Seminars in Orthodontics

EDITOR -IN-CHIEF
Elliott M. Moskowitz, DDS, MSd

EDITORIAL BOARD
EDITOR-IN-CHIEF EMERITUS
P. Lionel Sadowsky, DMD, BDS, DipOrth, MDent

Mani Alikhani, New York, NY (2017) Peter Ngan, Morgantown, WV (2015)

Rolf G. Behrents, St. Louis, MO (2017) Perry M. Opin, Milford, CT (2017)
S. Jay Bowman, Portage, MI (2017) Jae Hyun Park, Mesa, AZ (2017)
James Caveney, Wheeling, WV (2015) Sheldon Peck, Newton, MA (2014)
John Grubb, Chula Vista, CA (2015) C.B. Preston, Buffalo, NY (2017)
Greg Huang, Seattle, WA (2014) William R. Proffit, Chapel Hill, NC (2015)
Robert J. Isaacson, Edina, MN (2015) Eugene Roberts, Indianapolis, IN (2015)
Laurance Jerrold, Brooklyn, NY (2017) Emile Rossouw, Chapel Hill, NC (2017)
Lysle E. Johnston, Jr., Eastport, MI (2015) David L. Turpin, Federal Way, WA (2017)
Donald R. Joondeph, Bellevue, WA (2015) James L. Vaden, Cookeville, TN (2015)
Robert G. Keim, Los Angeles, CA (2017) Robert L. Vanarsdall, Jr., Philadelphia, PA (2015)
Richard Kleefield, Norwalk, CT (2015) Katherine Vig, Columbus, OH (2017)
Steven J. Lindauer, Richmond, VA (2015) Christos Vlachos, Homewood, AL (2014)
James A. McNamara, Jr., Ann Arbor, MI (2017) Timothy T. Wheeler, Gainesville, FL (2015)
Ravindra Nanda, Farmington, CT (2017) Leslie A. Will, Boston, MA (2017)

INTERNATIONAL
Adrian Becker, Jerusalem, Israel (2017) Rakesh Koul, Lucknow, India (2017)
Jose´ Alexandre Bottrel, Rio de Janeiro, Brazil (2015) Birte Melsen, Aarhus, Denmark (2017)
Theodore Eliades, Nea Ionia, Greece (2014) Antony McCollum, Bryanston, South Africa (2015)
W.G. Evans, Johannesburg, South Africa (2017) Eliakim Mizarahi, Ilford, England (2015)
Jorge Faber, Brasilia, Brazil (2017) Bjørn Øgaard, Oslo, Norway (2017)
Joseph Ghafari, Beirut, Lebanon (2017) Nikolaos Pandis, Corfu, Greece (2017)
Vicente Hernandez, Alicante, Spain (2017) Pratik K. Sharma, London, UK (2017)
Nigel Hunt, London, England (2015) George Skinazi, Paris, France (2015)
Haluk Iseri, Ankara, Turkey (2017) John C. Voudouris, Toronto, Canada (2017)
Roberto Justus, Mexico City, Mexico (2015) William A. Wiltshire, Winnipeg, Canada (2015)
Sanjivan Kandasamy, Midland, WA, Australia (2017) Björn U. Zachrisson, Oslo, Norway (2015)
 Seminars in Orthodontics
VOL 21, NO 1 MARCH 2015

Interdisciplinary Management of the Orthodontic Patient

Pratik Kumar Sharma, BDS(Hons), MFDS, MSc, MOrth, FDSOrth
Guest Editor

■ Introduction 1
Pratik Kumar Sharma

■ The orthodontic/periodontal interface 3

Ewa M. Czochrowska and Marco Rosa

■ Management of gingival recession in the orthodontic patient 15

Dominiki Chatzopoulou and Ama Johal

■ Interdisciplinary management of congenitally absent maxillary lateral incisors:

Orthodontic/prosthodontic perspectives 27
Pratik K. Sharma and Pranay Sharma

■ Multi-disciplinary management to align ectopic or impacted teeth 38

Padhraig S. Fleming

■ The role of distraction osteogenesis in patients presenting with dento-facial

deformity—An overview 46
Michael Millwaters and Pratik K. Sharma

■ Upper incisor trauma and the orthodontic patient—Principles of management 59

Monty Singh Duggal, Jay Kindelan, and Hani Nazzal
 Seminars in Orthodontics
VOL 21, NO 1 MARCH 2015

Introduction

A s orthodontists, we frequently encounter

patients who present with inter-disciplinary
problems and needs. Although demanding, the
Drs. Dominiki Chatzopoulou and Ama Johal
then follow with an overview of the topic of
gingival recession. This will be a valuable guide to
successful management of such cases can be the orthodontic reader as the emphasis of their
extremely fulfilling, not only from the patients' article is on the identification of the presence of
perspective, but also for the professional team recession defects and the assessment and man-
involved. agement of orthodontic patients with recession
The purpose of this issue of Seminars in or potential risk for recession.
Orthodontics is to describe the management of Next, the focus turns to hypodontia and the
patients presenting with a variety of multi- management of patients presenting with con-
disciplinary problems. For many years, our spe- genitally absent maxillary lateral incisors. Drs.
cialty has predominantly involved managing the Pratik and Pranay Sharma describe the joint
younger patients, but with increasing demand for orthodontic/prosthodontic elements of care
treatment amongst the adult population, the associated with both space closure and canine
emphasis on inter-disciplinary care, particularly substitution as well as space opening for an
with reference to periodontal and gingival con- implant-retained prosthesis. The key considera-
ditions, has taken an increasing precedence. As tions with both approaches are described, with an
such, two of the articles in this edition will focus emphasis on achieving an aesthetic, functional,
on the periodontal aspects of managing the and stable outcome as part of an inter-
orthodontic patient. disciplinary team.
In this issue of Seminars in Orthodontics, we Thereafter, Dr. Padhraig Fleming deals with
provide information to the reader that is valuable the issue of impacted teeth in his article. He
in treating patients who present with hypodontia, provides an evidence-based approach to the
periodontal and gingival problems, dental subject that is suitably illustrated with a number
trauma, impacted teeth, and dento-facial defor- of clinical cases. Importantly, this article high-
mity. As orthodontic clinicians, we are fortunate lights the key inter-disciplinary considerations
to have the opportunity to work with many other and decisions that need to be made when
dental specialties as the patients who present to managing impacted teeth.
us do so with a variety of conditions, necessitating The emphasis then changes to facial defor-
inter-disciplinary care. An understanding of the mity. Mr. Michael Millwaters and Dr. Pratik
principles of management is therefore crucial for Sharma provide an overview of the application of
us to be able to deliver optimal care. distraction osteogenesis in managing patients
Drs. Ewa Czochrowska and Marco Rosa begin with dento-facial deformity. One of the most
with an in-depth review of managing patients exciting developments in joint surgical man-
with periodontal disease. The article describes agement of patients over the last 30 years, the
the pathological basis of periodontal problems, article describes the history, biological basis, and
its assessment and management with relevance to clinical application of the technique in the
those patients undergoing orthodontic treat- maxillo–facial complex.
ment, and importantly covers the issue of Finally, this issue of Seminars in Orthodontics
retention. is completed with an in-depth article descri-
bing the management of patients presen-
ting with dental trauma. Prof Monty Duggal
& 2015 Elsevier Inc. All rights reserved. and Drs. Jay Kindelan and Hani Nazzal pro-
http://dx.doi.org/10.1053/j.sodo.2014.12.007 vide the reader with a comprehensive overview

Seminars in Orthodontics, Vol 21, No 1 (March), 2015: pp 1–2 1

2 Sharma

of dealing with a condition that is frequen- present with inter-disciplinary challenges more
tly encountered by the orthodontic practi- appropriately.
tioner.
Our hope is that this issue provides the reader Pratik Kumar Sharma, BDS (Hons), MFDS, MSc,
with useful clinical information that enables MOrth, FDSOrth
practitioners to manage those patients who Guest Editor
The orthodontic/periodontal interface
Ewa M. Czochrowska, DDS,PhD, and Marco Rosa, DDS

Pathologic tooth migration (PTM) is often observed in patients with

periodontitis, especially in the anterior region. Orthodontic treatment allows
correction of PTM and aims at preservation of natural teeth and establish-
ment of normal occlusion, but periodontal patients are at risk for further
progression of periodontitis. The most important criteria for success is
elimination of the active periodontal inflammation before and during
orthodontic tooth movement. Therefore, close collaboration between the
orthodontist and the periodontist is mandatory. General knowledge of the
etiology and manifestation of periodontitis and satisfactory patient's
cooperation is essential during the orthodontic treatment in affected
patients. Careful diagnosis, appliance construction, and permanent retention
is critical for a successful prognosis. (Semin Orthod 2015; 21:3–14.) & 2015
Elsevier Inc. All rights reserved.

Pathologic tooth migration aspects as a main reason for seeking treatment. A

recent study by Dragan7 shows that in patients with
athologic tooth migration (PTM) can be
P described as a change in tooth position that
occurs when there is a disruption of forces that
aggressive periodontitis (AP) the frequency of PTM
is more common (72%) than in patients with
chronic periodontitis (CP) (46%). It can be
maintain teeth in a normal relationship.1 PTM is
concluded that the destruction of periodontal
often observed in patients with periodontitis,
tissues plays a major role in etiology of PTM.
especially in the anterior region2,3 and is related
The most prevalent clinical manifestation of
to the extent of bone loss, gingival inflammation,
PTM is diastemas and spacing, labial flaring, tooth
and tooth loss.4 Martinez-Canut et al.4 evaluated
rotation, and extrusion (Figs. 1A–C and 2A–E).
852 adult patients with periodontal disease and
They may be related to the disruption of the dental
reported that PTM occurs in about 80% of teeth
equilibrium between the tongue and lips, resulting
with more than 50% bone loss. Towfighi et al.5
from the loss of alveolar bone in the course of
compared the mean clinical attachment loss (CAL)
periodontitis, since the resting tongue pressure is
between migrated and non-migrated anterior teeth
considerably greater than lip pressure (Fig. 1L).8
in patients with periodontitis. The mean CAL in
Dragan7 studied the prevalence of different forms
teeth with PTM was 4.79 ⫾ 0.28 mm, which was
of PTM in patients with periodontitis and
significantly higher than the mean CAL in teeth
concluded that the most common manifesta-
without PTM (3.21 ⫾ 0.18 mm). The reported
tions are diastemas and labial flaring, or combina-
frequency of PTM varies from 30% to 55% in
tion of both (Fig. 1A–C). Tooth extrusion was
patients with periodontitis. Brunsvold et al.6
significantly correlated with the amount of alveolar
evaluated records of 191 periodontal patients for
bone loss (Fig. 2A–E). Isolated forms of PTM were
their chief complaints at the first examination and
as common as a combination of different forms of
PTM was reported as a main reason in 9.4% of
PTM. The risk of occurrence of labial flaring, tooth
patients, while 25.6% reported different esthetic
rotation, and extrusion was higher in patients with
AP than in CP.
Department of Orthodontics, Medical University in Warsaw,
Warsaw, Poland; Post-graduate Orthodontic School, Medical Uni-
versity of Insubria, Varese, Italy; Private Practive, Trento, Italy.
Address Correspondence to Nowogrodzka 59, Warsaw 02-005, Treatment of PTM
Poland. E-mail: [email protected]
& 2015 Elsevier Inc. All rights reserved.
The treatment of PTM depends on its severity
1073-8746/15/1801-$30.00/0 and the amount of alveolar bone loss. Treatment
http://dx.doi.org/10.1053/j.sodo.2014.12.001 alternatives include spontaneous correction after

Seminars in Orthodontics, Vol 21, No 1 (March), 2015: pp 3–14 3

4 Czochrowska and Rosa

Figure 1. A 52-year old patient with chronic periodontitis was seeking orthodontic treatment because of the
progressive protrusion of her incisors and spacing in the anterior segments (A–C). She had been under
periodontal maintenance for the last 2 years. The first molars and lower right second molar had been previously
extracted. Fixed upper and lower appliances were inserted to correct cross-bite of the upper left lateral incisor, the
lower midline shift, and PTM in the anterior segments (D–F). After orthodontic treatment, the anterior cross-bite
was corrected and the incisors were retracted (G–I) using a surgical screw on the right side (J and K).
Interproximal reduction of the enamel was performed during the treatment to reduce the black triangles.
Superimposition confirmed retraction of the upper and lower incisors and retraction of the lips and a slight
increase of the lower anterior face height (L-N). Clinical measurements of the probing depths (blue lines) and
gingival levels (red lines) at 6 sites of each tooth were registered on the periodontal chart both before (O and P)
and after orthodontic treatment (Q and R). The bleeding on probing was 18% before orthodontic treatment,
while the mean probing depth was 2.8 mm and the mean attachment loss was 3.7 mm. The clinical status of the
periodontal tissues remained unchanged after the orthodontic treatment (mean probing depth ¼ 2.4 mm; mean
attachment loss ¼ 3.2 mm); however, the pocket depths increased in the upper arch and decreased in the lower
arch, probably as the result of the retraction and some intrusion of incisors. The alveolar bone was generally
preserved when comparing the pre- (S) and post-treatment (T) intraoral radiographs. Before the orthodontic
treatment, protrusion of the upper incisors and spacing was visible during smiling (U), this was corrected during
the orthodontic treatment (V).
 The Orthodontic/periodontal interface 5

Figure 1. (continued)

periodontal treatment and tooth extraction fol- in the course of periodontitis small diastemas less
lowed by prosthodontic replacements and than 1 mm were developed.9,10 Therefore, it is
orthodontic treatment (Fig. 1D–F). Spontaneous important to detect tooth migration early to
correction after periodontal therapy is possible, if enhance the effectiveness of the periodontal
6 Czochrowska and Rosa

Figure 2. A 35-year-old patient with aggressive periodontitis referred by the periodontist for the orthodontic
treatment because of pathologic tooth migration (A–J). The patient had a reduced overbite and overjet (B and C).
Extraction of the upper left first premolar and the lower right first molar had been previously performed, resulting
in asymmetric buccal segment relationships (D and E), asymmetric upper and lower arch (F and G), and marked
midline shift (B). Extensive bone loss was seen on the intraoral radiographs (H). The periodontal inflammation
was under control, and bleeding on probing was less than 15% in all teeth, before the commencement of
orthodontic treatment. Probing depths (blue lines) and gingival levels (red lines) at 6 sites of each tooth were
 The Orthodontic/periodontal interface 7

