized cortical particulate(LifeNet Health Inc., Virginia Beach, VA, USA) was then ap-

plied to the activated cortical plates. Flaps were returned totheir pre-surgical positions and sutured with interrupted loopsutures. Non-resorbable sutures (Gore-tex�, CV-5, RT-16,

fromW.L. Gore & Associates Inc., Medical Products Division,Flagstaff, AZ, USA) were used and the sutures were left for14 days before they were removed. Patient was kept under

antibiotic for 10 days following the surgery.

2.3. Treatment progress

At the suture removal appointment, 0.016 · 0.022-in. NiTiarchwire was inserted in the upper arch and 0.016-in. stainlesssteel was inserted in the lower arch with 150 g NiTi coil springs

attached from the mandibular first molars to the canines forretraction and powerchain to derotate the lower first premolars(Fig. 11A–C).

Four weeks later, continuous powerchian was inserted inthe upper arch and a 0.016 · 0.016-in. stainless steel archwirewith closing loops was inserted in the lower arch for incisors

retraction (Fig. 11D–F). Class III box elastics (3/16 in., 4 oz)were prescribed to be worn full-time. Archwires were activated

Figures 1–9 Pre-treatment extraoral, intraoral photographs and panoramic radiograph.

Orthodontic treatment of an anterior openbitewith the aid of corticotomy procedure: Case report 101

every 2 weeks, and 4 weeks later 0.016 · 0.022-in. stainless steelarchwire was inserted in the upper arch, and in the lower

0.016-in. stainless steel with helices was inserted (Fig. 11G–I). Powerchains were replaced every 2 weeks, and then finish-ing upper and lower 0.016 · 0.022-in. stainless steel archwires

were inserted and vertical anterior and posterior elastics wereused (Fig. 11J–L).

The total active treatment period was only 5 months. Then,preadjusted edgewise appliance were removed, upper and low-er lingual retainers were bonded and removable upper circum-

Figure 10 (A, C) Maxillary corticotomy of the buccal and palatal sides of alveolar bone with the grafting mixture covering the

decorticated bone. (B, D) Flaps returned to their pre-surgical positions and sutured with interrupted loop sutures.

Figure 11 Intraoral photographs at 2 weeks (A–C), 6 weeks (D–F), 10 weeks (G–I), and 4 months (J–L) after the corticotomy procedure.

102 A.S. Aljhani, A.M. Aldrees

ferential and lower Hawley retainers were inserted to be wornfull time.

Post-treatment evaluation of the patient revealed goodpreservation of the interdental papillae with no gingival reces-sion. Post-treatment OPG shows good parallelism of the roots,no significant reduction in the radiographic height of the cres-

tal bone and nor radiographic evidence of any significant api-cal root resorption. Treatment objectives were achieved and

the teeth are in good interdigitation with adequate overbite(Figs. 12–20). Final lateral cephalometric radiograph’s analysisshow an acceptable dental compensation achieved for theunderlying skeletal Class III discrepancy (Fig. 21).

Figures 12–20 Post-treatment extraoral, intraoral photographs and panoramic radiograph.

Orthodontic treatment of an anterior openbitewith the aid of corticotomy procedure: Case report 103

3. Discussion

The comprehensive orthodontic treatment of this adult patientwho presented with an anterior open bite was completed in

5 months which is significantly less than the routine durationthat conventional orthodontic treatment of similar cases re-

quires. The addition of the corticotomy procedure has been re-ported to shorten the conventional orthodontic treatment time

(Kole, 1959; Anholm et al., 1986; Gantes et al., 1990; Suya,1991; Chung et al., 2001; Hwang and Lee, 2001; Wilckoet al., 2001), and it was claimed that teeth can be moved 2–3

times further in 1/3 to 1/4 the time required for traditional

Figure 21 Final lateral cephalometric radiograph with a table illustrating analysis results. *Connor and Moshiri (1985). **Anderson

et al. (2000).

104 A.S. Aljhani, A.M. Aldrees

orthodontic therapy (Wilcko et al., 2001, 2003, 2008). The cur-

rent report confirms previously published findings and sup-ports this treatment option for an overall shorter treatmenttimes.

The concept of corticotomy as introduced by Kole (1959)relied on creating blocks of bone with the embedded teeth thatcan be moved rapidly with heavy forces. The same concept wasfollowed by the others who reported corticotomy-facilitated

orthodontic treatment of several cases (Anholm et al., 1986;Gantes et al., 1990; Suya, 1991; Chung et al., 2001). On theother hand, conventional orthodontic forces were advocated

by Wilcko et al. (2001, 2003, 2008), who explained the rapidtooth movement as an illustration of regional acceleratory phe-nomenon (RAP). This process was first described by Frost

(1983), who found that the surgical wounding of osseous tis-sues results in accelerated regional healing process (Frost,1983, 1989a,b). It can expedite hard- and soft-tissue healingtwo- to ten-fold, and it leads to decreased regional bone den-

sity and accelerated bone turnover (Frost, 1983). This was re-ported to occur in intraoral cortical bone by others too (Goldieand King, 1984; Shih and Norrdin, 1985; Yaffe et al., 1994).

