Readers forum

American Journal of Orthodontics and Dentofacial Orthopedics

Volume 138, Number 6

Authors response
Thank you for your compliments and your interest in our
case report, Lateral open bite: treatment and stability (Am J
Orthod Dentofacial Orthop 2010;137:701-11). We are glad
that you agree that extrusion of teeth for this patient was
the best treatment option, and that tongue thrusting was
most likely the etiologic factor of this malocclusion.
Therefore, to increase stability, myofunctional therapy was
indicated and performed after orthodontic treatment. The
functional exercises were not exactly those suggested by
Alexander (Alexander RG. The role of occlusal forces in
open-bite treatment. J Clin Orthod 2000;34:23-9) but perhaps
similar. Because the patient had muscle tonus and mobility
problems, exercises of isometric and isotonic contractions
were prescribed, associated with the work of correcting the
proprioceptive positioning of the tongue. Evidently, other
retention methods could have been used, including a Hawley
plate with tongue cribs, but in association with myofunctional
therapy, which seemed to be the most important for this patient. Shielding could also have been used during treatment
in association with vertical elastics, which are primarily responsible for closing the open bite. Again, thank you for
your positive comments.
Guilherme Janson
Karina Freitas
Marise Cabrera
Bauru, S~
ao Paulo, Brazil
Am J Orthod Dentofacial Orthop 2010;138:687
0889-5406/$36.00
Copyright 2010 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2010.10.014

Lateral open-bite treatment and

gingival health
I enjoyed the May case report, Lateral open bite: treatment and stability (Cabrera MC, Cabrera CAG, de Freitas
KMS, Janson G, de Freitas RM. Am J Orthod Dentofacial
Orthop 2010;137:701-11) and would like to congratulate the
authors on achieving an ideal occlusion, specifically moving
the maxillary left canine and the first and second premolars
buccally out of crossbite.
The gingival recession on these teeth as well as on the
mandibular left central incisor two years post-treatment merits
some discussion, as periodontal health is sometimes overlooked at the treatment planning appointment. I argue for
prophylactic soft-tissue grafting in the mandibular anterior
and maxillary right posterior sextants before orthodontic
movement out of the alveolar housing.
The patient had several risk factors for recession. First, he
presented with a thin, scalloped periodontal biotype.1 Second,
although there is no clear consensus on what constitutes
thin gingiva, one method is visualization of the shadow of
the periodontal probe through the sulcus.2 In this case, we assume that it is thin because the outline of the roots can be seen

687

through the gingiva. Thin tissue is more likely to recede due to

trauma or orthodontic movement than normal or thick tissue.3
In fact, the patient presented with initial signs of recession
(maxillary left central incisor).
Classic orthodontic-periodontic literature has consistently
shown that bone and gingival recession occur as the dentition
moves outside of the alveolar housing.4-6 According to
Millers classification7 any bone or papilla recession interproximally reduces the predictability of complete root coverage. Therefore, soft tissue grafting in cases similar to this is
more predictable before orthodontic treatment is initiated.
Rafiel M. Rafiee
Los Angeles, Calif
Am J Orthod Dentofacial Orthop 2010;138:687
0889-5406/$36.00
Copyright 2010 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2010.10.006

REFERENCES
1. Seibert J, Lindhe J. Esthetics and periodontal therapy. In: Lindhe J,
editor. Textbook of clinical periodontology. 2nd ed. Copenhagen,
Denmark: Munksgaard; 1989. p. 477-514.
2. Kan J, Rungcharassaeng K, Umezu K, Kois JC. Dimensions of
peri-implant mucosa: an evaluation of maxillary anterior single
implants in humans. J Periodontol 2003;74:557-62.
3. Dannan A. An update on periodontic-orthodontic interrelationships. J Indian Soc Periodontol 2010;14:66-71.
4. Karring T, Nyman S, Thilander B, Magnusson I. Bone regeneration
in orthodontically produced alveolar bone dehiscences. J Periodontal Res 1982;17:309-15.
5. Batenhorst KF, Bowers GM, Williams JE Jr. Tissue changes
resulting from facial tipping and extrusion of incisors in monkeys.
J Periodontol 1974;45:660-8.
6. Steiner GG, Pearson JK, Ainamo J. Changes of the marginal
periodontium as a result of labial tooth movement in monkeys.
J Periodontol 1981 Jun;52(6):314-20.
7. Miller PD Jr. A classification of marginal tissue recession. Int J
Periodontics Restorative Dent 1985;5:8-13.

Authors response
Thank you for your compliments and for your time to share
your perspectives on our case report, Lateral open bite: treatment and stability (Cabrera MC, Cabrera CAG, de Freitas
KMS, Janson G, de Freitas RM. Am J Orthod Dentofacial Orthop 2010;137:701-11). As we discussed in the article, prophylactic management of gingival recession in at-risk orthodontic
patients is a controversial issue. Therefore, in this patient, we
opted for a more cautious watch and wait approach,
according to the method of Andlin-Sobocki and Bodin (Andlin-Sobocki A, Bodin L. Dimensional alterations of the gingiva
related to changes of facial/lingual tooth position in permanent
anterior teeth of children. A 2-year longitudinal study. J Clin
Periodontol 1993;20:219-24) and decided to perform the grafts
after active treatment, because the teeth would be well aligned
and positioned, simplifying achievement of a correct gingival
contour. This would be the favorable consequence of this
decision. However, on the other hand, it would probably