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Management of Alveolar Bone Exostosis After Orthodontic Treatment

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Management of Alveolar Bone Exostosis After Orthodontic Treatment @2021 JCO, Inc. May not be distributed without permission. www.jco-online.com CASE REPORT Management of Alveolar Bone Exostosis after Orthodontic Treatment A MORNRUT MANOSUDPRASIT, DDS, MSD, CAGs WORATHEP CHANTADILOK, DDS MONTIAN MANOSUDPRASIT, DDS, MDS, FRCDT lveolar bone exostoses are masticatory hyperfunction, contin- benign localized outgrowths ued jaw growth past the age of ma- Aof buccal or lingual bone, con- turity, and even nutritional factors sisting of mature cortical and tra- such as high levels of polyunsatu- becular bone.1-3 The etiology of al- rated fatty acids or vitamin D. veolar bone exostosis is still These bony growths appear to have unclear. Causes may include genet- a genetic link, but environmental ic and functional influences, racial conditions can also influence their or autosomal dominant factors, size.4-7 Dr. Amornrut Dr. Chantadilok Dr. Montian Manosudprasit Manosudprasit Dr. Amornrut Manosudprasit is a faculty staff member, Dr. Chantadilok is an orthodontist, and Dr. Montian Manosudprasit is a Professor, Division of Orthodontics, Department of Preventive Dentistry, Faculty of Dentistry, Khon Kaen University, 123 Moo 16 Mittapap Road, Nai-Muang, Muang District, Khon Kaen, Thailand 40002. E-mail Dr. Amornrut Manosudprasit at [email protected]. JCO/APRIL 2021 © 2021 JCO, Inc. 210401 MANAGEMENT OF ALVEOLAR BONE EXOSTOSIS AFTER ORTHODONTIC TREATMENT Depending on its location in the jaw, an al- oped lamellae and Haversian systems.14,15 Another veolar bone exostosis can be classified as a torus report described alveolar exostosis following palatinus, a sessile or nodular bony mass common- orthodontic implant placement, but the pathogen- ly seen in the midline of the hard palate; a torus esis was unclear.16 A possible explanation was that mandibularis, a bony protuberance found on the excessive mechanical load on the bone could in- lingual aspect of the mandibular canine-premolar duce the formation of exostoses. region; a buccal bone exostosis, seen on the buccal The process involved in development of al- aspect of the alveolar ridge; or other types. Diag- veolar bone exostoses subsequent to orthodontic nosis should be based on a clinical examination treatment is also uncertain, but some evidence in- combined with radiographic findings. An exostosis dicates that it is related to alveolar bone thickening should be differentiated from an osteoma, which on the labial aspect caused by rapid upper incisor is rare. A torus is often obvious, presenting as sev- retraction.17 In that study, incisor inclination was eral rounded protuberances or calcified multiple associated with changes in overall bone thickness, lobules, whereas a buccal exostosis is singular and especially at the apical level. The present article may appear as a sharp, pointed bony projection describes a case in which alveolar bone exostoses producing tenderness just under the mucosa. His- developed after orthodontic anterior retraction. tologically, the two types are indistinguishable. The exostosis presents as a hard bony mass on pal- Diagnosis and Treatment Plan pation, but the overlying mucosa will be intact and show normal color when stretched.8-10 Radiograph- A 28-year-old female presented with the ically, these growths appear as well-defined round chief complaint of “my front teeth sticking out” or oval calcified structures over the dental roots.11 (Fig. 1). Clinical examination showed a symmet- The lesions do not have malignant transformation rical, round face with deficient lower facial height, potential. a straight-to-convex profile, and a normal mandib- No treatment is required for an alveolar bone ular growth pattern. The patient had slightly in- exostosis unless it is large enough to affect the competent lips at rest, with an interlabial gap of periodontal tissue, cause pseudo-swelling of the 4mm. The dental midlines were coincident with lip, or produce pain or discomfort for the patient. the facial midline. The canines were in a Class II Palatal or mandibular tori directly adjacent to the relationship, but the molar relationship was Class teeth can make hygiene more difficult, and they I. Both arches exhibited mild crowding of the an- may have to be removed for prosthetic restorations. terior teeth. The mandibular left first molar had Buccal exostoses can become traumatized and not undergone root-canal treatment with a poor resto- only interfere with oral hygiene, but also affect ration. smile esthetics.3 TMJ function was normal, with a normal Many authors have reported the development range of motion and no jaw deviation on opening of bony exostoses subsequent to dental procedures. and closing. There were no signs of active