Figure 2. (continued)

registered on the periodontal chart. Numbers in red represent severe periodontal involvement (I and J).
Extraction of the upper right first molar and the lower left second premolar were scheduled before the
orthodontic treatment commenced (0.018 slot, GAC Omni brackets) (F and G). After 3.5 years of orthodontic
treatment, the normalization of the overjet and overbite and arch symmetry was achieved accompanied by the
improvement in the smile esthetics (K–R). Normal tooth contacts were achieved, which should protect the gingival
papillae (L–Q). Fixed retainers in the anterior segments were placed and the upper removable plate was given for
night use during the first year and then 1–2 times/week (P and Q). The fixed retainers should be worn
permanently to prevent relapse of the malocclusion and the reoccurrence of PTM. The radiological examination
after orthodontics confirmed that the alveolar bone level was preserved (R); however, a marked radiolucency was
noticed on the lower right second molar. The patient was referred for further endodontic treatment. The
periodontal examination after the orthodontic treatment revealed the mean probing depth was reduced from
3.5 mm before the orthodontic treatment to 2.9 mm after the treatment. The mean attachment loss was
maintained (4.6 mm before and 4.4 mm after the orthodontic treatment). The overall prognosis of the
periodontal status is favorable if monitoring of periodontal inflammation and retention devices is continued. The
patient was very satisfied with the smile esthetics after the treatment.
8 Czochrowska and Rosa

treatment and for prevention of severe PTM, periodontal inflammation and maintain reduced
which may require complicated and time- but healthy periodontal tissues for many years in
consuming orthodontic or prosthodontic treat- majority of their patients. It was an important
ment. Tooth extraction followed by prostho- step for orthodontists to start orthodontically
dontic replacements may be recommended in correcting PTM or treating existing malocclusion
severe PTM associated with extensive alveolar in patients with periodontitis. Scientific reports
bone loss. Dental implants are often thought to from the 1980s clearly showed that tooth move-
be the “gold standard,” but long-term studies ment in patients with reduced, but healthy
show lower survival rate and higher number of periodontium does not result in significant fur-
complications in patients with periodontitis than ther bone loss.19–21 The same studies also showed
in patients with healthy periodontal tissues.11–14 that tooth movement in patients with active
Also, patients susceptible to periodontitis appear periodontal disease may lead to further
to be more susceptible to peri-implantitis.11,15,16 attachment loss.
De Boever et al.17 showed that periodontally The periodontal disease is associated with and is
healthy patients and patients with CP show no probably caused by a multifaceted dynamic inter-
difference in peri-implant variables and implant action of specific infectious agents, host immune
survival rate, while patients with AP have more responses, harmful environmental exposure, and
peri-implant pathology, more marginal bone loss, genetic susceptibility factors.22 During an
and a lower implant survival rate. This was also orthodontic assessment, it is important to register
confirmed in a systematic review by Al-Zahrani.18 family history for periodontitis, especially for
Traditional replacements of missing teeth, which younger patients with aggressive periodontitis,
use natural teeth as abutments, depend on the and the occurrence of other diseases, especially
amount of bone support and future progression diabetes, which may negatively affect the response
of periodontal disease at abutment teeth, which to periodontal treatment. Smoking, stress, and
may jeopardize their long-term prognosis. Tooth negative life style, including malnutrition, were also
extraction and prosthodontic replacements are documented to have positive correlation with the
elective alternatives to orthodontic treatment in progression of periodontitis.23
patients with PTM; however, it may be necessary The most common form of periodontal dis-
to perform pre-prosthodontic orthodontic ease, which is considered a type of infection, is
treatment in order to upright tilted teeth, opti- chronic periodontitis (CP) (Fig. 1). CP may start
mally re-distributing the remaining teeth or as a plaque-induced gingivitis and if left
leveling the alveolar bone. untreated may lead to irreversible loss of
attachment and bone; however, not all cases of
untreated gingivitis inevitably progress to perio-
Orthodontic treatment in patients with
dontitis. The amount of destruction of the
periodontitis
periodontal tissues in patients with CP is corre-
Correction of PTM and the existing maloc- lated with oral hygiene and local and general
clusion, reestablishment of tooth contacts and predisposing factors. The rate of progression is
gingival papillae, and overall improvement of the generally slow to moderate, with more severe
smile esthetics can be expected as a result of the forms present in about 10% of the population.
orthodontic treatment (Figs. 1 and 2). However, Aggressive periodontitis (AP) is a more rare form
patients with periodontitis are a high-risk group of periodontitis, which starts in younger adult
for the orthodontic treatment, because of pos- patients and progresses very rapidly (Fig. 2).
sibility for further progression of alveolar bone There is a clear family aggregation of cases in
loss. patients with AP with non-contributory medical
Advances in periodontology in the 1980s history. The amounts of microbial deposit are
enabled periodontists to understand the etiology inconsistent with the severity of periodontal tis-
of the disease process, which is generally a sue destruction. The simplified description of the
plaque-induced disease, stop its progression and most common features of CP and AP are pre-
even restore missing periodontal tissues using sented in the Table. The progression of CP and
guided tissue regeneration. Therefore, perio- AP is often episodic,24 which means that there
dontists were able to successfully control the are periods of remission, when orthodontic
 The Orthodontic/periodontal interface 9

Table. Simplified Description of the Main Differences Between Chronic and Aggressive Periodontitis
Variable Chronic Periodontitis Aggressive Periodontitis

Age Adults, may occur in children Mostly o30 years

Progression Slow or moderate, with periods of rapid progression Fast, attachment loss 43 mm/3 months
Commensurate with systemic risk factors, smoking, Non-contributory medical history
and stress
Microbial Variety of bacterial species Elevated proportions of A.a. and P.g.
deposits Often supra- and subgingival calculus Inconsistent with the severity of periodontal tissue
destruction
Others Associated with local predisposing factors Family history

treatment of PTM or existing malocclusion may clinical periodontal examination, which includes
be successfully performed. assessment of plaque and bleeding around 6 sites
Elimination of active inflammation within the of each tooth (Fig. 3). Also, it is important to
periodontal tissues is a key factor prior to starting measure the probing pocket depth (PD) and the
orthodontic movement in periodontal patients. It is clinical attachment loss (CAL) using calibrated
absolutely mandatory to perform orthodontic periodontal probe to register the amount of
treatment only in close collaboration with a bone loss at 6 sites for each tooth. Periodontal
periodontist, who will diagnose, treat, and follow up disease may not equally affect all teeth and all
longitudinally the status of periodontal tissues. The sites around each tooth (Figs. 1O–T and 2H–J
initial phase of periodontal treatment aims at and R–T). Different periodontal charts are
elimination of active inflammation within the widely used to register the amount of plaque,
periodontal tissues and usually includes hygiene presence of bleeding on probing and PD and
control, scaling and root planning, use of anti- CAL measurements, and furcation involvement.
bacterial drugs or antibiotics, and risk assessment. If This clinical examination should confirm
necessary, periodontal surgery is performed after a that there is no active inflammation within
successful initial phase. It is recommended to wait periodontal tissues and may be used to register
3–6 months after periodontal therapy before the status of hard and soft periodontal tissues
starting the orthodontic tooth movement25 in order before starting orthodontic treatment. The
to assess the response of periodontal tissues and to combination of increasing pocket depths and
evaluate patient's motivation for further treatment. frequent bleeding on probing is more likely to
lead to future attachment loss.26 Increased
plaque accumulation and bleeding on probing
Factors contributing to the treatment are known to negatively influence the clinical
success outcome of the periodontal therapy.27,28 Perio-
dontal examination may be performed by a
Monitoring of periodontal tissues periodontist or a trained orthodontist, and it will
Before starting orthodontic treatment in perio- serve as a baseline for monitoring the status of
dontal patients, it is recommended to perform the periodontal tissues during and after the

Figure 3. Periodontal probing at 6 sites of the upper right central incisor, which include the mesial, central, and
distal aspects on the buccal and palatal surfaces. Bleeding on probing is present on the distal palatal site of the
examined incisor.
10 Czochrowska and Rosa

orthodontic treatment. In the literature, no result of splinting properties of fixed orthodontic

direct guidelines for acceptable plaque accu- appliances.
mulation and bleeding on probing scores are
provided in patients with periodontitis before
Construction of orthodontic appliance
starting an active orthodontic treatment, but
those parameters should probably not exceed The majority of patients with periodontitis are
20% of all probing sites.21,28,29 treated with fixed orthodontic appliances
The extent of alveolar bone loss in patients because they are able to precisely control tooth
with periodontitis who are scheduled for ortho- movement, especially tooth rotation and intru-
dontic treatment is confirmed during radio- sion (Fig. 1D–F). Orthodontic attachments and
logical examination (Figs. 1S and 2H). It is remnants of orthodontic adhesives are known to
important for planning, performing, and significantly increase plaque accumulation
evaluating the outcome of orthodontic tooth during the orthodontic treatment,30–33 which is
movement in periodontally compromised teeth. an important risk factor in patients with perio-
Intraoral dental radiographs are advisable to dontitis. They are also responsible for the
measure the amount of bone destruction at the increase of supra- and subgingival microflora and
mesial and distal surfaces of teeth. Panoramic their shift to more pathogenic species.34–36
radiographs have limited value to precisely During the first few months after placement of
visualize alveolar bone loss. CT or CBCT fixed orthodontic appliances in periodontally
examinations allow for 3-dimensional imaging healthy patients, the increase in the pathogenic
of hard tissues, but their radiation dose is much bacteria is observed, which is followed by their
higher than 2-dimensional imaging and their use decrease during treatment and after debonding
therefore should be justified in each case. without permanent destructive effects on deep
During the orthodontic treatment, a patient periodontal tissues.37–39 Therefore, the con-
should be examined by a periodontist every 3–6 struction of a fixed orthodontic appliance in
months to monitor the status of periodontal patients with periodontitis should be designed
tissues.21,25 If unsatisfactory, then the ortho- with respect to its plaque-retention properties
dontic treatment should be stopped until there is and preferably kept as simple as possible.
evidence of remission of the disease. Ortho- Application of molar bands may also result in
dontists should monitor the oral hygiene and increased plaque accumulation, probing pocket
accumulation of the supragingival calculus dur- depth, and colonization of bacteria.30,34 Huser
ing the control visits and detect signs of gingival et al.40 showed that placement of orthodontic
and periodontal inflammation. These include bands results in an increase in the percentage of
alterations in color (red hue), texture and vol- spirochetes, motile rods, filaments, and fusiforms.
ume (edema and enlarged gingival contours) of Small but significant loss of attachment was
the marginal gingiva, and bleeding on probing reported for banded teeth after orthodontic
from the gingival pocket areas and increased treatment in comparison with controls, even if
mobility (sign of periodontal infection or trauma good oral hygiene was maintained during
from occlusion during orthodontic treatment). treatment.41,42 Bonded molar tubes should be
Any signs of periodontal inflammation during considered, whenever possible, because they allow
orthodontic treatment should be registered and for better control of plaque accumulation at the
if present, the patients must be referred to a gingival part of the orthodontic appliance. How-
periodontist. ever, recent study on microbiologic and perio-
If patients with periodontitis are properly dontal changes after placement of orthodontic
diagnosed and treated before starting the attachments over a 1-year period did not report
orthodontic treatment, then during orthodontic significant differences between banded and
tooth movement their periodontal status is bonded sites.43 Steel ligatures used for attachment
generally satisfactory and should not present a of teeth to the archwire significantly reduce plaque
major problem. Often patients with severe bone accumulation and amount of microorganisms in
loss and increased tooth mobility before the the plaque in comparison with elastomeric rings,44
orthodontic treatment report improvement in and they are certainly recommended in
chewing and biting during the treatment as a periodontal patients. Sukontapatipark et al.45
 The Orthodontic/periodontal interface 11

studied bacterial colonization associated with fixed should be considered when determining the
orthodontic appliances using a scanning electron individual risk profile.52
microscope and reported that after 2–3 weeks they Patients with severe periodontitis and PTM
found the presence of mature plaque on the excess before orthodontic treatment will need perma-
adhesives and a gap along the edge of bonding nent retention of the affected teeth, even if a
composite and a tooth surface, which was normal and well-balanced occlusion was achieved
consistently associated with bacterial accumu- after the orthodontic treatment. The optimal
lation. They concluded that the excess bonding long-term retainer in patients with periodontitis is
material is the critical site for plaque accumulation a round, spiral fixed retainer (0.019 or 0.0215
associated with fixed orthodontic appliances. coaxial steel wire) bonded palatally or lingually on
Therefore careful removal of excess bonding each tooth at the anterior maxillary or mandibular
material around orthodontic brackets is man- segment53 (Figs. 1I and K, and 2P–Q). If there is a
datory also in adult patients with periodontitis.31 need for splinting posterior teeth after the
Loss of alveolar bone in the course of perio- orthodontic treatment, fixed retainers are
dontitis moves the center of resistance closer to placed buccally,54 where they are more stable
the root apex, which should be incorporated in and well accepted by patients. Fixed retainers
the biomechanic design of orthodontic appli- work as a physiologic splint in patients with
ances. Reduction of orthodontic forces is rec- reduced periodontal support, because they
ommended, and it may be necessary to add a allow the individual teeth within the retainer to
larger moment produced by a couple applied to exert physiologic mobility.25 Fixed retainers must
the tooth to overcome the tipping moment and be properly adjusted to the morphology of teeth
produce bodily movement.46,47 and bonded with caution, avoiding overhanging
remnants of the composite, which may act as a site
for plaque retention. Especially in patients with
Retention
periodontitis, fixed retainers should be
Results of stability of the orthodontic treatment periodically checked by the orthodontist (every
are less predictable in adult patients than in 12 months) for signs of increased plaque and
children and adolescents, because of the ana- calculus accumulation and possibility of
tomic and biologic differences in tissue reaction debonding. Sandblasting can improve the
and general cessation of growth and develop- bonding strength of a fixed retainer, especially
ment.3,25 This is even more important in adult when bonded to artificial teeth. Also, new bonding
patients with periodontitis, where retention is the systems can improve retention properties of
inherent part of their orthodontic treatment. orthodontic adhesives. In the maxilla, it is
Reduced height of the alveolar bone may not mandatory to avoid occlusal interferences
provide enough support for the resting pressure during bonding of a fixed retainer on the
of lip and cheek,8 especially for teeth with severe palatal surfaces of anterior teeth.20
bone loss.48 Thilander49 stated the following, Establishment of a well-balanced occlusion
“retention is a continuation of orthodontic during front and lateral excursions and good
treatment. The patient must be well informed torque control of teeth included in the fixed
and motivated to co-operate to avoid possible retainer are important clinical factors for long-
relapse.” This issue should be adequately stressed term stability of fixed retainers. Other types of
before starting orthodontic treatment, together periodontal splints including glass-fiber are also
with information about the need for further used for retention in periodontal patients, but
monitoring of periodontal tissues by a perio- they are generally more bulky than traditional
dontist and follow-up of retention devices by the fixed retainers and are therefore less hygienic.
orthodontist. Patients who are regular compliers Removable retainers may risk ongoing jiggling of
during periodontal maintenance therapy show the teeth if the retainer is worn on a part-time
less recurrence of periodontitis and less tooth basis.25 Animal studies55 confirmed that jiggling
loss than irregular compliers.50,51 The pattern of forces can result in attachment and bone loss of
compliance is very important in maintaining a affected teeth. However, bone regeneration was
long-term good periodontal status and important possible after cessation of “jiggling” forces in
risk factors, especially diabetes and smoking, alveolar bone dehiscences. In the maxilla, a
12 Czochrowska and Rosa

