Indentation Corticotomy: Periodontally Promoted Orthodontic Treatment
1,2Department of Periodontics, NITTE (Deemed to be University), AB Shetty Memorial Institute of Dental Sciences, Deralakatte, Mangaluru, Karnataka, India
Corresponding Author: Shiny Inasu, Department of Periodontics, NITTE (Deemed to be University), AB Shetty Memorial Institute of Dental Sciences, Deralakatte, Mangaluru, Karnataka, India, Phone: +91 9986672589, e-mail: email@example.com
How to cite this article: Inasu S, Thomas B. Indentation Corticotomy: Periodontally Promoted Orthodontic Treatment. J Health Sci Res 2021;12(2):40–43.
Source of support: Nil
Conflict of interest: None
An interrelationship between orthodontist and the periodontist is necessary under various conditions. One of the most important aspects in which both parties must come upon agreement for the need of corticotomy is case selection. During orthodontic treatment, several types of malocclusion can be treated by altering the balance between apposition and resorption through selectively injuring the cortical plate of the alveolus which accelerates tooth movement, thereby reducing the risk of extraction and providing long-term stability support; such type of treatment plan is referred to as periodontally accelerated osteogenic orthodontics. This procedure involves selective alveolar decortications, placement of bone grafting material, along with application of orthodontic force. There are different types of corticotomy procedures such as circumscribed, triangular, and indentation, where each technique differs from each other based on their indication, contraindication, and limitations. Placement of bioabsorbable grafting material over the decortications site should be carried out at utmost care and followed by suturing the flap to a final position. After 1 or 2 weeks, orthodontic tooth movement begins.
Keywords: Corticotomy, Esthetics, Osteogenic, Periodontium, Surgery.
Dentofacial esthetics is of great importance to adults under any age limit.1 Orthodontic treatment is considered as one of the dental esthetic choices of treatment for adults, as a result an increase in demand for orthodontic treatment.2 However, these adults have more concerns related to type of appliance, duration of treatment, and cost.
Another important aspect in terms of tooth movement during orthodontic treatment, it differs from adults and children.3 This is due to the growth of maxilla, mandible, collagen fibers maturation rate, periodontal hyalinization, and alveolar flexibility, which differs among children and adults.3 As age increases, periodontal complications for adult’s also increase due to cell mobilization, slower rate of conversion of collagen fibers, and rigidity nature of alveolar bone.3 Hence, orthodontic treatment makes it more time-consuming and challenging for adults.
In 1959, Köle introduced the concept of corticotomy procedure for rapid tooth movement, where the alveolar bone is cut for tooth movement. He has gained more experience in correcting various malocclusion cases by performing corticotomy and osteotomy procedures.1 Both cortical and marrow bone between tooth were removed. Disadvantage of this procedure is its surgical invasiveness.4 An osteotomy procedure called corticotomy is a surgical procedure where, only cortical bone is cut, perforated or mechanically altered, while medullary bone remains intact.5
A new innovative technique was introduced by Wilcko et al., which involves a combination of surgical corticotomy procedure along with placement of grafting material, referred to as accelerated osteogenic orthodontics (AOO) and more recently to as periodontally accelerated osteogenic orthodontics (PAOO).6 This technique has offered solutions to many severe malocclusion cases such as reduced treatment time, accelerate in tooth movement, long-term support of periodontium. A change in bone metabolism occurs due to the intentional injury performed on cortical bone leading to a transient state of osteopenia, described as rapid acceleratory phenomenon (RAP).5
Initially, use of hand-pieces and surgical burs were carried out for corticotomy procedure, but these devices cause more risk of damage to supporting structures.4,7,8 To reduce the risk of damage, other devices such as laser,9 perforator,10–12 and piezoelectric apparatus were used.13–16
There are different terms used for the corticotomy procedures such as AOO technique,6,17–20 selective alveolar decortication (SAD),4 PAOO,6,17–20 corticotomy-facilitated orthodontics (CFO) known as speedy orthodontics.4 These techniques differ from each other only due to the addition of bone grafting along with corticotomy.21
The selection of the design of corticotomy procedures is at utmost important part of the treatment plan. There are different types of corticotomy procedures such as circumscribed, triangular, and indentation, where each technique differs from each other based on their indication, contraindication, and limitations.22
In this case report, a patient complaint of forwardly placed upper and lower front teeth and was diagnosed with Angles class I malocclusion with proclination. In this corticotomy procedure, indentation technique was used which reduce the risk of root injury, and also can be used for thinner cortical bone.22
A 29‐year‐old male patient came to Department of Periodontics, AB Shetty Dental College, Mangaluru had a complaint of forwardly placed upper and lower front teeth. The case was diagnosed as Angles class I malocclusion with proclination. Treatment plan was discussed with orthodontist, later explained to the patient, and decision was made. Informed consent was taken from the patient after describing surgical procedure to the patient. No relevant medical history reported.
