©2018 JCO, Inc. May not be distributed without permission. www.jco-online.com Pre-Orthodontic Periodontal Augmentation for Lower Incisor Introducing Invisalign® First Advancement in Adolescent Patients clear aligners, specifically JAMES B. GRAY, DMD designed for growing patients. COLIN RICHMAN, DMD Do more for your Phase 1 nsufficient mandibular arch length can be addressed by a number of ortho- patients with unique innovations dontic methods, including extraction, interproximal reduction (IPR), later- tailored to their specific needs. Ial expansion, and proclination and advancement of the incisors. Depend- ing on the patient, each choice will have different ramifications in terms of Treatment for a broad range of malocclusions the duration and complexity of treatment, the functional occlusion, the perio- Designed for predictable dental arch expansion dontium, the facial soft-tissue response, and the stability of the correction. New and improved staging patterns Short clinical crown support Orthodontic proclination and protrusion of the dehiscences.1-4 Because the gingival tissues seem to Erupting permanent dentition support lower incisors appear to have relatively few compli- obtain their blood supply from the underlying alve- cations, particularly if the attached gingiva is thick olar bone, a deficiency of alveolar bone associated enough, but iatrogenic effects and unwanted recip- with bony dehiscences or fenestrations results in a Little smiles deserve rocal movements are still possible. Lower incisor compromised blood supply to the overlying gingival Invisalign First treatment. proclination can negatively impact the interincisal tissue, making it susceptible to gingival recession. angle and the functional incisal relationships. Mov- Contributing factors may include preexisting con- Fewer food restrictions ing the teeth away from the integrity of the alveolar ditions, the height and thickness of the attached complex can lead to alveolar bone fenestrations and gingiva, the shape of the symphysis, the direction Patient’s regular routine of brushing and extent of orthodontic tooth movement, and the degree of plaque control.5-24 and cleaning is easily maintained The extent to which the lower incisors can be More comfortable process* advanced without causing additional problems must be a clinical determination, because reliable objec- tive measures are lacking. Cone-beam computed tomography (CBCT) emphasizes the presence of alveolar bone rather than the absence, which can lead to an overestimation of fenestrations and de- hiscences. If gingival recession is present or develops as a result of orthodontic movement, mucogingival grafting has traditionally been the treatment of Dr. Gray Dr. Richman Visit invisalign.com/invisalignfirst or choice.25 Soft-tissue gingival augmentation is wide- call (866) 866-5941 to learn more. Dr. Gray is in the private practice of orthodontics at Gray Orthodontics, ly used in cases of gingival recession, but does not 10930 Crabapple Road, Suite 240, Roswell, GA 30075; e-mail: drgray@ address the dehiscence of alveolar bone. Several creatingsmiles.net. Dr. Richman is an Associate Clinical Professor, College of Dentistry, Augusta University, Augusta, GA, and in the pri- authors have described alveolar augmentation by vate practice of periodontics in Roswell, GA. means of corticotomies and bone grafting.26-32 © 2018 Align Technology. All rights reserved. * Compared to traditional appliances used for Phase 1 treatment. Data on file at Align Technology. AD10050 Rev A VOLUME LII NUMBER 10 © 2018 JCO, Inc. 513 PRE-ORTHODONTIC PERIODONTAL AUGMENTATION FOR INCISOR ADVANCEMENT This article illustrates a similar but more lim- placed. Under either oral or intravenous sedation, ited technique, called pre-orthodontic periodontal a full-thickness facial flap was mobilized through augmentation (POPA), which can be used to pre- periosteal fenestration from the distal aspect of vent gingival recession in growing patients. each lower canine, taking care not to contact the exposed root surfaces. Interproximal vertical corti- Procedure cotomies were performed by piezocision, and interproximal and lingual fiberotomies by the Ed- In each of the three cases presented here, the wards technique.33 The bone-grafting material, dentoalveolar complex was insufficient to support reconstituted in venous blood, comprised 50% the desired anterior movement of the lower incisors. demineralized freeze-dried human allograft and Each patient presented with retrusive, retroclined, 50% mineralized bovine heterograft. A 2-3mm or upright lower incisors and excessive overbite. layer of graft material was applied over the root Orthodontic treatment was initiated in the late surfaces, extending apically to cover the symphy- mixed