removable plate with a labial bow is used together showed bone loss greater than 2 mm on the
with the fixed retainer in the anterior segment radiographs. Interestingly, there was a negative
for better control of proclination of upper relationship between initial bone level and
incisors and tooth position in the posterior subsequent bone loss during treatment,
segments. indicating that pretreatment periodontal
destruction may not be a risk factor for
orthodontic tooth movement.
The influence of orthodontic treatment on
Patients with periodontitis are obviously at
periodontal parameters
greater risk for further decline of their perio-
Most of the studies assessing the periodontal dontal parameters after orthodontic treatment.
outcome after the treatment are based on Boyer et al.65 compared longitudinally alveolar
comparisons of defined periodontal parameters bone level in a group of patients with
such as PD and CAL, but their reduction can be periodontitis (mean ¼ 16 years, range: 11–32
defined as a surrogate outcome, in comparison years) who underwent periodontal treatment or
with the tooth loss, which is in fact the tangible combined periodontal and orthodontic
outcome of major concern to the patient. But if treatment. There was no statistically significant
remission of periodontal inflammation was ach- difference between the groups, and the authors
ieved before starting orthodontic tooth move- concluded that orthodontic treatment does not
ment, then during orthodontic treatment, no negatively influence the periodontal outcome
tooth loss is generally observed, even for patients and may be even beneficial in the long-time
with severe or aggressive periodontitis (Figs. 1O–V perspective. Long-term preservation of perio-
and 2H–J and S–T).56 dontal tissue status after orthodontic treatment
Increased accumulation of dental plaque and was also confirmed in a large group of patients
development of gingival inflammation was with periodontitis.66
reported after placement of orthodontic fixed A recent study used the linear model to
appliances in periodontally healthy compare the PD, CAL, and bone level before and
patients.30,36,57,58 However, previous longitudinal after orthodontic treatment of patients with
studies did not confirm significant differences in chronic and aggressive periodontitis.67 Patients
periodontal parameters between orthodontic with AP showed statistically significant reduction
patients and control, untreated individuals.59–61 in PD and significant increase in CAL
Bollen et al.62 preformed a systematic review on measurements compared to patients with CP,
the effects of orthodontic therapy on periodontal but the clinical significance was hardly
health and found that orthodontic treatment was noticeable. Teeth with severe periodontitis and
associated with 0.13 mm of alveolar bone loss and female patients showed significantly higher
0.23 mm of increased pocket depth when reduction in PD and CAL after orthodontic
compared with no treatment. The authors treatment. Smoking was associated with
concluded that orthodontic therapy has a small reduction of CAL measurements. There was no
detrimental effect on the periodontal tissues. A significant influence of the type and severity of
systematic review by van Gastel et al.63 on the periodontits, gender, or smoking on the amount
relationships between malocclusion, orthodontic of bone loss before and after orthodontic
treatment, and periodontitis confirmed that the treatment. It was concluded that generally
few studies that have been published reported orthodontic treatment had no detrimental
minor loss of attachment during orthodontic effect on the periodontal status, even in
treatment. patients with severe and aggressive periodontitis.
Adult patients are more prone to periodontal
breakdown during active orthodontic tooth
movement than children and adolescents.21,30,64 Conclusions
Nelson and Årtun64 reported a mean alveolar
bone loss of 0.54 mm (SD ¼ 0.62) after (1) Orthodontic correction may be desirable in
orthodontic treatment for maxillary anterior patients with periodontitis and severe PTM,
teeth in the consecutive samples of 315 adult but it must be performed during remission of
patients. However, only 2.5% of all patients a periodontal inflammation and always in
 The Orthodontic/periodontal interface 13

close cooperation with a periodontist. 13. Fransson C, Tomasi C, Pikner SS, et al. Severity and
pattern of peri-implantitis-associated bone loss. J Clin
(2) Orthodontic appliances should be designed
Periodontol. 2010;37(5):442–448.
carefully, after considering plaque-retention 14. Simonis P, Dufour T, Tenenbaum H. Long-term implant
properties. survival and success: a 10-16-year follow-up of non-
(3) The status of periodontal tissues should be submerged dental implants. Clin Oral Implants Res.
regularly monitored during orthodontic 2010;21(7):772–777.
treatment. 15. Schou S, Holmstrup P, Worthington HV, et al. Outcome
of implant therapy in patients with previous tooth loss due
(4) After treatment, fixed retainers are recom- to periodontitis. Clin Oral Implants Res. 2006;17(suppl
mended in the anterior segments to prevent 2):104–123.
relapse of PTM and to support teeth with 16. Heitz-Mayfield LJ, Lang NP. Comparative biology of
severe bone loss. chronic and aggressive periodontitis vs. peri-implantitis.
Periodontol 2000. 2010;53:167–181.
17. De Boever AL, Quirynen M, Coucke W, et al. Clinical and
radiographic study of implant treatment outcome in
Orthodontic correction in patients with
periodontally susceptible and non-susceptible patients: a
periodontitis is possible, but the maintenance of prospective long-term study. Clin Oral Implants Res.
healthy periodontium and supervision of fixed 2009;20(12):1341–1350.
retainers are mandatory for medium to long- 18. Al-Zahrani MS. Implant therapy in aggressive periodon-
term success. titis patients: a systematic review and clinical implications.
Quintessence Int. 2008;39:211–215.
19. Elliasson LA, Hugoson A, Kurol J, et al. The effects of
orthodontic treatment on periodontal tissues in patients
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Management of gingival recession in the
orthodontic patient
Dominiki Chatzopoulou, Dipds, MClin Dent in Perio (Eng), and
Ama Johal, BDS, PhD, FDS (Orth) RCS

Gingival recession (GR) is a common periodontal condition that affects a

large portion of the young and adult population and negatively affects the
esthetic aspects of the smile. It has been described as relatively complex in
terms of its multifactorial cause, variable subjective outcomes, and con-
tinuously evolving treatment modalities, but it appears to present a simple
objective manifestation that can be quite challenging to the orthodontist. The
available options for treating the condition consist of a varied range of
nonsurgical and surgical techniques, which lie mainly within the field of
Periodontology but may include Orthodontics and the broader field of
Restorative Dentistry. In addition, the high association of GR with perio-
dontal disease progression would imply an understanding of the latter by the
orthodontist would be required in order to effectively diagnose and treat the
condition accordingly. Currently, cosmetic expectations have risen to such a
level that they constitute a major factor for an orthodontist when planning
treatment for patients in whom restoring function could outweigh esthetic
harmony. (Semin Orthod 2015; 21:15–26.) & 2015 Elsevier Inc. All rights
reserved.

Introduction A secondary objective is to present and evaluate

ontroversy exists in the literature between the current evidence base in relation to the impact
C the role of orthodontic treatment and
gingival recession. Gingival recession is a fre-
of orthodontic treatment on the gingival tissues.
Since the patient's esthetic values may change over
quently observed clinical condition characterized time, resulting in an increased cosmetic expect-
by exposure of tooth cementum, predominately ation, and while esthetics has proven to be the key
on the labial surfaces of teeth, and is reported to determinant for treatment, orthodontists need to
be present in the vast majority (50–88%) of the update and develop their knowledge base and skills
adult dentition.1 The primary objective of the in order to respond to those perceived needs. An
present article is therefore to increase the important aspect of this process is the orthodontist
knowledge, interest, and ability of orthodontists being able as a professional health care provider to
to carry out the following: recognize conditions where treatment could lead to
increased functional and esthetic satisfaction and if
1. Identify the presence of recession defects necessary refer patients accordingly to a perio-
2. Assess and manage orthodontic patients with dontist. The patient's perceived importance of the
recession or potential risk for recession smile in facial esthetics has resulted in the appli-
cation of the latest regenerative materials and
surgical techniques to periodontal recession
Centre for Adult Oral Health, Institute of Dentistry, London, UK; defects.2
Centre for Oral growth and Development, Institute of Dentistry,
London, UK.
Address correspondence to: Dominiki Chatzopoulou, Dipds,
MClin Dent in Perio (Eng), Centre for Adult Oral Health, Institute Definition
of Dentistry, 4 Newark Street, London E1 4AT, UK. E-mail:
[email protected] GR or marginal tissue recession is defined as the
& 2015 Elsevier Inc. All rights reserved.
location of the marginal tissue apical to the
1073-8746/15/1801-$30.00/0 cement–enamel junction (CEJ) with exposure
http://dx.doi.org/10.1053/j.sodo.2014.12.002 of the root surface [American Academy of

Seminars in Orthodontics, Vol 21, No 1 (March), 2015: pp 15–26 15

16 Chatzopoulou and Johal

Periodontology (AAP)—Glossary of Periodontal Predisposing Precipitating factors

Terms]. Diagnostic difficulties may however factors
occur when the CEJ of a tooth is lost due to
restorations, e.g., crowns and fillings or to
Thin gingival
Plaque and calculus
abrasion and abfraction lesions.3 According to biotype
Periodontal disease
the classification system established at the
Bone
TB trauma
International Workshop for Classification of dehiscence
Tooth movement
Periodontal Diseases and Conditions, GR is
Attachment
Smoking
recognized as a type of periodontal condition of frenum
Healing after periodontal
classified under the sub-category of “Mucogin- treatment
gival deformities and conditions around teeth.”4
Malocclusion

Subgingival crown margins
Prevalence

Overhanging fillings

Partial dentures
A review of cross-sectional epidemiological
Self-inflicted trauma habits
studies on GR would suggest that 88% of patients
Chemical trauma
aged 65 years and above and 50% of patients
aged 18–64 years present at least one or more
sites with recession.1 From these studies, it is clear
that the prevalence and severity of GR increases Predisposing factors
with age5–8 and that it may be present in pop-
These are factors that predominantly occur in
ulations with high standards of oral hygiene6,9 as
the area of interest and predispose to the
well as those deprived of professional dental care
occurrence of recession.11
and education.7 Thus, GR affects mainly buccal
surfaces of predominantly upper canines,
premolars, and molars and is frequently Gingival biotype
associated with wedge-type defects at the cer- There is current evidence to support that the
vical part of affected teeth.9 Populations with quality rather than the quantity of attached
poor standards of oral hygiene may also present gingiva is a predictive factor of GR. During the
recession defects associated with calculus development of recession in a thin biotype, the
accumulation and progression of destructive epithelial proliferation occupies the full volume
periodontal disease.7 Males appear to be more of the connective tissue, resulting in rapid
severely affected in both categories.5,7,8 Smok- recession of the gingiva. On the contrary, with a
ing,7,8 mal-aligned teeth,5 and tooth brushing thick biotype, the inflammation may be confined
trauma9,10 have been identified as possible risk to the region of the sulcus and does not neces-
indicators for development of GR in these sarily extend to destroy the outer gingival tissue.
studies. The study by Addy et al.10 also reported a As such, pocketing rather than recession would
correlation between an increased prevalence of occur and the residual gingival tissue would
GR associated with upper left region of the persist as the periodontal pocket wall.12 Studies
mouth with right-handed subjects. On the con- reporting on the development of GR after labial
trary, studies performed by Marini et al.11 failed movement of lower incisors have also demons-
to find differences in the occurrence of GR trated that a thin gingival margin is a significant
between right and left side of the mouth. predisposing factor for the development of GR13
with gingival thickness of less than 0.5 mm
Etiology rendering the site more susceptible.13

GR is considered to be a multifactorial perio-

Quantity of attached gingiva
dontal condition. In order to effectively under-
stand the contribution of each of these factors in A recently released AAP Consensus Statement on
the initiation and development of the condition, Mucogingival Conditions14 defined an inadequate
it may be convenient to classify the etiology into amount of keratinized tissue as less than 2 mm of
predisposing and precipitating factors11: width, of which less than 1 mm is attached
 Management of gingival recession 17

width of keratinized tissue as a variable, and

long-term results of at least 5 years should be
reported.

Bone morphology
Due to either developmental or iatrogenic etiology,
a part of a root can be deprived of its normal bone
housing, resulting in a bone dehiscence that is
formed more frequently at the buccal aspect of the
root.16 The subsequent loss of bone support to the
soft tissue margin may predispose the site to
potential recession. The bone crest usually is
approximately 2.5–3 mm apical to the gingival
margin, although extreme variations from this
value can be observed.16 For example, a
dehiscence produced by movement of a tooth
out of the cortical plate can be improved by re-
Figure 1. High muscle attachment of the frenum positioning of the tooth within the arch as it has
resulting in direct pull on the gingival margin. been reported that buccal alveolar bone has the
potential to regenerate. Consequently, tooth posi-
tion can primarily affect the bone morphology
gingiva. Early concepts in periodontology around a tooth, such that a buccally orientated
considered width of attached gingiva (Figs. 1 course of eruption may therefore be prone to
and 2) to be a significant factor in determining development of dehiscences and recession.5 The
the susceptibility of a given site to the develop- effect of occlusal trauma in initiation of GR lies
ment of GR. Absence of a certain zone of within the concept of bone dehiscence
“adequate” band of gingiva would reduce the development. Occlusal trauma has however not
tissue resistance to plaque accumulation and been significantly found to cause recession, with a
muscle attachment and lead to recession and number of published examples in the literature
pocket formation. Further studies are however where tooth malposition caused by occlusal trauma
welcome, as Palmer and Cortellini15 in the and/or malocclusion have generated severe
Consensus Report of the Sixth European recession defects. Thus, orthodontically posi-
Workshop on Periodontology recommend that tioning teeth within the alveolus should help to
randomized control trials (RCT) of root maintain adequate bone volume and density,
coverage (RC) techniques should include reducing the risk of GR.

Figure 2. Gingival recession associated with localized plaque-induced inflammatory lesion.

18 Chatzopoulou and Johal

High attachment of frenum frequency of toothbrush (TB) trauma in the

development of GR. Such recession has been
Although evidence from published literature
reported to be relatively common in populations
appears to be inconclusive on the role of high
with high standards of oral hygiene, where it is
frenal attachment (Fig. 1) in the development of
usually located at buccal surfaces of canines,
GR, orthodontists are advised to examine
premolars, and molars6,9,10 with associated
carefully the magnitude of the pulling force on
wedge-shaped hard tissue defects (Fig. 3).
the gingival tissues. According to Allen et al.,17
Increased hardness of bristles has been pos-
the high frenal attachment can predispose a site
itively correlated to GR; however, no correlation
to GR in 2 possible ways: firstly, attachment close
was found by Tsami-Pandi and Komboli-
to the gingival margin compromises the plaque
Kontovazeniti.18 A systematic review of the effects
removal from the area, or secondly, by direct pull
of TB trauma on GR concluded that there was
of the frenum on the margin (Fig. 1).
inconclusive evidence to support or refute the
The tension test is used in order to assess the
association between TB and GR and that factors
magnitude of the pulling force on the gingival
that have been associated with development and
margin. This involves tension being applied to
progression of recession are duration, frequency of
the associated part of the lip or the frenum itself,
brushing, technique, brushing force, frequency of
with subsequent gingival margin blanching.17
changing toothbrushes, and hardness of bristles.
Removal of frenum and deepening of the
Bass (and its modification) is the technique most
vestibule may be the first surgical procedures
commonly recommended by dentists due to its
carried out by periodontists in order to correct
superiority to scrubbing techniques in removing
recession defects.
plaque from the gingival margin.19 However,
evidence regarding its contribution in deve-
Precipitating factors lopment of recession is inconclusive, as several
studies appear to show that there could be a
Plaque, calculus, and periodontal disease significant correlation.20 According to Sandholm et
Based on the classic study by Baker and Seymour 12 al.,20 individual dexterity appears to be the most
on the pathogenesis of GR, the presence of important factor influencing the association.
plaque/calculus deposits around teeth can
induce an inflammatory response in the con- Orthodontic tooth movement
nective tissue, through the activation of innate and
A number of animal studies have attempted to
immune responses, resulting in attachment loss.
evaluate the effect on both the gingival and bony
Attachment loss can therefore manifest either as
tissues of moving teeth outside the cortical plate
recession of the gingival margin, pocket for-
and the resultant changes with and without
mation, or a combination of both. During
moving these teeth back into bone. It appears that
progression of periodontal disease, buccal sites
moving teeth outside the cortical plate and
tend to be more susceptible to GR than inter-
retaining them in this position results in loss of
proximal, where increased probing depths are
both bone and soft tissue. In contrast, moving the
more evident. This can be justified, according to
Baker and Seymour's12 hypothesis, by the presence
of thick tissue located interproximally being
associated with pocket formation whereas thin
tissue, found buccally, being associated with
GR during the development of periodontal
disease. A localized plaque-induced inflamma-
tory lesion can be the cause of a recession defect
(Fig. 2).