Phase I periodontal therapy which includes scaling and root planning, oral hygiene instructions, plaque control measures were provided for the patient prior to surgical and orthodontic treatment. Reevaluation of phase I therapy was monitored monthly during the treatment period.
Initially, local anesthesia was given prior to surgical procedure (Fig. 1). An incision extending from gingival margin toward level apical to the apices of mandibular anterior teeth was given vertically, followed by buccal intracrevicular incisions connecting these initial vertical incisions. With the periosteal elevator, the flaps were raised beyond the level of the apices of the teeth (Fig. 2). An indentation corticotomy was planned for mandibular anterior teeth. Using a round fissure bur mounted on a micromotor hand piece, indentations in the form of vertical buccal grooves were made through the cortical layer of the exposed bone, starting 1.5 mm below the interdental crest. Decorticated sites were covered with bioabsorbable grafting material (Figs 3 and 4). An in-depth saline irrigation was done at the surgical sites prior to flap repositioning and sutured. Patient was given antibiotics and analgesics for 1 week. Suture removal was done after 3 weeks (Fig. 5). Follow-up was done after 3 months (Fig. 6). Presently patient is undergoing orthodontic treatment.
This case report concluded that the technique used has been shown how corticotomy along with bone graft facilitates tooth movement during clinical perio-ortho-treatment in adult patients, which helps to reduces treatment time, long-term posttreatment stability, less root resorption and gingival recession, both metal and ceramic brackets can be used.5
This procedure should be avoided in any patients having any form of periodontal pathology or deformity that compromises the periodontal health, less attached gingiva, patients on long-term steroid therapy, or any other medications that slow down bone metabolism such as NSAIDs. All the risks and possible after-effects should be explained to the patient prior to the initiation of the treatment.4
Mucogingival surgeries such as intrabony periodontal defects and guided bone regeneration require additional bone grafting material to fill in the defect which would help in the formation of new cells to repair the periodontal damage. There are different types of bone grafting materials, which can be either osteoinductive or osteoconductive or both. Autogenous bone graft in particulate form has been considered as one of the most successful graft materials for filling, sinus augmentation, and other surgeries. However, another limitation of this procedure is difficulty to reduce the risk of leakage and displacement particulate bones substitutes. Additionally, the soft tissue tension caused by these flaps sutured to its final position to adapt bone graft material over the coronal alveolar crest would lead to vertical alveolar bone loss.
This report concludes that the procedure is an invasive procedure and limits duration of treatment, thereby facilitating tooth movement at faster rate, which overcomes other limitations such as duration of treatment and reducing the adverse effects on teeth. Although, this procedure provides adequate results, a pouch design would be appropriate for filling bone-grafting material. Future research is required to overcome these drawbacks and provide better results.
Authors would like to thank the patients for their support and cooperation throughout the treatment and follow-up period.
Shiny Inasu https://orcid.org/0000-0003-2407-3282
Biju Thomas https://orcid.org/0000-0001-8908-1019
1. Kole H. Surgical operations on the alveolar ridge to correct occlusal abnormalities. Oral Surg Oral Med Oral Pathol 1959;12(5):515–529. DOI: 10.1016/0030-4220(59)90153-7.
2. Mathews DP, Kokich VG. Managing treatment for the orthodontic patient with periodontal problems. Semin Orthod 1997;3(1):21–38. DOI: 10.1016/s1073-8746(97)80037-0.
3. Ong MM, Wang HL. Periodontic and orthodontic treatment in adults. Am J Orthod Dentofacial Orthop 2002;122(4):420–428. DOI: 10.1067/mod.2002.126597.
4. Lee W. Corticotomy for orthodontic tooth movement. J Korean Assoc Oral Maxillofac Surg 2018;44(6):251–258. DOI: 10.5125/jkaoms.2018.44.6.251.
5. Abu-Hussein M, Watted N, Hegedűs V, et al. Corticotomy in the modern orthodontics. IOSR J Dent Med Sci 2015;14:68–80. DOI: 10.9790/0853-141136880.