or early permanent dentition using twin .018" sis, and the graft was covered with a layer of acel- or .022" brackets with a modified Roth prescription. lular dermal matrix. The primary flap was then Orthodontic fixed appliances and active arch- secured 1mm coronal to the cementoenamel junc- wires were placed about one month prior to the tions of the teeth. Appropriate post-treatment anti- POPA procedure to take advantage of the regional biotics and nonsteroidal anti-inflammatory drugs acceleratory phenomenon (RAP). The RAP is a were recommended, along with acetaminophen tissue reaction to a noxious stimulus—in this situ- and chlorhexidine mouthrinses, and a soft diet was ation, the POPA surgery—that increases the heal- prescribed for five days. ing capacities of the affected tissues. In the alveo- SureSmile* finishing procedures were ap- lar bone, cellular activity and bone remodeling plied in each case during the last six months of increase during the RAP and return to normal active treatment. The SureSmile software uses after a few months. Placing active appliances prior CBCT to create a three-dimensional virtual mod- to POPA therefore maximizes the potential of el of the teeth, roots, occlusion, bone, nerves, and tooth movement while avoiding the need for the soft tissues. The individual teeth are digitally customary three-week healing period after surgery. placed in the desired positions as these movements Our POPA procedure differed from that of are measured in all three planes of space. The pro- previous reports in that it was applied in growing gram then uses a robot to bend the Copper Ni-Ti** patients. The gingival flap design, corticotomies, archwires to the customized prescription. These and tissue augmentation were all limited to the shape-memory wires are activated by body tem- facial aspects of the lower anterior alveolar bone perature. and anterior teeth, making this technique less ex- tensive and invasive than others. Essentially, the Case 1 POPA procedure addressed the discrepancy be- tween root volume and alveolar bone volume by A 12-year-old female presented with Class I increasing bone volume on the pressure side of the skeletal and dental relationships, mandibular ante- planned tooth movement. rior recession, an excessive overbite, crowding in After pretreatment periodontal evaluation, both arches, a large Bolton tooth-size discrepancy the orthodontist was consulted to determine the with 3.3mm of mandibular excess, and a soft lip direction and amount of tooth movement and, posture (Fig. 1, Table 1). Thin attached gingiva and therefore, the amount of augmented bone to be facial root prominence of the lower incisors and canines were noted (Fig. 2). The POPA surgical *Registered trademark of OraMetrix, Inc., Richardson, TX; www. procedure revealed multiple dehiscences (Fig. 3). suresmile.com. **Registered trademark of Ormco Corporation, Orange, CA; www. In this case, POPA included simultaneous hard- ormco.com. and soft-tissue grafting. 514 JCO/OCTOBER 2018 GRAY, RICHMAN Fig. 1 Case 1. 12-year-old female patient with Class I skeletal and dental relationships, excessive overbite, and upper anterior recession before treatment. VOLUME LII NUMBER 10 515 PRE-ORTHODONTIC PERIODONTAL AUGMENTATION FOR INCISOR ADVANCEMENT TABLE 1 CASE 1 CEPHALOMETRIC ANALYSIS Norm Pretreatment Post-Treatment Difference SNA 82.0° 80.7° 80.5° −0.2° SNB 80.2° 78.1° 79.9° 1.8° ANB 2.0° 2.6° 0.6° −2.0° Facial axis 90.0° 88.1° 87.3° −0.8° GoGnSN 32.0° 32.1° 31.8° −0.3° U1-NA 4.0mm 3.1mm 6.7mm 3.6mm L1-APo 0.0mm 0.0mm 3.1mm 3.1mm U1-SN 104.0° 99.4° 111.6° 12.2° L1-GoGn 90.0° 86.1° 98.6° 12.5° Interincisal angle 130.0° 142.4° 118.0° −24.4° Fig. 2 Case 1. Thin attached gingiva and prominent roots. Fig. 3 Case 1. Dehiscences and fenestrations revealed during pre-orthodontic periodontal augmentation (POPA) surgery. *Registered trademark of OraMetrix, Inc., Richardson, TX; www.suresmile.com. 516 JCO/OCTOBER 2018 GRAY, RICHMAN A B A C D Fig. 4 Case 1. A. Patient after 15 months of orthodontic treatment. B. Cone-beam computed tomography (CBCT) image. C. Final SureSmile* scan (taken 21 months after treatment), documenting retention of grafted bone. D. Superimposition of pre- and post-treatment cephalometric tracings. VOLUME LII NUMBER 10 517 PRE-ORTHODONTIC PERIODONTAL AUGMENTATION FOR INCISOR ADVANCEMENT photographs were taken for the SureSmile process, and the final, robotically fabricated .017" × .025" Copper Ni-Ti archwires were worn for three months in both arches. With excellent patient compliance, active orthodontic treatment time was 15 months (Fig. 4). Post-treatment evaluation demonstrated a healthy and robust dentoalveolar complex, advancement and proclination of the lower incisors, bony apposition on the facial aspect of the