Toothbrush trauma Figure 3. Recession associated with tooth brushing

trauma. The marginal gingiva is clinically healthy and
Contradictory evidence is apparent when abrasion defects of various extensions can be noted in
reviewing the literature regarding the role of the exposed roots.
 Management of gingival recession 19

teeth back to within the alveolus was accompanied in even more advanced GR patterns,
by a gain in bone of up to 50%, but importantly no depending on the amount of tissue resection
soft tissue benefit was observed.21 It is worth performed. 25 Patients should always be warned
noting that the quality of available scientific about the esthetic outcome anticipated from
evidence up to date is weak, with small samples a designed treatment plan, particularly as this
(r5) of either dogs or monkeys included. is a primary initiating patient concern.
A recent systematic review by Joss-Vassalli et Interestingly, long-term coronal rebound of
al.,22 designed to evaluate the clinical evidence for the soft tissue margin following specific types
any association, concluded there was a weak of surgery tends to partially compensate for
evidence base (with studies being predominately attachment loss resulting from the periodontal
retrospective in nature and graded of low-to- surgery.26 An important observation in
moderate quality). In particular, shortcomings the literature has been the risk involved
included a short-term follow-up at the end of following overinstrumentation of shallow
active treatment and weak methodology, with healthy sites.
studies containing too many confounding varia-
bles that were not controlled for. Furthermore, Presence of malocclusion
contradictory results were found regarding the
correlation between incisor proclination and A Class II Division 2 malocclusion can be asso-
subsequent gingival recession, with the authors ciated with direct trauma to both the labial
recommending caution in interpreting the find- gingival margin of lower incisors and the palatal
ings. According to Wennström et al.,23 as long as margins of upper incisors. This particular incisor
the tooth is moved within the envelope of alveolar relationship may therefore generate recession
bone, GR will not occur, irrespective of the quality defects in these areas, often resulting in inden-
(volume) and quantity (width) of attached tations in the gingivae.3
gingiva. If labial tooth movement results in the It does appear from the literature that Class III
development of alveolar bone dehiscence, the risk dental decompensation, in preparation for a
of recession development is evident. combined surgical–orthodontic correction, may be
a risk factor for GR. Sperry et al.26 in a retrospective
Smoking “matched” study (n ¼ 32) demonstrated increased
labial recession in patients undergoing Class III
Smokers usually present with GR, without the decompensation. Artun and Krogstad27 reported
tendency to bleed on probing and the fact they increased clinical crown height and GR at 3-year
appear to have more recession than non-smokers follow-up, with a statistically significant correlation
has been attributed to the long-term reduction of with width of the mandibular symphysis.
the gingival blood flow.3 Destructive oral hygiene
habits, adopted in an attempt to remove staining, Restorative dentistry
may partly contribute to the increased pre-
valence of recession in smokers. Increased Subgingival and overhanging restoration margins
prevalence and severity of GR has been found can be considered a local risk factor in the
in populations using smokeless tobacco, with the development of periodontal disease and have also
mandibular buccal areas being more severely been implicated in GR. According to Valder-
affected. haug,28 attachment loss is expressed as recession
of the gingival margin when the margin is thin and
Healing after periodontal treatment thus “permits” the inflammation to occupy the full
volume of the connective tissue.
Pocket reduction after nonsurgical and surgi-
cal periodontal treatment is accompanied by a
Partial dentures/orthodontic appliances
shrinkage of marginal gingival tissue, which is
in turn a result of the control of the inflam- Poorly designed partial dentures with inadequate
mation. Consequently, a common outcome of support can physically traumatize periodontal
the treatment is elongation of the clinical tissues.17 However, response to this kind of trau-
crowns of the affected teeth.24 Surgical ma could be inflammatory rather than recession
treatment of periodontal defects can result in nature.3 It is more likely that plaque accumu-
20 Chatzopoulou and Johal

lation is the main causative factor associated with Classification

recession rather than any aspect of denture
Classification of the different types of recession
design per se. Orthodontic appliances can
defects would appear to be essential for the
similarly act as precipitating factors, through
diagnosis, management, and predictability of
the increased plaque stagnation and poor
subsequent nonsurgical and surgical procedures.
standards of oral hygiene.
Although a number of published studies have
attempted to introduce a classification system,
Self-inflicted trauma/chemical trauma the most commonly used is that proposed by
Habitual behavior, such as finger nail picking at Miller.30 Miller's classification utilizes the inter-
the gingival margin29 and lip and tongue pier- proximal tissue height and the MGJ as primary
cings have been reported to cause localized GR. variables for the classification (Fig. 4):
Topical cocaine application can cause rapid GR Class I implies that the defect is located at a
and dental erosion. It should be noted, however, level coronal to MGJ with no interproximal
that most of above publications are case reports tissue loss.
in nature. Class II is denoted by extension of soft tissue
recession to MGJ but with no interproximal soft
tissue loss.
Outcomes of gingival recession and Class III is similar to Class II, differing in that
indications for treatment interproximal soft tissue has been lost to a level
Common outcomes of GR and subsequent apically to the interproximal CEJ.
indications for treatment are as follows: Class IV implies that the interproximal soft
tissue recession has proceeded to a level apically

Root dentine hypersensitivity to the buccally observed soft tissue free gingival

Esthetic concerns margin.

Plaque retention and inflammation This method presents the advantage of accu-

Tooth abrasion rate recording of each component of the GR

Root caries defect and the ability to correlate treatment
prognosis/outcome and anatomical features,
Although the recession defect can progress whereas, previous classification systems used
and remain unnoticed and symptomless, these either anatomical features or treatment prog-
defects in others may also cause esthetic distress, nosis only. Full root coverage can be expected for
pain, and fear of tooth loss.3 Self-awareness of the Miller Class I and Class II defects. Only partial
condition can sometimes be contributed to the root coverage (RC) is achievable for Class III and
presence of a high lip line coupled with the no predictable RC can be expected for Class IV.31
development of interproximal tissue recession2
appearing as “black triangles”; dietary acidic Management
factors may lead to increased severity of pain
symptoms10 and individual mentality with regard Risk assessment
to oral and general health issues and their The development of gingival recession during or
interrelation with quality of life. after orthodontic treatment could be a sig-
nificant problem and the need for the ortho-
dontist to undertake a risk assessment before
Pathogenesis of gingival recession
treatment is commenced, with appropriate
The pathogenesis of GR remains unclear, and consent, are highlighted and summarized below.
although a number of theories do not necessarily The basic periodontal examination (BPE)
explain the mechanism of recession caused by reviewed by Palmer and Floyd32 provides an
tooth brushing trauma, they do support the initial assessment of the patient's treatment
concept that overzealous TB may lead to sub- needs. The GR defect should be assessed
clinical inflammation by increasing epithelial applying Miller's classification. Study casts and
permeability, which may in turn progress to clinical photographs may be helpful means in
GR.12 recording the progression of recession over time,
 Management of gingival recession 21

Figure 4. (A) Miller Class I recession defect: defect does not extend to MGJ and no interproximal tissue has been
lost. (B) Miller Class II recession defect: defect extends to MGJ and no interproximal tissue has been lost. (C)
Miller Class III recession defect: defect extends to MGJ and loss of interproximal tissue. (D) Miller Class IV
recession defect: defect extends to MGJ and loss of interproximal tissue to a level apically to recession defect.

combined with the traditional use of a graduated nonsurgical treatment procedures applied.3
probe.17 Management of the condition would Additionally, the management of the afore-
firstly require addressing the etiologic factors: mentioned would alleviate the patient from symp-
toms such as dentine hypersensitivity and conditions

Atraumatic tooth brushing technique such as root caries that could further compromise

Oral hygiene advice the integrity of the oral cavity. The application of

Smoking cessation advice desensitizing and bonding agents, aiming to block

Treatment of periodontal disease the dentinal tubules, has been proposed for the

Treatment of localized inflammatory lesions treatment of sensitivity, whereas high-fluoride con-

Orthodontic treatment of malpositioned teeth centration varnishes and dentifrices (e.g., Dura-

Correction of deficient restorations phat) are used in treating both sensitivity and root
caries. Dietary advice should be provided on the
In turn, this would offer a healthy environment consumption of acidic drinks, associated with sen-
and lead to improved success with any surgical or sitivity10 and high-sugar-concentration products that
22 Chatzopoulou and Johal

provide the nutritional environment for root caries or interproximal enamel reduction. Removal of
lesions. These carious lesions may also be restored occlusal trauma and reduction of a traumatic
by conventional restorative techniques in situations overbite should be considered and adopted by the
where lesions are not cleansable.3 Esthetic issues orthodontist to ensure maximum benefit and
raised by the presence of recession defects can be minimum detriment to the gingival tissues.
resolved only by either nonsurgical or surgical If recession occurs during or after orthodontic
correction of these defects. treatment, a decision has to be made in terms of
selecting the most appropriate method for
Nonsurgical management of recession defects recession coverage. The opinion of a perio-
dontist should be sought, not only in relation to
Nonsurgical management of gingival recession
the timing of any mucogingival surgical proce-
can be divided into preventive care and non-
dures that may be judged necessary, but also in
surgical correction of the defects.
relation to the sequence of the steps for ach-
ieving the best level of root coverage and elim-
Clinical management of gingival recession in
inating any negative patient symptoms.
orthodontics
The importance of re-educating the patient with
Contradictory results were found in the literature respect to their brushing technique and control of
regarding the role of orthodontic treatment on inflammation should be highlighted, in con-
gingival tissues. The above highlights the need junction to considering well-controlled ortho-
for the orthodontist not to undertake a risk dontic and periodontal maintenance, which would
assessment prior to initiation of treatment. secure tissue health and good clinical outcomes.
The cause-related management of GR initially Retrospective studies designed to evaluate the
requires early identification of both predisposing effect of orthodontic treatment on labial gingival
and precipitating factors (highlighted earlier) recession 5 years post-treatment suggest that a
and their continuous assessment during ortho- change in lower incisor inclination did not affect
dontic treatment. A baseline assessment of these development of labial gingival recession.33 When
factors in combination with a record of GR, via comparing a group of orthodontically treated
the Miller classification, would be a wise man- patients to a matched control group, recession
agement strategy for the orthodontist to adopt was consistently higher in the treated patients
and increase the awareness of potential risks of than in untreated subjects.33 These findings are
recession or need for a referral, either prior to or consistent with other studies comparing treated
during orthodontic treatment. At this stage, and untreated groups, with significantly greater
clinical photos are necessary and if recession is levels and frequency of recession being apparent
present prior to orthodontic treatment, ideally in the treated patients.34,35 In addition to the
further incisor proclination should be avoided. A above, it appears that age at the end of treatment
baseline assessment of patient's oral hygiene and was the greatest predictor36 and the retainer type
gingival inflammation with the presence of local was not an influencing factor in labial GR. The
factors including tartar and calculus deposits lower incisors appear to be the most susceptible
should be considered important factors by the to the development of labial gingival recession.
orthodontist for a potential risk of recession or In summary, while controversy still exists in
further progression during treatment. It is relation to the role of orthodontic treatment and
important that the orthodontist considers care- GR, with an implied risk for recession under
fully the effect of their treatment modalities, specific conditions being accepted in the pub-
aiming to minimize the risk of further recession lished literature, it is equally important to rec-
or will not cause negative gingival changes fol- ognize that a number of orthodontic procedures
lowing the completion of orthodontic treatment. have reported benefits in relation to GR and
In the presence of dehiscence or if fenestration improved patient oral hygiene and wellbeing.
is suspected, the orthodontist is advised to avoid
over-expansion of the arch and in turn, consider
Recent treatment advances
the application of light, controlled forces and to
attempt to maintain the teeth within the dento- There is no consistent or objective information in
alveolar envelope by considering dental extractions the literature or consensus agreement on a
 Management of gingival recession 23

Figure 5. Localized gingival recession, with low frenal attachment affecting the lower left central incisor (A) and
following surgical repair (B), with more than 80% coverage achieved and substantial increase in both the width
and thickness of the keratinized tissue.

clinical approach regarding soft tissue augmen- modified coronally advanced tunnel flap appro-
tation prior to orthodontic treatment. However, ach in treating GR has been demonstrated, with
the preferred approach in these susceptible the advantages of optimizing esthetics (tissue
patients should be to ensure optimal oral hygiene blending) and good long-term (5 years) out-
and the use of a free gingival graft with removal come.39 A number of options exist for recession
of the frenum, if present. The orthodontist coverage in the case of multiple recession sites:
should modify their treatment mechanics to the modified coronal advancement flap with or
avoid over-expansion, attempt to maintain the without graft is preferred in the maxilla,40 while
teeth within the dento-alveolar envelope by in the mandible, its use in conjunction to a
considering dental extractions or interproximal connective tissue graft should be considered.41
enamel reduction, and monitor the need for a Alternative methods include the envelope techni-
mucogingival graft after treatment. que with connective tissue graft42 or the laterally
Nowadays, with the development of tissue positioned flap with or without connective tissue
engineering science, various biomaterials have graft.
been introduced for clinical use. In terms of what With regard to the Miller's Class III defect, the
is the best method(s) for recession coverage, modified coronal advancement tunnel technique
there is a need to distinguish between single and with connective tissue graft should be considered.
multiple recessions. With respect to single gin- While a free gingival graft can be used in both single
gival recession, enamel matrix derivative (EMD) and multiple gingival recessions, it is associated with
appeared to have the most longstanding evi- high morbidity due to graft removal from the palate
dence in comparison to other biomaterials and and sometimes necrosis of the graft. A frenectomy
demonstrated similar efficacy with the GTR can also be considered, if thought to be contrib-
techniques.37 Using the above biological agents utory. Oral hygiene status should be monitored, as it
(e.g., EMD) in conjunction with flap surgery has is an important factor in securing good outcome. A
been shown to be beneficial.38 The use of a combination of different materials and surgical
24 Chatzopoulou and Johal

Figure 6. Surgical exposure reveals the extent of the localized gingival recession, with bone loss affecting the lower
left central incisor (A) and following a 2-stage approach, involving a frenectomy, coronally advanced flap, and free
gingival graft (B and C).

techniques also seemed to be appealing and demonstrated to be the most efficient method
demonstrated encouraging results in some studies43 for the achievement of complete root coverage,
(Figs. 5 and 6). but they are not the only method.45 According to
General factors, which influence treatment the published literature, CAF with or without the
outcome include tooth (crown morphology), soft use of EMD,46 is another clinical modality with
tissues (biotype), bone morphology (presence or proven efficacy in root coverage. Other methods,
absence of interproximal bone), environment such as the connective tissue graft procedures,
(smoking), and defect size (deeper 45 mm and were the most durable techniques with good
wider 43 mm defects being associated with more outcomes. A number of factors, concerning the
difficult root coverage). A number of specific patient and the surgical site also have to be
surgical considerations were also identified as correctly evaluated prior to application of any
being important to success: flap thickness regenerative procedure and should be strictly
(Z1.1 mm), post-surgical position of the gingival controlled during the postoperative healing
margin (the higher the better), and maintaining period.
a stable flap under low tension provided there is
optimal wound healing. The precise flap design
and appropriate management were also consid-
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Interdisciplinary management of congenitally
absent maxillary lateral incisors: Orthodontic/
prosthodontic perspectives
Pratik K. Sharma, BDS (Hons), MFDS RCS, MSc, MOrth RCS, FDS Orth RCS,
CILT, and Pranay Sharma, BDS MFDS RCPS MClin Dent (Prosthodontics) MRD

Aesthetic considerations continue to become more relevant in dentistry, with

patients becoming increasingly discerning about the results achieved from a
cosmetic point of view. As such, the orthodontic/prosthodontic interface, in
relation to managing congenitally absent maxillary lateral incisors, requires
an integrated management approach, ensuring an aesthetic as well as a
functional and stable outcome. This article explores the key orthodontic and
prosthodontic approaches to achieve optimal treatment outcomes. (Semin
Orthod 2015; 21:27–37.) & 2015 Elsevier Inc. All rights reserved.