perio- Periodontal surgery causes trauma to local and dontal disease. adjacent tissues, which facilitates the activation of The panoramic radiograph showed normal osteogenic progenitor cells leading to excessive overall alveolar bone support and no pathological bone growth. Moreover, patients presenting with lesions. Cephalometric analysis indicated a mild tori or any type of bony exostoses are highly sus- skeletal Class II relationship (ANB = 6°) with a ceptible to bony overgrowth responses.12,13 Place- normal vertical facial configuration and normal ment of a pontic denture over an edentulous ridge maxillary incisor inclination and position (Table can lead to alveolar bone enlargement, known as 1). The upper lip was protrusive, but the lower lip subpontic osseous hyperplasia. Histological exam- was normal relative to the E-line. ination has shown these lesions to be composed of Orthodontic treatment objectives were to re- dense masses of mature bone with normally devel- tract the upper and lower anterior teeth, establish JCO/APRIL 2021 210402 MANAGEMENT OF ALVEOLAR BONE EXOSTOSIS AFTER ORTHODONTIC TREATMENT a functional occlusion, achieve proper overjet and alignment was achieved, bony hard-tissue growths overbite, improve the lip relationship and the na- were noted on the buccal surfaces of the attached solabial angle, and ensure long-term stability. gingivae of the upper and lower anterior teeth. The Since the patient’s chief complaint was pro- bony lesions were hard and oval-shaped, and the trusion of the anterior teeth, we planned to use overlying gingiva was pale and thin, indicating conventional orthodontic mechanics to retract the buccal alveolar bone exostoses. The patient also anterior teeth bodily, thus maintaining the normal complained about traumatic ulceration when incisor inclinations. Three extraction options were brushing her upper teeth. At this point, after 36 considered. The first called for extraction of the months of orthodontic treatment, the fixed appli- upper first premolar, lower right first premolar, and ances were removed and 4-4 lingual retainers were lower left first molar (the endodontically treated bonded in both arches (Fig. 4). tooth). The second involved extraction of all four The decision was made not to remove the first premolars, combined with endodontic retreat- lower anterior exostosis, since it was less developed ment and proper restoration of the lower left molar. than the upper one and didn’t affect the patient’s The third option was to remove the four first pre- esthetics and function. The patient was referred for molars and lower left first molar, followed by an alveoloplasty to remove the upper exostosis. Under implant to replace the lower left first molar. The local anesthesia, a full-thickness mucoperiosteal first option was chosen by the patient. flap was reflected to provide clear access (Fig. 5). The patient was referred for extraction of the The bony protuberance was removed with a upper third molars before orthodontic treatment, bone-cutting carbide bur under continuous saline but the left lower third molar was preserved to oc- irrigation, and the bone was then smoothed with a clude with the opposing tooth. bone file. After the area was cleaned with normal saline solution, the flap was closed with 5.0 silk Treatment Progress sutures. Antibiotics, analgesics, and .12% chlor- hexidine gluconate mouthrinse were prescribed. Treatment was initiated with an .022" × .028" No postoperative complications occurred. A Roth-prescription appliance in both arches and follow-up appointment was scheduled seven days bonded tubes on the upper and lower molars. Lev- after surgery to check the wound healing and re- eling and alignment were carried out on .016", move the sutures (Fig. 6). There was no sign of .016" × .022", and .019" × .025" nickel titanium infection at the surgical site, and periodontal health archwires (Fig. 2). Because of the asymmetrical was acceptably maintained. extractions, moderate posterior anchorage was used in the upper arch and the lower right quad- Treatment Results rant, but minimal anchorage in the lower left quad- rant. Post-treatment evaluation 15 months after After three months of treatment, the canines surgery showed normal healing (Fig. 7). The pa- were distalized for seven months on a rigid .019" tient exhibited a harmonious facial balance with × .025" stainless steel archwire. Retraction of the improvement in the lateral profile and lip compe- upper and lower incisors was completed in anoth- tence. She had good dental alignment, proper over- er five months (Fig. 3). To prevent tipping during jet, adequate overbite, a slightly Class II canine the anterior retraction, an upper sweep curve and relationship, a Class I molar relationship on the a lower reverse curve of Spee were bent into the right side, and a full-cusp Class II molar relation-
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