6. Wilcko WM, Wilcko T, Bouquot JE, et al. Rapid orthodontics with alveolar reshaping: two case reports of decrowding. Int J Periodontics Restorative Dent 2001;21:9–19. PMID: 11829041.
7. Dibart S, Sebaoun JD, Surmenian J. Piezocision: a minimally invasive, periodontally accelerated orthodontic tooth movement procedure. Compend Contin Educ Dent 2009;30(6):342–344, 346, 348–350. PMID: 19715011.
8. Sebaoun JD, Surmenian J, Dibart S. Accelerated orthodontic treatment with piezocision: a mini-invasive alternative to conventional corticotomies. Orthod Fr 2011;82(4):311–319. DOI: 10.1051/orthodfr/2011142.
9. Han KH, Park JH, Bayome M, et al. Effect of frequent application of low-level laser therapy on corticotomized tooth movement in dogs: a pilot study. J Oral Maxillofac Surg 2014;72(6):1182. e1–e12. DOI: 10.1016/j.joms.2014.02.028.
10. Prasad S, Ravindran S. Effect of micro-osteoperforations. Am J Orthod Dentofacial Orthop 2014;145(3):273. DOI: 10.1016/j.ajodo.2014.01.003.
11. Alikhani M, Raptis M, Zoldan B, et al. Effect of micro-osteoperforations on the rate of tooth movement. Am J Orthod Dentofacial Orthop 2013;144(5):639–648. DOI: 10.1016/j.ajodo.2013.06.017.
12. Cheung T, Park J, Lee D, et al. Ability of mini-implant-facilitated micro-osteoperforations to accelerate tooth movement in rats. Am J Orthod Dentofacial Orthop 2016;150(6):958–967. DOI: 10.1016/ j.ajodo.2016.04.030.
13. Gibreal O, Hajeer MY, Brad B. Efficacy of piezocision-based flapless corticotomy in the orthodontic correction of severely crowded lower anterior teeth: a randomized controlled trial. Eur J Orthod 2019;41(2):188–195. DOI: 10.1093/ejo/cjy042.
14. Alfawal AMH, Hajeer MY, Ajaj MA, et al. Evaluation of piezocision and laser-assisted flapless corticotomy in the acceleration of canine retraction: a randomized controlled trial. Head Face Med 2018;14(1):4. DOI: 10.1186/s13005-018-0161-9.
15. Sathyanarayana HP, Srinivasan B, Kailasam V, et al. Corticotomy and piezocision in rapid canine retraction. Am J Orthod Dentofacial Orthop 2016;150(2):209–210. DOI: 10.1016/j.ajodo.2016.06.004.
16. Abbas NH, Sabet NE, Hassan IT. Evaluation of corticotomy-facilitated orthodontics and piezocision in rapid canine retraction. Am J Orthod Dentofacial Orthop 2016;149(4):473–480. DOI: 10.1016/ j.ajodo.2015.09.029.
17. Wilcko MT, Wilcko WM, Pulver JJ, et al. Accelerated osteogenic orthodontics technique: a 1-stage surgically facilitated rapid orthodontic technique with alveolar augmentation. J Oral Maxillofac Surg 2009;67(10):2149–2159. DOI: 10.1016/j.joms.2009.04.095.
18. Wilcko MT, Wilcko WM, Murphy KG, et al. Full-thickness flap/subepithelial connective tissue grafting with intramarrow penetrations: three case reports of lingual root coverage. Int J Periodontics Restorative Dent 2005;25(6):561–569. PMID: 16353531.
19. Wilcko MT, Ferguson DJ, Makki L, et al. Keratinized gingiva height increases after alveolar corticotomy and augmentation bone grafting. J Periodontol 2015;86(10):1107–1115. DOI: 10.1902/jop.2015.150074.
20. Wilcko W, Wilcko MT. Accelerating tooth movement: the case for corticotomy-induced orthodontics. Am J Orthod Dentofacial Orthop 2013;144(1):4–12. DOI: 10.1016/j.ajodo.2013.04.009.
21. Zimmo N, Saleh MH, Mandelaris GA, et al. Corticotomy-accelerated orthodontics: a comprehensive review and update. Compend Contin Educ Dent 2017;38(1):17–25. PMID: 28054789.
22. Kook YA, Lee W, Kim SH, et al. Corticotomy-assisted space closure in adult patients with missing lower molars. J Clin Orthod 2013;47(2): 85–95. PMID: 23660766.
© The Author(s). 2021 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and non-commercial reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.