Introduction approximately 20% of all absent permanent

teeth.10 Bilateral agenesis of maxillary laterals
tooth is defined as congenitally missing if it
A has not erupted in the oral cavity or is not
visible on radiographs, assuming it has not been
has been reported to be more common than
unilateral agenesis.11
Given that maxillary lateral incisor agenesis is
extracted or lost through trauma.1 The con-
a relatively common occurrence, treatment
genital absence of a tooth (hypodontia) results
planning dilemmas exist that are best overcome
from a disturbance during the early stages of tooth
via an interdisciplinary approach that establishes
development. Among individuals with missing
not only an optimal aesthetic result but also
teeth, those who most frequently request treat-
conforms to principles of a functional and
ment are those with missing maxillary anterior
stable occlusion (Fig. 1). The management of
teeth,2 especially with agenesis of the permanent
absent maxillary lateral incisors can broadly be
maxillary lateral incisors.3,4
divided into two strategic approaches. Space
The congenital absence of teeth is one of the
closure involving canine substitution is a well-
most common developmental abnormalities in
recognised modality for the management of
humans.5–8 The term hypodontia is generally
patients presenting with this condition (Fig. 2).
used to describe the absence of one to six teeth,
Alternatively, space re-opening and prosthetic
excluding the third molars.7 The majority (80%)
replacement of the absent tooth or teeth is the
of patients with hypodontia lack only one or two
other commonly advocated technique (Fig. 3).
teeth,6 predominantly the permanent second
The relative indications/contraindications
premolars and maxillary lateral incisors.5
and advantages/disadvantages of each approach
The incidence of developmentally absent per-
have been widely described and debated in the
manent maxillary lateral incisors is 1–2% in
orthodontic literature, with no clear consensus
Caucasian populations9 and accounts for
on the ideal technique for management based on
the current available evidence.
Queen Mary's School of Medicine & Dentistry, London, UK;
Department of Orthodontic, Dental Institute, Royal London Hospital,
Orthodontic space closure
New Rd, Whitechapel, London E1 1BB, UK; UCL Eastman CPD,
London, UK. The applicability of space closure will be pre-
Corresponding author at: Department of Orthodontic, Dental
dominantly dependent on the ability of the
Institute, Royal London Hospital, New Rd, Whitechapel, London, E1
1BB, UK. E-mail: [email protected] maxillary permanent canine to be modified in
& 2015 Elsevier Inc. All rights reserved.
such a way as to substitute a lateral incisor. This
1073-8746/15/1801-$30.00/0 becomes critically important in cases that present
http://dx.doi.org/10.1053/j.sodo.2014.12.003 with unilateral absent maxillary lateral incisors

Seminars in Orthodontics, Vol 21, No 1 (March), 2015: pp 27–37 27

28 Sharma and Sharma

Figure 1. Lack of interdisciplinary planning highlighted in two cases with less-than-ideal treatment outcomes. (A)
Space closure attempted with canine substitution resulting in poor aesthetics and resultant spacing in the upper
arch. (B) Attempted prosthetic replacement of absent maxillary lateral incisors with inadequate space has resulted
in a poor outcome due to labial positioning of the crowns with an unsatisfactory colour match and discolouration
of the overlying gingival soft tissues.

where the challenge confronting the inter- labio-lingually) than the adjacent lateral incisor.
disciplinary team is to achieve a symmetrical Furthermore, the maxillary canine is usually
appearance in the aesthetic zone.12 The indica- darker in colour owing to the increased satu-
tions for space closure have been clearly pre- ration (Chroma). The first premolar is generally
sented in the literature and include a tendency shorter and narrower than the adjacent canine. If
toward maxillary crowding, a well-balanced pro- these differences are not addressed, the aesthetic
file with normally inclined incisors, canines and outcome will be compromised.15 An initial inter-
premolars of similar size, dento-alveolar pro- disciplinary approach is recommended to assess
trusion, Class II molar occlusion and no man- the predictability of a satisfactory outcome being
dibular crowding or protrusion, and a Class I achieved with recontouring of the maxillary
occlusion with crowding in the mandibular arch canine and to determine if any additional resto-
that necessitates extraction therapy.13,14 rative input will be required to ensure a pleasing
The width, length, colour and the incisal con- aesthetic and functional outcome. The nature of
tour of the maxillary canine clearly differ from joint intervention should be clearly agreed to and
those of the lateral incisor (Fig. 4). In patients communicated between clinicians to ensure that
with maxillary lateral incisor agenesis, space the desired goals are accomplished.
closure can create issues in matching size, Careful correction of the crown torque of a
shape and colour. This is because the canine is mesially relocated canine along with providing
normally longer and larger (mesio-distally and optimal torque and mesial rotation of the first

Figure 2. An example of a patient treated with canine substitution. (A) A 12-year-old patient presented with a Class
II malocclusion with Class II molars and absent maxillary incisors. (B) End treatment result with maxillary canines
adjacent the central incisors. The patient refused canine incisal edge re-contouring as he was satisfied with the end
result.
 Interdisciplinary management of congenitally absent maxillary lateral incisors 29

Figure 3. An example of a patient treated with space re-opening and prosthetic replacement of absent maxillary
lateral incisors. (A) 11-year-old girl with a Class I malocclusion and upper arch spacing. (B) Space re-distributed
with comprehensive orthodontic treatment and interim resin-retained bridges in situ until the patient is old
enough to have implant-retained prosthesis.

premolars would effectively enhance aesthetics in labial root torque to 71 of palatal root torque.
cases of orthodontic space closure.15 Adequate The palatal root torque also helps reduce the
palatal root torque delivery to the maxillary apical gingival migration that can be unsightly.
canine can be achieved using a number of Mesial rotation of the first permanent pre-
techniques, including the use of a torqueing molars is desirable in the majority of cases and can
auxiliary wire or with appropriate third-order be achieved using a rectangular stainless steel
archwire bends incorporating additional palatal archwire with a suitable distal offset or by placing
root torque.14 Alternatively, the use of a local the first premolar bracket more distal to the facial
bracket variation on the maxillary canine can axis point to encourage mesial rotation. In addi-
convey the desired torque requirements without tion, it may be necessary to sequentially modify the
the need for archwire bends. The standard palatal cusps of the first premolars as they adopt a
Andrews canine bracket provides 71 of labial more mesial position within the arch.
root torque, but this is inappropriate in the The canine crown frequently needs remor-
incisor region where palatal root torque is phologising to alter its shape to resemble a lateral
required. Some clinicians advocate bonding incisor. The maximum convexity at the mesial
lateral incisor brackets on the canines in such and distal surfaces of the maxillary canine should
cases, but difficulties may be encountered with be reduced to create a vertical surface rather
the brackets being too thick labio-lingually, the than a convex one.14 It is advisable for this to be
bonding bases having an incorrect contour, and carried prior to completing space closure in the
there is insufficient palatal root torque. The maxillary arch. Moreover, the maxillary canine
preferred option is to invert an Andrews canine tip requires rounding off to obtain a straighter
bracket that will reverse the torque from 71 of incisal edge similar to the lateral incisors.16,17
Composite resin can be added to create incisal
corners, with a more rounded disto-incisal cor-
ner. If appropriate, the bulbous labial surface of
the maxillary canine crown should be adjusted by
recontouring the labial surface. This should be
done with care, ensuring integrity of the thin
enamel at the cervical region, and thereby
avoiding the underlying dentin that reveals a
darker colour. Modification to the shape of the
palatal surface of the maxillary canine may help
to provide more favourable anterior guidance, as
the canine is much thicker labio-lingually than
the lateral incisor.
Figure 4. Variation in morphology, size and colour of
the maxillary upper right canine and maxillary upper Addressing discrepancies in colour between
left lateral incisor. This case would not be favourable the darker maxillary canines and the surround-
for canine substitution. ing dentition can be accomplished most
30 Sharma and Sharma

conservatively with the intentional use of external potential success of this approach does however
vital bleaching.15 require an integrated treatment planning with all
Another important consideration in canine relevant clinical specialists (Orthodontist, Pros-
substitution is ensuring the integrity of the gin- thodontist and Periodontist) working together to
gival heights particularly in patients with a high agree and deliver desired outcomes.
smile line. Assessment of gingival aesthetics is of
critical importance in patients with high lip lines,
where the gingival margins are clearly visible and Orthodontic space opening and prosthetic
in patients with high aesthetic demands. Treat- replacement
ment methods of developing gingival harmony Orthodontic space opening during adolescence
may involve periodontal plastic surgery or is an alternative common treatment for patients
orthodontics. Periodontal surgery may involve with congenitally missing maxillary lateral inci-
additive or resective gingival techniques and sors. This approach is advocated when, following
orthodontics may involve intrusion or extrusion interdisciplinary assessment, it is clear that the
techniques of the first premolars and maxillary patient does not meet the necessary optimal
canines, respectively. However, intrusion of the criteria for space closure and canine substitution
first premolars to restore gingival harmony will (Fig. 4). In these situations, space opening and
require the need for restorations to the crowns of prosthetic replacement may offer the best solu-
these teeth to ensure aesthetics and function. tion (Fig. 5). The restorative options commonly
This can be achieved with either direct or indi- include implant-retained prosthesis or a tooth-
rect bonded restorations. Orthodontic treatment supported restoration.
planning of such cases should give due consid-
eration to bracket placement to fulfill the Implant-retained prosthesis
objectives above with an emphasis on bracket
position being guided by the gingival margin Implants are often used to replace the missing
rather than the incisal edges of the relevant tooth/teeth without affecting the adjacent teeth,
teeth. Additionally, it may be necessary to particularly in younger patients with unrestored
incorporate archwire bends to ensure the desired dentitions.18 Implant therapy in partially eden-
vertical positioning of teeth to suitably influence tulous patients has become a well-established
the gingival architecture. treatment modality and anterior single-tooth
With increasing emphasis on the aesthetic replacement has become a highly predictable
outcome of treatment, orthodontic space closure treatment solution, with various studies reporting
of missing maxillary lateral incisors will occa- excellent long-term outcomes in terms of integra-
sionally require additional restorative input, over tion and function.19 Although the use of osseo-
and above those outlined above, such as com- integrated implants has gained a significant
posite bonding or laminate veneers to the max-
illary canines, first premolar and less frequently
the central incisors. This will naturally impact on
the overall conservative nature of treatment and
the long-term need for maintenance of any
restorations placed.
The major advantages of orthodontic space
closure for young patients with lateral incisor
agenesis and a coexisting malocclusion is the
relative stability of the finished result and the
possibility to complete treatment in adolescence
knowing that the need for long-term tooth
replacement and subsequent maintenance in an
aesthetic zone is negated.15 If carefully planned, Figure 5. Case shown in Fig. 4 at the end of the
orthodontic phase of management. The patient is now
this approach can be the most conservative ready for prosthetic replacement of the upper right
treatment option yet at the same time yield lateral incisor and “build-up” of the microdont upper
long-term aesthetically pleasing outcomes. The left lateral incisor.
 Interdisciplinary management of congenitally absent maxillary lateral incisors 31

reputation over the last 50 years as a consequence rehabilitation with an implant-retained prosthe-
of reported success rates,20 significant aesthetic sis.” Research suggests that facial growth continues
challenges remain associated with their use. past adolescence and is subject to gender varia-
Clearly, this has significant implications in rela- tion. On average, facial growth in females con-
tion to replacing absent lateral incisors, given the tinues to the age of 17 years, however, in males,
increasing emphasis on aesthetically driven facial growth is not complete until around 21 years
outcomes. Careful case evaluation and treat- of age. It is therefore recommended that
ment execution can, however, yield aesthetic, osseointegrated implants are not placed in
stable and functional outcomes for the benefit of females before 17 years of age and accordingly in
patients (Fig. 6). The criteria necessary to ensure males until 21 years of age.
treatment success with the use of osseointegrated Various techniques have been described to
implants are considered below. determine growth patterns in patients, including
the use of hand–wrist radiographs and cervical
spine maturation. However, the most predictable
Timing of implant placement
and precise assessment of cessation of facial
Endosseous implants should only be placed if growth is ascertained from the information that
growth of the face and maxillofacial complex can be obtained from lateral cephalogram radio-
has been completed.21 This is because implants graphs. Superimposition of serial lateral cepha-
behave like ankylosed teeth22 and should not be lograms taken 6 months to 1 year apart can be
placed in growing patients as this risks develop- used to assess changes in vertical face height and
ment of progressive infra-occlusion of the implant consequently two consecutive such radiographs
restoration and development of aesthetic, func- showing no change in vertical parameters can be
tional and possible periodontal dilemmas that gauged as a suitable benchmark to facilitate
are not easily remedied. The question that arises implant placement without significant further
is “when is facial growth complete to allow growth anticipated.

Figure 6. Completed implant-supported crown restoration showing optimal implant positioning and a good
aesthetic outcome.
32 Sharma and Sharma

Retention and space maintenance prior to the desired position of the canine and the central
implant placement incisor and in so doing help to reduce any root
approximation during retention that may
Clearly, in patients having orthodontic treatment
compromise implant placement.18
during their adolescence, retention of the
More recently, the use of miniscrew-retained
occlusion and space maintenance of the lateral
prosthesis has been described as a suitable
incisor edentulous span, in particular, takes on
interim restoration prior to formal implant
paramount importance.
placement. The use of such a technique, in the
Several years can elapse between completion
authors' opinion,26 is not recommended as it may
of orthodontic treatment for a teenage patient
lead to two potential problems. Firstly, the
and implant placement because of continued
emergence profile of any coronal interim
facial growth and compensatory tooth erupt.22–24
restoration is compromised owing to the rela-
Consequently, it is not uncommon to wait a
tively thin diameter of the miniscrew adversely
number of years after orthodontic treatment
affecting aesthetics. Furthermore, placement of a
before placing a lateral incisor implant.18 After
miniscrew in a growing patient will compromise
successful orthodontic space opening at the
the vertical osseous ridge development, particu-
implant site and an interval of a few years, the
larly, if a number of years of growth are
central incisor and canine roots have been
anticipated and this will impact on future
reported to re-approximate during retention
implant placement as dealing with vertical
and prevent implant placement.25 In addition, it
ridge defects present prosthodontists with a
was found that 11% of the patients experience
significant challenge.
relapse significant enough to prevent implant
placement.18 Accordingly, a key consideration
for the dental team is to ensure avoidance of re- Implant site development
lapse that may compromise the restorative phase
The bucco-lingual thickness of the alveolus must
of management and consequently impact on the
be suitable to allow for three-dimensional
overall success of treatment.
placement of the implant in the ideal position
A removable retainer (either Hawley or essix
to ensure an aesthetic and predictable outcome.
retainer) incorporating a suitably fabricated
Absence of the permanent lateral incisor com-
prosthetic tooth is a suitable method to tempo-
monly results in inadequate bucco-lingual bone,
rarily restore the edentulous space whilst provid-
with the alveolar ridge in this area being typi-
ing retention when the period before implant
cally deficient for implant placement, thereby
placement is relatively short (Fig. 7). However, in
necessitating bone augmentation procedures
instances where treatment finishes in adolescence
(Fig. 8A–D).
and implant placement is not anticipated for a
A novel method to develop width of the
number years, a removable retainer may not be
alveolar bone has been described if the perma-
the ideal solution. Therefore, a more appropriate
nent maxillary canine erupts (or is guided to
option might be a fixed retainer incorporating a
erupt) next to the central incisor.16 In this
prosthetic tooth, e.g., a conventional palatal wire
situation, the increased bucco-lingual width of
with a prosthetic tooth or a resin-bonded bridge
the canine will favourably develop the thickness
(Fig. 3B). These types of interim retainers have
of the edentulous ridge in this previously defi-
been reported as being excellent for maintaining
cient area. Subsequently, following its eruption,
the permanent canine can be orthodontically
moved into its optimal Class I position with an
increased bucco-lingual alveolar width estab-
lished in the lateral incisor region. Crucially, if a
lateral incisor implant site is developed by this
method, its bucco-lingual dimensions are
retained and remain stable.16
Figure 7. Example of a vacuum-formed retainer The presence of inadequate bone that has not
incorporating a prosthetic upper right lateral incisor been modified by the approach outlined above
tooth. can have profound effects on the resulting
 Interdisciplinary management of congenitally absent maxillary lateral incisors 33

Figure 8. Reduced bucco-lingual ridge width with marked buccal concavity present in the lateral incisor region (A
and B). Following implant placement, buccal horizontal bone volume has been increased using guided bone
regeneration techniques (GBR), using xenograft particulate material and a collagen membrane (C and D).
Definitive restoration completed with a satisfactory aesthetic and functional result (E).

