SPEEDY ORTHODONTICS

By K SARAVANAN First year PG : Department of Orthodontics and Dentofacial orthopedics

WHY SPEED?
Many orthodontic patients jeopardize their dental health and decline treatment, due to its long treatment times

Corticotomy facilitated orthodontics emerged to speed up orthodontic treatment

INTRODUCTION
What is Corticotomy?
A corticotomy is defined as a surgical procedure whereby only the cortical plate is cut ,perforated or mechanically altered This is in contrast to osteotomy which is surgical cut through both cortical bone and medullary bone

Historical prospective
BONY BLOCK TECHNIQUE It was first introduced by DR KOLE in 1959(interradicular corticotomy and supra apical osteotomy) In 1979 DR DUKER by experimenting on beagle dogs concluded that neither the pulp nor the periodontium were damaged following CFOT(interdental cuts 2mm short of alveolar crestal bone level)

COMBINED CORTICOTOMY AND OSTEOTOMY

 GANERSON ET AL in 1978 revised DR KOLE`s Technique without the supra apical osteotomy. DR KOLE`s EXPLANATION TO TOOTH MOVEMENT IDEA BEHIND HIS WORK Teeth move faster when the resistance exerted by the surrounding cortical bone is reduced POST SURGERY and APPLICATION OF ORTHODONTIC FORCE

Movement of the entire alveolar cortical block

FOR EXAMPLE :MOVING BLOCKS OF BONE WITH CROWNS OF TEETH AS HANDLES

DRAW BACKS
1. CORTICOTOMY and OSTEOTOMY Depending on the severity of injury to the trabecular bone

There were increased risk of postoperative tooth devitalization and even bone necrosis 2. CORTICOTOMY ALONE

Less injury and also prevention of post operative de vitalization

DISCOVERY OF RAP
A distinguished orthopedist DR HAROLD FROST discovered that there was direct correlation between

Degree of injuring of bone and its intensity of healing response

He called it the RAPID ACCELERATORY PHENOMENON

Rapid acceleratory phenomenon

Such healing response can be considered as a physiological emergency mechanism

which accelerates the healing of injuries that would affect survival i.e this phenomenon causes bone healing 10-50 times faster than normal bone turnover
Increased osteoblastic , osteoclastic activity and increased levels of local and systemic inflammation

Sequence of events
Cortical activation Transient osteopenia in alveolar bone Reduction of biomechanical resistance Rapid tooth movement through trabecular bone Spatial window : RAP to the teeth surrounded by corticotomy over a range of 3-4months

Amount of force
1. Initial report Heavier forces are required in cases of bone block movement after corticotomy to move the tooth bone block

2. Confirmed report
Conventional forces are sufficient REASON : Forces are not concentrated on tooth perio complex surrounded by rigid bone but forces are concentrated on tooth perio complex surrounded by low density trabecular bone.

Force and Hyalinization

Sequence of events Tissue necrosis caused by excessive compression of the pdl(see notes)

Vascular access of osteoclasts to PDL- lamina dura interface is limited

Extensive ,prolonged hyalinization causes slow tooth movement Thus as stated earlier , better mechanical loading is the reason why CAT shows a less period of hyalinization Thus decreased necrosis leads to direct bone resorption and faster tooth movement

FURTHER REPORTS
Lee et al described that there were differences in bone regeneration after corticotomy and osteotomy The prolonged period of hyalinization is the reason to explain why there is some degree of root resorption in conventional orthodontic tooth movement , which is not observed in CAT A recent histological study showed that selective alveolar decortication induced increased turnover of alveolar spongiosa (SEBEON ET AL). Corticotomy was found to produce bone resorption around the moving teeth by day 21 after surgery and the area refilled with bone after 60 days.(WANG ET AL )

WILCKODONTICS
IN 1995 DRS WILCKO using their knowledge of corticotomy and RAP developed their Patented periodontally accelerated osteogenic orthodontics(PAOO) It is a combination of selective alveolar decortication and alveolar augmentation by grafting also reffered it as ACCELERATED OSTEOGENIC ORTHODONTICS

Technique
1. Administration of local anaesthesia 2. Crevicular incision is made buccaly and lingual extending two to three teeth beyond the area to be treated

3. FULL THICKNESS FLAP ELEVATED BEYOND THE APEX OF THE TOOTH IF POSSIBLE
4. The area is debrided and curettage is done to remove any inflammed tissue

1. Alveolar activation is done with selective alveolar decortications on both buccal and lingual sides using piezosurgery technique or routine burs 2. Vertical corticotomy cuts are made between the roots stopping just short of alveolar crest(usually 3mm). The cuts are connected beyond the apices of the teeth with scalloped horizontal cuts

3. Cortical perforation can be made at selective areas to increase blood supply to the graft material

Placement of bone grafts

1. Use of mix of demineralized freezedried bone and bovine bone with clindamycin. 2. Care should be taken not to place an excessive amount of bone graft which might interfere with flap placement

To treat recession

1. Flaps are repositioned back allowing sufficient bone coverage 2. Interrupted loop sutures are made

3. Periodontal dressing is made for eventful healing

Recovery from PAOO surgery

Total recovery from the procedure usually takes 710 days There might be mild swelling and it might require use of ice packs. Clhorhexidine mouth wash may be used

Orthodontic adjustments post PAOO

Two weeks, post surgery orthodontic treatment are resumed The intervals for orthodontic adjustments averaged two weeks Depending on the case the braces are put for 3-9 months

After braces removal ,a retainer for atleast 6 months is usually recommended

Patient Qualification
Dr Wilcko says PAOO Technique can correct most of the orthodontic problems that are treated with traditional braces . It is to overcome short comings of conventional method such as a) long treatment time, b)limited encelope of tooth movement

c)difficulty of producing movement in certain

direction

Certain Clinical indications

1. Resolve crowding 2. Accelerate canine retraction after premolar extraction

3. Facilitate eruption of impacted teeth

4. Facilitate slow orthodontic expansion

5. Molar intrusion and open bite correction

6. Manipulation of anchorage

Contraindications
Bone loss Periodontal disease Rhematoid arthritis patients who require regular dose of NSAIDS Class 3 condition

Side effects
Slight interdental dental bone loss in few cases Loss of attached gingiva Subcutaneous haematomas have been reported in face and neck after intensive corticotomies. No effect on vitality of the pulps are seen

Advantages
Less time than traditional orthodontics less likelihood of root resorption History of relapse has been very low Prevent devitalization of teeth Prevent periodontal damage

Disadvantages
Expensive procedure Mildly invasive surgical procedure Patients who take NSAIDS on a regular basis or have chronic health problems cannot be treated It does not lend itself to class 3 malocclusion cases

CONCLUSION
Conventional orthodontics typically takes 18 and 24 months to achieve desired results PAOO also known as WILCKODONTICS can straighten most pateints teeth in 3-8 months This option is particularly appealing in adult patients who wants to shorten treatment time Thus, PAOO puts orthodontics on a fast track by incorporating changes in the structure of surrounding bone