Wilcko et al. (2008) showed that transient localized demineral-ization–remineralization in the bony alveolar housing occurs,and the demineralization of the alveolar bone over the root

surfaces leaves the collagenous soft tissue matrix of the bone,which can be carried with the root surface and then remineral-izes following the completion of the orthodontic treatment.

Initially, the term ‘‘Accelerated Osteogenic Orthodontics’’was used to describe the combined corticotomy-facilitatedorthodontics and periodontal alveolar augmentation (Wilckoet al., 2001). Later, Wilcko et al. (2008) have modified it to

be ‘‘Periodontally Accelerated Osteogenic Orthodontics’’(PAOO) technique. In their case reports, Wilcko et al. (2008)have emphasized that after a 2-week post-operative waiting

period to permit demineralization, extraction spaces can be

closed in 6–8 weeks with efficient orthodontic forces. Thatcoincided with the technique employed in the treatment ofthe current case, in which major tooth movement occurred in

the first 4 months with conventional forces. In a recent reportcomparing the alveolar bone reactions to osteotomy-assistedand corticotomy-assisted tooth movement, Lee et al. (2008)found evidence of regional accelerated phenomenon in the

alveolar bone of the corticotomy-treated animals and distrac-tion osteogenesis in the osteotomy-assisted tooth movementanimals by microCT. This confirms by microimaging tech-

niques the hypothesis of the difference in the healing processesinvolved in both procedures.

Original corticotomy-facilitated orthodontic treatment in-

volved buccal and lingual osteotomy cuts with orthopedicforces, and the use of alveolar augmentation with demineral-ized bone graft was advocated by Wilcko et al. (2001, 2003)to cover any fenestrations and dehiscences and to increase in

the bony support for both the teeth and the overlying and softtissues. Surface computed tomographic scans taken before andafter the treatment showed a return of the layer of mineralized

bone over the roots of the teeth and a general increase of thebone volume in the cases presented by Wilcko et al. (2001,2003). The use of particulate autogenous bone graft harvested

from the rami and exostosis of a case was reported by Nowzariet al. (2008), and no changes in the bone configuration wereobserved a year after the completion of treatment. More con-

trolled studies are still required to investigate the value of thealveolar augmentation as a routine step in the decorticationtechnique, and the effects of different grafting materials onthe alveolar bone. While osteotomy cuts were recommended

on both alveolar surfaces (buccal and lingual) (Kole, 1959;Wilcko et al., 2001, 2003), two recently published case reportsshowed the results of selective corticotomy limited to the buc-

Orthodontic treatment of an anterior openbitewith the aid of corticotomy procedure: Case report 105

cal and labial surfaces to reduce the operation time and

post-operative patient discomfort, and avoid the risk of violat-ing vital lingual anatomy (Germec et al., 2006; Nowzari et al.,2008). The current case was managed with both buccal and lin-gual cuts and efficient tooth movement was observed, however,

elimination of the lingual cuts should be studied in futuretrials.

Most of the recently published literature showed no adverse

effects of the corticotomy on the periodontium (Germec et al.,2006; Iino et al., 2006; Nowzari et al., 2008; Oliveira et al.,2008; Wilcko et al., 2008). In this case, no reduction in the crest

bone height, gingival recession, and apical root resorptionwere seen after the orthodontic treatment. The need for morefrequent activation compared to conventional orthodontic

treatment, the extra expenses for the periodontal surgery,and the post-operative discomfort were the disadvantages ofthis technique that the patient need to tolerate for a fastercourse of treatment.

Anterior open bite is often accompanied with anterior ton-gue placement between the separated anterior teeth as amaneuver to close off the front of the mouth and form an ante-

rior seal. However, forward resting posture of the tongue, dueto the prolonged duration of this pressure, could affect toothposition and cause anterior open bite (Proffit et al., 2006).

The exact etiological factors for the anterior open bite in thecurrent case could not be determined, but successful closureof the open bite was achieved within a short period of timein spite of the accompanied tongue thrust. This indicates that

the accelerated tooth movement brought by the corticotomycan overcome the lingual resistance to teeth retraction by thetongue. Increased stability provided by PAOO has been re-

ported by Wilcko et al. (2008) and that was explained by theloss of tissue memory from high tissue turnover of the perio-dontium, and the increased thickness of the alveolar cortices

from the augmentation grafting. It is possible that more stabil-ity of the correction achieved in this case is expected due to thereasons illustrated previously.

Since most of what we know about the decortication proce-dures in orthodontics is based on case reports, more labora-tory and clinical studies are needed to explain themechanisms involved in this process at the molecular level,

and to explore the long term effects of this procedure.

4. Conclusions

Comprehensive orthodontic treatment with the aid of thedecortication technique is an effective treatment option in

adults to achieve a significant reduction in the treatment dura-tion. In addition, with the combination of both periodontalsurgery and orthodontic treatment, this option would be an

excellent approach for managing preexisting periodontal prob-lems through increasing the alveolar volume and reducing thelikelihood of gingival recession.

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