aesthetic outcome of any proposed implant aesthetic and natural buccal soft tissue archi-
restoration. Placing dental implants in a deficient tecture that is conducive with the planned
ridge necessitates deeper positioning to avoid implant restoration (Fig. 8).
alveolar dehiscence. Furthermore, it will result in
a thin layer of bone on the buccal aspect adver-
Coronal space development
sely affecting the surrounding soft tissues.
Additionally, there is significant risk of the Planning for single-tooth anterior implant
implant components becoming visible buccally, involves the consolidation of an ideal amount of
producing in an unsightly “dark” colour of the coronal space for the missing tooth while simul-
soft tissues. Therefore, alveolar ridge augmen- taneously creating an adequate mesio-distal inter-
tation becomes necessary not only to provide radicular space for the safe placement of the
support for the implant but also to ensure an eventual implant. Furthermore, a symmetrical
34 Sharma and Sharma

tooth arrangement that displays appropriate dental picture. Therefore, simply using the
dominance of certain teeth and also provides a concept of a formula may not yield a successful
sense of proportionality is important in estab- outcome, particularly with reference to aes-
lishing an aesthetic smile. In relation to this, the thetics, and in any given case, subtle variations
height and width-to-length ratio of the individual should be introduced to match the age, race and
teeth are criteria that need to be considered. personality as well as taking into account the
Ideal coronal space can be created ortho- wishes of the individual. This process can be
dontically with the principal issue being deter- conducted with the use of a “Diagnostic Wax up”
mining the required space necessary at the that provides information to the multi-
coronal level to ensure an aesthetic prosthesis disciplinary team with respect to the proposed
can be fabricated. In cases of unilateral agenesis objectives. Additionally, the “Diagnostic wax up”
of the maxillary lateral incisor, the contralateral can be used as a tool to allow the patient visu-
tooth should be used as guide to determine the alisation of the end result and to suggest mod-
space required, assuming the aforementioned ifications to the final aesthetic outcome.
tooth has normal morphology and size in both Despite the considerations above, some gen-
the mesio-distal and occluso-gingival dimensions. eral guidelines are required as a baseline starting
However, it is not uncommon to see cases point for creating a beautiful tooth arrangement.
where the contralateral lateral incisor is either The findings of Sterrett et al.29 provide useful
peg-shaped, microdont or congenitally absent, in information to determine the final size and
which case, the approach described above cannot proportion of a tooth, in that, the crown
be applied. Various alternative techniques have height-to-width ratio of a tooth is a more suit-
been advocated to ascertain the ideal coronal able reference, rather than simply using the
space requirements in these cases that are pre- dimensions of a tooth. The study proposes that
dominantly based on the use of formulas. the ideal maxillary central incisor should have a
Application of the “Golden Proportion,” or width-to-length ratio of approximately 0.75–0.85.
alternatively, a simple formula as given by Chu,27 A ratio below 0.6 would create a long narrow
has been described in the literature. As defined tooth and a ratio above this would result in a
by the Golden Proportion, a ratio of 1 is given to short wide tooth. On average the central incisor
the lateral incisor with regard to mesio-distal may be between 9.5 and 10.2 mm in length and
width. The central incisors will then have a 1.618 8.1 and 8.6 mm in width. Given this, guidelines
ratio and the canines will have 0.618 ratio, when for developing an aesthetic maxillary anterior
compared to the lateral incisors. While there is tooth arrangement would be as follows; the
no doubt that objects such as buildings, paintings crown width-to-length ratios of the canines and
and sculptures as well as living organisms like incisors are similar and have a range of 77–86%;
plants that display such golden proportion are on average the lateral incisor may be between 7.8
perceived to be beautiful, its relevance to the and 8.7 mm in length and 6.1 and 6.6 mm in
dentition is less clear. Great emphasis has been width and central incisors are wider than lateral
placed on utilising the golden proportion in incisors by 2–3 mm.
dentistry, however studies have demonstrated The patient's occlusion will influence the
that the actual measurements of most people's ability of ideal coronal space creation and a
anterior teeth do not conform to it.28 Strict adhe- minimum of 1 mm (ideally 1.5 mm) is necessary
rence to and application of the golden propor- between the implant and the adjacent tooth to
tion to every case would result in unnecessary limit the adverse consequences of bone remod-
narrowing of the maxillary arch. In reality, subtle elling in the area beside a dental implant. An
variations to sizes and proportions are accept- inability to achieve this will compromise the
able, of more importance is achieving balance aesthetic result due to apical migration of the
and symmetry between the teeth, to provide an papillary tissue leading to poor papillary aes-
overall harmonious final result. thetics. To overcome this, the orthodontist may
Tooth size and proportion are subject to great need to consider additional mechanisms of space
individual variation, furthermore, some patients creation such as the use of enamel reduction
presenting with hypodontia will have associated techniques to the proximal surfaces of the per-
microdontia that can complicate the overall manent canines and central incisors or in the
 Interdisciplinary management of congenitally absent maxillary lateral incisors 35

premolar regions. Furthermore, advances in dental root level, ensuring sufficient divergence of the
implant design and shape, such as, use of narrow- roots can prove complex. Furthermore, having
diameter and tapered implants—internal con- sufficient coronal space cannot be used as
nection implants incorporating platform switching measure of adequate space at the apical
concept—help overcome situations where ideal level, given the variation in anatomy described
space creation is particularly challenging and lead above.
to more predictability in maintaining crestal bone The orthodontic creation of adequate inter-
levels and pleasing soft tissues profiles. radicular space may involve angulating the roots
of the maxillary canine and central incisor away
from the implant site. Alteration of the normal
Apical space development bracket angulation on the aforementioned teeth
Creating adequate space between adjacent roots can help achieve the required root divergence,
is critical to enable safe placement of the implant with the central incisor bracket angulated mesio-
without risking contact with adjacent roots. gingivally and the canine bracket over-angulated
Commonly, this involves creating a minimum of disto-gingivally. Alternatively, transposing a cen-
6 mm of space so that an implant can be placed tral incisor bracket from the adjacent quadrant
safely with at least 1 mm between its surface and onto the central incisor neighbouring the
the surrounding root surfaces (Figs. 4, 5, and 9). implant site will achieve the same desired effect
As a result of the tapering anatomy of the with respect to the angulation of the central
maxilla that results in a narrower apical arc at the incisor. Such change to the central incisor

Figure 9. Radiographs showing adequate root divergence with sufficient inter-radicular space for safe placement
of an implant in the upper right lateral incisor site. (A) pre-treatment and (B) mid-treatment OPG.
36 Sharma and Sharma

Figure 10. A 13-year-old patient with absent maxillary lateral incisors and space re-opening for prosthetic
replacement of absent teeth. Good axial angulation of the UL1 and adequate coronal space for restoration of the
UL2; however, the OPG demonstrates poor root morphology of UL1 that will impede the ability to place an
implant in the upper left lateral incisor region (A–C).

angulation, although subtle, can result in unfa- Summary

vourble consequences, with loss of coronal space
This article has highlighted the approaches in
for the prosthesis and/or loss of optimal align-
dealing with congenitally absent maxillary lateral
ment as a result of separation of the central incisor
incisors. Both canine substation and space re-
crowns at their incisal edges. This can be over-
opening for implant rehabilitation can result in
come by utilising interproximal stripping between
pleasing outcomes as part of an interdisciplinary
the central incisors in order to achieve adequate
approach. The key to achieving satisfactory
closure at the incisal edges and modification of
treatment outcomes is underpinned by the
the mesio-incisal corner of the over-angulated
interplay of the multidisciplinary team working
central incisor to restore incisal edge alignment.
together to ensure the best possible outcomes. As
Occasionally, unfavourable root morphologies
aesthetic-driven outcomes take increasing prec-
or dilacerations will prevent the desired apical
edence, the importance of engaging all members
space creation from being achieved (Fig. 10).
of the multidisciplinary team becomes ever more
This situation can also arise where the congenital
critical, as management of this condition invar-
absence of maxillary lateral incisors is
iably involves addressing deficiencies in the
confounded with associated microdontia,
aesthetic zone.
making ideal apical space creation particularly
challenging. Where possible, such complicating
features that will hinder the feasibility of implant References
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Multi-disciplinary management to align ectopic
or impacted teeth
Padhraig S. Fleming

The orthodontist is the central member of a team dealing with the

management of impacted or ectopic teeth with the knowledge and ability
to either avert or simplify treatment with relatively straightforward measures
such as interceptive primary extractions or orthodontic space redistribution.
However, in many cases, ectopic and impacted teeth may present complex
treatment planning decisions requiring the integrated expertise of a range of
dental specialists including periodontists, prosthodontists, and oral surgeons
to produce lasting functional and esthetic improvements with minimal short-
term or long-term biologic cost. (Semin Orthod 2015; 21:38–45.) & 2015
Elsevier Inc. All rights reserved.

Introduction particularly important in the planning stages with

implications for extraction decisions and operative
mpacted teeth are those that fail to reach the
I correct occlusal position due to tooth, bone,
or soft tissue impediment. While an ectopic tooth
procedures, and ultimately influencing the dura-
tion and ease of subsequent orthodontic treat-
ment, and the longevity and esthetics of the final
may erupt, it develops in an abnormal position.
outcome. These interactions will be discussed in
Maxillary canines are both commonly impacted
this review, with particular emphasis on the
and susceptible to ectopic development. With the
management of ectopic or impacted maxillary
exception of third molars, maxillary canines are
canines.
most likely to develop ectopically with a reported
frequency of between 0.8% and 3%.1 Other
commonly impacted teeth include maxillary Interceptive management
central incisors and those terminal in their
series including second premolars and third Seminal research by Ericson and Kurol2 indicated
molars. that removal of primary maxillary canines is a
Traditionally, management of ectopic and predictable and relatively conservative solution to
unerupted teeth centers on the orthodontist; this the ectopically developing palatal maxillary canine
approach allows the full range of options including with a reported eruption rate of 78% following
interceptive approaches, space recreation, auto- interceptive extraction over a 12-month period.
transplantation, and orthodontic mechanical The success rate, however, declined to 64% with
eruption to be considered. However, successful medial displacement of the canine beyond the
management of impacted or ectopic teeth may midline of the adjacent lateral incisor. These
require an integrated approach between ortho- findings in 10–13 year olds with uncrowded arches
dontists, oral surgeons, periodontists, and pros- were mirrored in a subsequent study involving
thodontic specialists. Interdisciplinary input is crowded malocclusions.3
Recently, however, the merit of removing pri-
mary canines has been questioned4 on the basis
Institute of Dentistry, Barts and The London School of Medicine
that prospective studies in this area have consis-
and Dentistry, Queen Mary University of London, London, UK. tently been compromised by failure to justify the
Address correspondence to Dr. Padhraig S. Fleming, BDent Sc sample size, confounding, and inadequate expla-
(Hons), MSc, PhD, MOrth RCS, FDS (Orth) RCS, FHEA, Institute of nation of randomization procedures, allocation
Dentistry, Barts and The London School of Medicine and Dentistry,
concealment, and efforts to reduce measurement
Queen Mary University of London, Turner St, London E1 2AD, UK.
E-mail: padhraig.fl[email protected] bias. There are also instances of spontaneous
& 2015 Elsevier Inc. All rights reserved.
improvement of canines suggesting their behavior
1073-8746/15/1801-$30.00/0 can be erratic, irrespective of primary tooth
http://dx.doi.org/10.1053/j.sodo.2014.12.004 removal (Fig. 1). Furthermore, the use of a

Seminars in Orthodontics, Vol 21, No 1 (March), 2015: pp 38–45 38

 Multi-disciplinary management to align ectopic or impacted teeth 39

autonomous eruption of canine teeth; eruption

rates of 75% have been demonstrated with fixed
appliances. However, in this study, active
treatment was preceded by interceptive loss of
primary canines, which may therefore have
inflated the potential benefit of fixed
appliance-based space generation. In a follow-
up study, the influence of the degree of ectopia
on eruptive potential was highlighted with more
medially displaced canines less likely to erupt
without recourse to surgical exposure.10 Age was
also found to have an influence on the likelihood
of eruption with the prognosis for eruption
poorer in subjects older than 13 years with
more medially displaced canines.
Figure 1. Spontaneous improvement in the position
of palatal ectopic canines despite the persistence of the Clearly, a high percentage of impacted can-
primary maxillary canines. ines tend to respond favorably to space recre-
ation either with or without orthodontic
extractions (Fig. 2). The buccal position of
range of mechanics including cervical pull impacted canines is a byproduct of their
headgear, straight pull headgear, rapid maxillary developmental position, crowding, and their
expansion, or removal of multiple primary teeth propensity to follow the buccal path of least
has been considered in more recent research resistance. Occasionally, however, even impacted
either as an alternative to or as an adjunct to buccal canines without a significant degree of
interceptive removal of primary canines. These ectopia display reduced eruptive potential and
space-generating procedures have generally may require surgical exposure to facilitate
demonstrated an advantage over isolated removal eruption. Typically, this may be undertaken
of primary canines.5–8 However, these studies are with a local exposure or apically repositioned
typically compromised by similar limitations to flap. Other impacted teeth including premolars
earlier related clinical trials.4 tend to respond equally favorably to space
recreation in adolescence obviating the need
for surgical intervention in many cases (Fig. 3).
Space recreation in the permanent
Therefore, the position of the orthodontist as
dentition
the gatekeeper overseeing the coordination of
Based on the aforementioned research, space care of patients with ectopic teeth is justified, and
creation appears to be of potential benefit in the necessity to resort to combined, orthodontic-
encouraging eruption of ectopic canines in the surgical management of ectopic and impacted
mixed dentition. Similarly, the benefit of teeth is correspondingly reduced. However,
improving space conditions has been demon- in certain instances, joint intervention is
strated in the permanent dentition. Olive9 has unavoidable and can be anticipated at initial
advocated space redistribution to encourage presentation.

Figure 2. Space recreation for buccal impacted canine following removal of heavily-restored maxillary first molars.
40 Fleming

Figure 3. Impacted maxillary and mandibular second premolars related to premature loss of primary molars (A).
Removal of the maxillary first premolars in conjunction with space maintenance with a Nance palatal arch (B) and
space recreation with a lip bumper (C) facilitated eruption of the permanent teeth (D).

Surgical exposure and orthodontic greater emphasis on communication between

alignment orthodontist and surgeon to generate realistic
plans and facilitate efficient and safe tooth
When interceptive procedures fail or are consid-
movement by performing the correct procedure,
ered inappropriate, combined assessment with an
while optimizing force delivery and vectors.
oral surgeon or periodontist to facilitate ortho-
Ectopic buccal canines present a particular
dontic alignment of an ectopic tooth is often
challenge in negotiating the root of the maxillary
indicated. There are a number of key consid-
lateral incisor during alignment.14,15 Careful surgi-
erations when planning this type of treatment.
cal and orthodontic planning is therefore required
to allow unimpeded and efficient movement of the
Position of impacted/ectopic tooth
canine (Fig. 4) without inducing or aggravating
The position of unerupted teeth has been linked resorption of the lateral incisor. Multiple surgical
to the likelihood of a favorable response to procedures are possible depending on the location
interceptive extractions and space recreation; of the tooth; clear communication with surgical
similarly, the prognosis and treatment time for colleagues is therefore paramount.
mechanical eruption and alignment of canines is Circular open exposures of buccal canines are
influenced by the degree of displacement. rarely possible in view of the constraints placed by
In particular, vertical displacement in excess the requirement for attached gingivae to provide
of 14 mm above the occlusal plane11 and a predictable, stable attachment. When canines
pronounced medial displacement12,13 have are displaced superiorly, provision of attached
been shown to lead to increased treatment times. gingivae is no longer possible unless the gingival
While this difference in treatment time is related attachment is repositioned during the exposure.
to the distance that the object tooth is required to Apically repositioned flaps are, therefore, typi-
move, it is compounded by greater surgical cally preferred to maintain an adequate width of
complexity in managing more displaced teeth attached gingivae; however, with significant
and may be further complicated by anatomical vertical displacement, apical repositioning
issues, including position of the lateral incisor would expose a large denuded area, which may
roots, orientation of the canine, and difficulty in require a secondary grafting procedure. Con-
accessing the displaced tooth. These issues place sequently, surgical exposure and bonding may be
 Multi-disciplinary management to align ectopic or impacted teeth 41

Figure 4. Buccal ectopic maxillary right canine with impacted upper right second premolar related to an infra-
occluded second primary molar. The canine was erupted buccally and moved distally to limit the risk of resorption
to the maxillary right lateral incisor. The canine was aligned although the adjacent lateral incisor underwent some
resorption; a decision was therefore made to accept inadequate labial root torque of the lateral incisor.

undertaken, with the bonded attachment placed increase in the likelihood of unsuccessful treat-
palatally. While inferior movement of the canine ment among adult patients with ectopic teeth.17
is often needed to permit eruption into attached It is believed, for example, that palatally displaced
gingivae, this may be unfeasible due to the close canines lack sufficient eruptive impetus to
proximity of the root of the incisor. Buccal penetrate the palatal cortical plate and mucosa
movement of the canine can first be undertaken naturally resulting in impaction.18 This inertia is
until the canine becomes more superficial buc- thought to become more marked with increasing
cally, and a minor secondary surgical procedure age and has been apportioned to a form of “disuse
can be performed at that point with an apically atrophy”18 within the periodontal ligament. This
repositioned flap to provide an adequate band of characteristic makes impacted teeth less likely to
attached gingivae.16 Consequently, close liaison erupt naturally after the third decade and similarly
with surgical colleagues is necessary to facilitate more problematic during mechanical orthodontic
timely referral for the secondary procedure to eruption, although exceptions do arise (Fig. 5).
avoid the risk of eruption into friable, free gingival The unpredictable nature of orthodontic erup-
attachment. Alternatively, consideration may be tion of impacted teeth in adults often warrants a
given to actively moving the lateral incisor palatally more conservative approach to orthodontic and
to limit the potential for obstruction to tooth surgical management, with greater emphasis on the
movement and associated deleterious potential merits of prosthodontic approaches.
consequences including resorption of the lateral Consequently, irreversible decisions including
incisor root (Fig. 4). Moreover, the bonded extraction of adjacent permanent teeth and indeed
attachment on the lateral incisor can be early loss of primary canines during treatment is
temporarily omitted, programmed to impart best-avoided as primary teeth are a natural space
palatal root torque during the rectangular wire maintainer, may aid in retention of alveolar bone,
phase, or can be altered to allow free tipping of the and their presence is known to be of psychological
incisor during the initial treatment phases, for benefit where permanent teeth are lacking.19
example, using Tip-Edge brackets. Moreover, prior to placement of complete labial
appliances, eruptive forces may be delivered using
lingual attachments or palatal invisible auxiliaries
Age
(Fig. 6) due to the heightened esthetic premium in
Impacted teeth are a feature of malocclusion adults. Where orthodontic approaches are consi-
consistently shown to prolong orthodontic dered unrealistic or inadvisable, the displaced tooth
treatment.11–13 There is also an exponential may be replaced prosthetically with a dental
42 Fleming

Figure 5. A 22-year-old female presented subsequent to recent eruption of palatal ectopic maxillary canines, the
primary canines were retained. Both canines were aligned with fixed appliances.

implant. Prior to this approach, a decision in exposure of maxillary canines appears to differ
relation to possible removal of the impacted little in respect of surgical time, treatment out-
tooth and the extent of the resultant bony defect comes, and periodontal health.24 Nevertheless,
is facilitated by 3-dimensional imaging techniques.20 there are potential indications for either
technique; however, individual preference
appears to be important in many scenarios.
Type of surgical exposure
Where the canine is not deeply impacted,
Initial observational research on the relative wide, open exposures have the obvious
merits of open and closed eruption techniques advantage of allowing complete visualization of
was equivocal in terms of periodontal health and the crown permitting accurate bond placement.
treatment times.21–23 More recent prospective Incorrect positioning of attachments in closed
research has confirmed that open and closed techniques may be undetected until the canine

Figure 6. A 26-year-old female was concerned in relation to the mobility of the maxillary primary canines. Both
canines were significantly displaced and had a guarded prognosis for alignment (A). A palatal arch with auxiliaries
was placed to initiate eruption prior to removal of the primary canines and placement of labial fixed appliances (B)
and complete alignment of the canines (C).
 Multi-disciplinary management to align ectopic or impacted teeth 43

has been erupted, inducing unwanted rotations restorative element in many cases, even when the
and prolonged treatment. It is therefore im- tooth itself can be aligned. Moreover, ectopic
perative that if closed exposures are planned, canines can induce invasive root resorption of
communication in relation to the desired lateral incisors potentially compromising the
position of the attachment is clear; typically, longevity of these teeth. It is accepted that
these should be placed near the cusp tip to resorption of teeth ceases following the removal
facilitate efficient tooth movement with minimal of the cause, potentially by orthodontically erupt-
unwanted rotation. Conversely, placement closer ing or extracting the canine. Indeed, resorbed
to the cervical margin risks periodontal problems incisors have been shown to have excellent
and rotation of the canine rather than efficient longevity.25 Consequently, the restorative and
labial movement. periodontal implications must be balanced
Open surgical exposure allows the orthodontist against orthodontic considerations to develop a
to control the position of the attachment and may unified approach to management of ectopic teeth
allow eruption without resort to active forces.18 with roots shorter than 10 mm likely to exhibit
With deep impactions, closed exposures are usually mobility.26 For these patients, a combined and
favored as open exposures may necessitate informed decision must be made as to whether to
excessive bone and soft tissue removal risking consider maintaining the compromised tooth or
periodontal damage to the impacted tooth or attempting to orthodontically reposition the
neighboring roots. Deeply impacted teeth may also ectopic canine mesially to produce a more
become enveloped by soft tissue with inadequate predictable result. Where restorative problems
exposure particularly if unsupervised. including significant reduction in the mesio-distal
width of the incisor and unfavorable gingival
architecture dictate extraction of the tooth, the
Restorative considerations
canine may be repositioned mesially (Fig. 7). A
The association between canine ectopia and a major advantage of this approach is the need for
variety of dental anomalies including absence of limited active restorative intervention, with only
lateral incisors and microdont and misshapen conservative reshaping and direct composite
maxillary lateral incisors is established. As such, buildup of the canine required. Additional
management of ectopic teeth may incorporate a palatal root torque should be added to the

Figure 7. A Class I malocclusion with ectopic maxillary left canine and diminutive lateral incisors with mandibular
arch crowding (A). After joint consultation, a decision was made to orthodontically align the ectopic canine with
loss of the diminutive lateral incisors and 2 mandibular premolar units. The maxillary canines were reshaped
incrementally (B) and restored with direct composite (C) to simulate lateral incisors.
44 Fleming

Figure 8. Appearance 2 years following removal of orthodontic appliances; treatment involved alignment of the
maxillary left canine, which was buccally ectopic (A). A connective tissue graft and tunnel technique was
performed to restore gingival symmetry (B). (Courtesy of Dr. Ronan Allen.)

canines by selecting an appropriate bracket or by mixed dentition to facilitate their correction.

imparting supplementary torque with an archwire Orthodontists have the potential to avert
bend. When the canine is placed in the position impactions and complex associated treatment by
of the lateral incisor, it may also be extruded to relatively simple means including interceptive
harmonize the gingival levels with respect to the extractions and space recreation. However,
adjacent teeth,27 as the gingival zenith of a natural impacted teeth may present complex manage-
lateral incisor lies 1–1.5 mm inferior to that of a ment issues and a wide range of treatment options
central incisor, while the canine and central many of which are time-consuming and
incisor gingival margins should lie at the same demanding in terms of compliance. Consequently,
vertical level. a team approach to formulating treatment plans
Following alignment of ectopic teeth, major and overseeing the management of impacted
considerations include both the stability of tooth teeth is central to managing difficult cases, which
positioning and the stability of the periodontal are recalcitrant to conservative measures.
attachment.28,29 Short-term follow-up has dem-
onstrated little difference in periodontal
attachment loss adjacent to maxillary canines
based on the type of initial exposure. However, References
there does appear to be a minor but statistically 1. Ericson S, Kurol J. Radiographic assessment of maxillary
significant susceptibility to recession following canine eruption in children with clinical signs of eruption
surgical exposure and orthodontic alignment. disturbances. Eur J Orthod. 1986;8:133–140.
There remains, however, little long-term data on 2. Ericson S, Kurol J. Early treatment of palatally erupting
maxillary canines by extraction of the primary canines.
the likelihood and possible progression over Eur J Orthod. 1988;10:283–295.
time, necessitating further surgical advice and 3. Power SM, Short MB. An investigation into the response
interception (Fig. 8). of palatally displaced canines to the removal of deciduous
canines and an assessment of factors contributing to
favourable eruption. J Orthod. 1993;20:215–223.
Conclusions 4. Parkin N, Benson PE, Shah A, et al. Extraction of primary
(baby) teeth for unerupted palatally displaced permanent
Impacted teeth are commonly encountered by canine teeth in children. Cochrane Database Syst Rev.
orthodontists with referrals typically made in the 2009;15:2.
 Multi-disciplinary management to align ectopic or impacted teeth 45

5. Leonardi M, Armi P, Franchi L, et al. Two interceptive 19. Laing E, Cunningham SJ, Jones S, Moles D, Gill D.
approaches to palatally displaced canines: a prospective Psychosocial impact of hypodontia in children. Am
longitudinal study. Angle Orthod. 2004;74:581–586. J Orthod Dentofacial Orthop. 2010;137:35–41.
6. Armi P, Cozza P, Baccetti T. Effect of RME and headgear 20. Chappuis V, Engel O, Reyes M, Shahim K, Nolte LP, Buser
treatment on the eruption of palatally displaced canines: D. Ridge alterations post-extraction in the esthetic zone: a 3D
a randomized clinical study. Angle Orthod. 2011;81:370–374. analysis with CBCT. J Dent Res. 2013;92:195S–201S.
7. Baccetti T, Leonardi M, Armi P. A randomized clinical 21. Wisth PJ, Norderval K, Bøe OE. Periodontal status of
study of two interceptive approaches to palatally displaced orthodontically treated impacted maxillary canines. Angle
canines. Eur J Orthod. 2008;30:381–385. Orthod. 1976;46:69–76.
8. Alessandri Bonetti G, Zanarini M, Incerti Parenti S, et al. 22. Becker A, Brin I, Ben-Bassat Y, et al. Closed-eruption
Preventive treatment of ectopically erupting maxillary surgical technique for impacted maxillary incisors: a
permanent canines by extraction of deciduous canines postorthodontic periodontal evaluation. Am J Orthod
and first molars: a randomized clinical trial. Am J Orthod
Dentofacial Orthop. 2002;122:9–14.
Dentofacial Orthop. 2011;139:316–323.
23. Schmidt AD, Kokich VG. Periodontal response to early
9. Olive RJ. Orthodontic treatment of palatally impacted
uncovering, autonomous eruption, and orthodontic
maxillary canines. Aust Orthod J. 2002;18:64–70.
alignment of palatally impacted maxillary canines. Am
10. Olive RJ. Factors influencing the non-surgical eruption of
J Orthod Dentofacial Orthop. 2007;131:449–455.
palatally impacted canines. Aust Orthod J. 2005;21:95–101.
11. Stewart JA, Heo G, Glover KE, et al. Factors that relate to 24. Parkin NA, Milner RS, Deery C, et al. Periodontal health
treatment duration for patients with palatally impacted of palatally displaced canines treated with open or closed
maxillary canines. Am J Orthod Dentofacial Orthop. surgical technique: a multicenter, randomized controlled
2001;119:216–225. trial. Am J Orthod Dentofacial Orthop. 2013;144:176–184.
12. Fleming PS, Scott P, Heidari N, et al. Influence of 25. Becker A, Chaushu S. Long-term follow-up of severely
radiographic position of ectopic canines on the duration resorbed maxillary incisors after resolution of an etio-
of orthodontic treatment. Angle Orthod. 2009;79:442–446. logically associated impacted canine. Am J Orthod Dento-
13. Zuccati G, Ghobadlu J, Nieri M, et al. Factors associated facial Orthop. 2005;127:650–654.
with the duration of forced eruption of impacted 26. Jönsson A, Malmgren O, Levander E. Long-term follow-
maxillary canines: a retrospective study. Am J Orthod up of tooth mobility in maxillary incisors with orthodon-
Dentofacial Orthop. 2006;130:349–356. tically induced apical root resorption. Eur J Orthod.
14. Pitt S, Hamdan A, Rock P. A treatment difficulty index for 2007;29:482–487.
unerupted maxillary canines. Eur J Orthod. 2006;28: 27. Kokich VO Jr, Kinzer GA. Managing congenitally missing
141–144. lateral incisors. Part I: canine substitution. J Esthet Restor
15. Stivaros N, Mandall NA. Radiographic factors affecting Dent. 2005;17:5–10.
the management of impacted upper permanent canines. 28. Zasciurinskiene E, Bjerklin K, Smailiene D, Sidlauskas A,
J Orthod. 2000;27:169–173. Puisys A. Initial vertical and horizontal position of
16. Becker A. Orthodontic Treatment of Impacted Teeth. 3rd ed., palatally impacted maxillary canine and effect on
Chichester, UK: Wiley-Blackwell; 2012. periodontal status following surgical-orthodontic treat-
17. Becker A, Chaushu S. Success rate and duration of ment. Angle Orthod. 2008;78:275–280.
orthodontic treatment for adult patients with palatally 29. Parkin NA, Milner RS, Deery C, et al. Periodontal
impacted maxillary canines. Am J Orthod Dentofacial Orthop.
health of palatally displaced canines treated with open
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18. Kokich VG. Preorthodontic uncovering and autonomous
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eruption of palatally impacted maxillary canines. Semin
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Orthod. 2010;16:205–211.
The role of distraction osteogenesis in patients
presenting with dento-facial deformity—
An overview
Michael Millwaters, BDS, FDS RCS (Eng), MB BS, FRCS (OMFS), and
Pratik K. Sharma, BDS (Hons), MFDS RCS, MSc, MOrth RCS, FDS Orth RCS, CILT

Distraction osteogenesis is a novel clinical technique aimed at generating

bone and associated soft tissue by incremental separation of the surgically
separated bone segments. The technique has gained increasing popularity in
managing severe dento-facial deformity since its application to the maxillo-
facial region was first described. This article will provide an overview of the
history of the technique, the biological basis of distraction osteogenesis, and
its clinical application in the maxillo-facial skeleton. (Semin Orthod 2015;
21:46–58.) & 2015 Elsevier Inc. All rights reserved.

Introduction for femoral extension using axial forces of dis-

traction. He acknowledged that he was not the
steogenic distraction is a well-established
O surgical treatment used to lengthen bones
and thereby correct deformities. It has a wide
first to attempt bone lengthening, but he is rec-
ognized as the first to describe some of the
important principles, including gradual length-
range of oro-facial applications including treat-
ening using moderate forces for larger defects.
ment of congenital and post-traumatic deformity.
Interest in the application of osteogenic dis-
In this article, we will not be discussing its use in
traction continued to evolve in the fields of
craniofacial congenital deformity but will be
orthopedics and traumatology, with Abbott3
concentrating on its use in dento-facial deform-
contributing to improvements in the technique
ity. In treating such problems, it has the advan-
by incorporating pins instead of casts as described
tages of both increasing the bone and soft tissue
by Codivilla. Furthermore, Allan4 in 1948
envelope and avoids the use of bone grafting.
established the use of a screw device to control
the rate of distraction.
History However, lengthening of bones produced a
number of associated complications, which
The technique to lengthen long bones was first included non- or fibrous union, infection, and
described by Codivilla1 in his original article other local wound problems. These continued to
published in Italian in 1903. This was then re- be problematic until the pioneering work of
published in English in 1905 following his pre- Gavriil Ilizarov (Fig. 1) in Siberia in the 1950s. He
sentation to the Annual Meeting of the American developed an external fixator shaped as a ring
Orthopaedic Association in June 1904.2 Codivilla's with a series of wires, which reduced the
case report described bone-elongation techniques incidence of complications.5 His significant
research described the biological principles of
Department of Oral and Maxillo-facial Surgery, Dental Institute, distraction and determined the technical
Royal London Hospital, Whitechapel, London, UK; Department of
protocols for the technique that are broadly
Oral and Maxillo-facial Surgery, Princess Alexandra Hospital,
Harlow, UK; Queen Mary's School of Medicine & Dentistry, Greater applicable today.6–9 He proposed that the
London, UK; Department of Orthodontics, Dental Institute, Royal application of gradual traction stimulates and
London Hospital, London, UK. maintains regeneration and active growth.
Corresponding to: Department of Oral and Maxillo-facial Surgery, In 1973, Synder et al. demonstrated man-
Dental Institute, The Royal London Hospital, Whitechapel, London dibular lengthening by gradual distraction in a
E1 1BB, UK. E-mail: [email protected]
canine study using an extra-oral device. Dis-
& 2015 Elsevier Inc. All rights reserved.
1073-8746/15/1801-$30.00/0
traction was not attempted in the oro-facial
http://dx.doi.org/10.1053/j.sodo.2014.12.005 region until the work of McCarthy et al. in

Seminars in Orthodontics, Vol 21, No 1 (March), 2015: pp 46–58 46

 The role of distraction osteogenesis in patients presenting with dento-facial deformity—An overview 47

Figure 1. Gavriil Ilizarov with a young patient undergoing limb-lengthening treatment.

New York in the late 1980s and early 1990s.10–12 periosteal supply alone will allow normal healing
McCarthy and his co-workers described the first and therefore corticotomy is rarely practiced.
successful use of extra-oral distraction to the Following placement of the distraction device
mandible in a small series of patients with con- and osteotomy, the bone ends are held stable for
genital mandibular deformity. They also the “latent phase.” This allows bony healing to
included discussion of the histologic changes begin in the gap between the cut ends and for a
seen in distraction, which led to greater under- soft callus to begin to form. At the end of the
standing of the process. Following this work, latent period, distraction is commenced, and the
there was a period of great interest in distraction bone ends are slowly separated during the “dis-
both experimentally and clinically with case traction phase.” During this period, osteogenesis
reports leading to studies of its application at a is induced to produce bone in the gap between
variety of oro-facial sites. the separated bone fragments. When the bone
has been separated the planned amount, dis-
traction is stopped, and the bone is held stable to
allow the “consolidation phase.” During this
Technique and pathophysiology
period, the initial immature bone formed during
The basic process in distraction osteogenesis is active distraction matures and remodels.
the formation of new bone between 2 bony There are some controversial themes in the
surfaces that are being progressively separated. process of distraction centered on the latent
The technique employed is usually of sub- period, the rate and frequency of distraction
periosteal surgical osteotomy of the bone to be employed, and the period needed for con-
distracted. However, the initial work on dis- solidation. The initial work of Ilizarov6,7 sug-
traction described corticotomy rather than for- gested that a latent period of approximately 7
mal osteotomy, as the endosteal blood supply was days is required before distraction is started. It
felt to be important. It is now recognized that the was suggested that if distraction is begun too
48 Millwaters and Sharma

soon, then there is a danger of non-union, days post-activation. At 3 weeks, calcification of

whereas if it is begun too late (typically after 10 the collagen bundles begins, and this progresses
days), then the bone may already have united. throughout the bony gap. McCarthy described 4
However, this work was carried out on long bones zones in the distraction gap: (1) a Fibrous central
that do not have the excellent blood supply of the zone, (2) an osteoid containing Transition zone,
craniofacial skeleton, and it has been suggested (3) a Remodeling zone, and (4) a Mature bone
that satisfactory healing in this region will follow zone. Essentially, this describes how mineraliza-
if shorter latent periods are allowed. It has also tion spreads from the peripheries of the bony gap
been suggested that in children there is no toward the center to allow union with immature
danger in abandoning the latent period due to bone, which then remodels and forms mature
their faster bony healing. bone sequentially. McCarthy also describes how
The rate of distraction as suggested by Ilizaroz the tension applied across the bony gap to the
is normally 1 mm/day. If the rate is below developing callus causes elongation of the
0.5 mm/day, then the bone ends may unite callus.13,14
prematurely, whereas if it is above 2 mm/day The tension applied across the distraction site
then, as above, non-union can occur and fibrous also causes changes in the surrounding soft tis-
healing will result. These figures are generally sues, with an increase in the mass of soft tissue,
respected and applied with some individual including muscle. This is an effect not seen in
variation depending upon the bony site and age conventional orthognathic surgery and is one of
of the patient. The frequency of distraction has the advantages of osteogenic distraction, partic-
been debated, with Ilizarov suggesting that ularly, in those deformities that have associated
multiple small increments throughout the day soft tissue defects.
are optimal. Most clinicians, however, ask their
patients to activate the device once or twice a day
for convenience. Applications
There is some controversy around the length Distraction osteogenesis now has a wide range of
of time required for consolidation, with the time possible applications in the craniofacial skeleton.
suggested varying according to the degree of As we disclosed at the outset of this article, we will
distraction undertaken. The initial long bone not be discussing its use in treating craniofacial
studies suggested a range from 6 to 12 weeks. In syndromic or congenital problems. With regards
the facial skeleton, the rule has usually been that to treating dento-facial deformities, distraction
the consolidation phase should be twice the time can be used in both the mandible and the
taken for distraction. However, patient variables maxilla. The general areas where distraction is
such as health and age and local factors such as applied are to treat transverse discrepancies in
the condition of the surrounding tissues and the jaws, dento-alveolar defects due to atrophy of
which bone/bones are being distracted should edentulous segments, oncologic or post-
be considered. The importance of holding the traumatic defects where tissue has been lost
distracted segment in a stable position over this (severe maxillary retrusion or mandibular ret-
period should not be underestimated; otherwise, rognathia), and finally temporo-mandibular joint
there may be unwanted callus molding or ankylosis. There are other less common uses, but
interference with the formation of normal bone.8 in general, the dento-facial deformities are
The histological appearance and changes seen acquired except for the transverse jaw
in the distraction site have been well described by discrepancies.
McCarthy in his initial experimental studies.11
He found that the latent period shows the
Mandibular distraction
normal process of fracture healing, and he
relates the formation of hematoma, migration Following the successful application of dis-
of inflammatory cells, synthesis of collagen traction osteogenesis to the mandible,10,12,15
matrix, and angiogenesis. Examination of the progress in the use of the technique to address
bony gap during the early distraction phase mandibular deficiency has continued with sig-
shows a fibrovascular matrix aligned along the nificant innovation in the design of distractors.
distraction vector with osteoid appearing at 14 The initial distractor devices were extra-oral
 The role of distraction osteogenesis in patients presenting with dento-facial deformity—An overview 49

and were only capable of unidirectional man- treated conservatively. Initially, he made a good
dibular lengthening, which presented limi- recovery but developed difficulty with jaw
tations, as many mandibular deformities require movements over the succeeding 2 years and
multidirectional correction involving the ramus, noticed that his jaw became proportionately
the corpus, and the angle of the mandible. The smaller and displaced to the right. Clinical
development of bidirectional and multidirec- assessment revealed a severe skeletal II pattern
tional distraction devices was subsequently with marked mandibular retrognathia, an
described allowing manipulation of bone seg- increased Frankfort-mandibular plane angle, and
ments in multiple planes of space.16 decreased lower anterior face height with chin
The advent of intra-oral distractors offered point to the right (Fig. 2). His temporo-
obvious improvements owing to the discreet mandibular joints (TMJ) were non-tender with
nature of the devices and negated the need for no clicking or crepitus, but his mouth opening
extra-oral incisions and associated facial scaring. was limited to 15 mm with marked deviation to
Having said this, intra-oral distractors have lim- the right and no excursive movements to the left
itations owing to anatomical constraints with an (Fig. 3). Intra-orally, he had a severe Class II
intra-oral approach that restrict their size and division 1 malocclusion with an overjet of 16 mm
design. Strategies to overcome these short- and an increased traumatic overbite to the palate
comings included the use of specifically designed (Figs. 4 and 5). Special investigations included a
devices based on anatomic location or clinical dental panoramic tomogram (Fig. 6), lateral
application and the use of custom-made dis- cephalogram (Fig. 7), and CT scan of the jaws.
tractors. More recently, intra-oral devices have These revealed markedly abnormal TMJs with
evolved, with unidirectional, bidirectional, and the left being small and remodeled and the right
multidirectional distractors being described. showing extensive, abnormal remodeling of the
Furthermore, the advent of curvilinear types of glenoid fossa, articular eminence, and condylar
distractors has allowed distraction in a plane that head and formation of a pseudojoint with no
aims to replicate the growth path of the bony ankylosis (Figs. 6 and 7). The diagnosis was
mandible. that of post-traumatic pseudo-ankylosis of the
The application of distraction osteogenesis in right TMJ leading to restriction of growth.
managing severe mandibular deficiency is Management required construction of stereo-
detailed in the case history described below. lithographic models, and we determined that
A male patient aged 28 years presented with osteogenic distraction would be required to allow
limited mouth opening and jaw movement and correction of the severe mandibular deformity
was unhappy with the appearance of his face using a body osteotomy to allow distraction to
(Figs. 2 and 3). He reported having fallen from a elongate the body of the mandible.
scooter at the age of 11 years and suffered a The surgical procedure involved the applica-
fracture of the mandible bilaterally, which was tion of AO internal craniofacial distractors via an

Figure 2. Facial views showing severe mandibular deficiency and asymmetry, with chin pointed to the right.
50 Millwaters and Sharma

Figure 3. Limited mouth opening and minimal left and right excursive movements.

Figure 4. Intra-oral views showing the extent of the increased overjet.

Figure 5. Intra-oral frontal, left, and right buccal views highlighting the extent of the presenting malocclusion.
 The role of distraction osteogenesis in patients presenting with dento-facial deformity—An overview 51

Figure 6. Dental panoramic tomogram showing the extent of the condylar abnormality.

intra-oral approach under general anesthesia. lip and chin post-operatively, but this had
Bilateral buccal sulcus incisions exposed the returned to normal by 1 year post-distraction.
mandible in the lower molar regions. The dis- Overall, the patient has had an extremely
tractors were pre-fitted and then removed to pleasing outcome from intervention that has
allow the osteotomies to be carried out bilaterally remained stable, with this technique being more
in the lower first molar region with saws and appropriate over conventional orthognathic
osteotomes. Once the splits were complete, the intervention, given the nature and severity of the
distractors were replaced and small skin incisions presenting condition.
placed to allow transcutaneous positioning of the
distractor arms. The distractors were opened a
few millimeters to check function before deac- Maxillary/midface distraction
tivation and suturing of the intra-oral wounds The use of distraction osteogenesis should be
with resorbable sutures. The patient was dis- considered in patients where the maxillary
charged the following day without incident and deficiency is so marked that it is out of the
re-attended at the outpatient clinic after a latent “envelope of correction” with conventional
period of 7 days for activation of the distractors. orthognathic surgical techniques or risks insta-
The active phase of distraction continued for 21 bility and relapse.
days until an overjet of 1 mm was reached
(Figs. 8–10). The rate of distraction was initially
1 mm/day bilaterally but was varied after the
14th day to an increased rate of 1.5 mm/day on
the right to correct the asymmetry of the man-
dible. Over the distraction period, the patient was
kept under regular review and required advice
for pain management, as the distraction was
painful.
Removal of the transcutaneous arms of the
distractors took place after a further 28 days to
allow skin closure (Fig. 11), and the
consolidation period lasted a further 4 months
before removal of the internal distractors via the
original intra-oral incisions (Figs. 12–14). The
patient did suffer from recurring local infections
in the left wound requiring repeated courses of
antibiotics during the consolidation period, but
we noted that he had good bone formation on
both sides when the distractors were removed. Figure 7. Lateral cephalogram confirms the extent of
He also had some altered sensation in his lower the mandibular deficiency.
52 Millwaters and Sharma

Figure 8. Left and right facial views at the end of the active phase of distraction.

The possibility of maxillary distraction was facilitate distraction of the maxilla without the
originally demonstrated in animal studies where obvious stigma of an external frame. A major
gradual midface advancement, segmental ante- disadvantage of such internal devices relates to
rior maxillary distraction, and multiple segmen- the unidirectional pattern of advancement, lim-
tal distraction were described.17–19 iting manipulation of the maxilla in 3
Since then, the application to humans has been dimensions.
described with the use of external and internal
distractors. The external devices offer the advantage
of being adjustable in 3 dimensions as advancement
Dento-alveolar distraction
is occurring. Furthermore, the use of Rigid External One of the interesting applications of distraction
Distractor (RED) is a relatively straightforward is in relation to augmenting atrophic maxillary
technique to apply for the surgeon, and activation is and mandibular alveolar ridges, which have been
simple from the patient's perspective. The major proved challenging to treat with alternative
downside of the external devices is that they are methods such as grafting-based procedures.
worn as an external “halo” even during the con- Subsequent to the early work by Chin and
solidation phase, which has implications for patients Toth20 who demonstrated the clinical application
from a psychosocial point of view. of vertical alveolar ridge distraction, the use of
The development of internal devices has the technique has gained popularity. Alveolar
popularized the use submucosal devices to deficiencies are capable of being treated with

Figure 9. Frontal facial views at the end of active phase of distraction.

 The role of distraction osteogenesis in patients presenting with dento-facial deformity—An overview 53

Figure 10. Dental panoramic tomogram taken at the end of the active phase of distraction. The internal
distractors are evident bilaterally with significant separation of the osteomized bone at the distraction sites.

both horizontal and vertical elongation of the jaws (Fig. 15). Where this is the case, establishing
deficient alveolus. A perceived advantage of this the true extent of the transverse discrepancy is
technique includes a progressive elongation of crucial by eliminating the apparent discrepancy
the surrounding soft tissues with limited risk of that will resolve with antero-posterior correction.
wound dehiscence and bone exposure. Orthodontic expansion, which is predom-
The key to achieving success is careful planning inantly tooth borne, is appropriate where trans-
and execution as part of an interdisciplinary team verse discrepancies are small and can be resolved
to ensure occlusal goals are met, as the use of with buccal movement of teeth. However, with
alveolar distraction techniques is not without risk. moderate to severe transverse maxillary defi-
ciencies, surgically assisted rapid expansion of
the palatal suture has become an established
Transpalatal/transmandibular distraction
method for treating skeletally mature patients
osteogenesis
(Figs. 16 and 17).
Transverse maxillary deficiency commonly Modalities such as surgically assisted rapid palatal
manifests as unilateral/bilateral posterior cross- expansion (SARPE) and segmental Le Fort
bites (Fig. 15) and associated crowding of the osteotomy to address transverse discrepancy,
arch, frequently, in the anterior region. although commonly advocated, present challenges
Transverse deficiencies of this nature, as is the including alveolar bone bending, root resorption,
case of skeletal III malocclusions, may present lateral tooth displacement, extrusion, and tipping.21
with associated antero-posterior and vertical jaw Relapse is the main problem after a maxillary
discrepancies that can accentuate the transverse osteotomy combined with a mid-palatal osteot-
discrepancy due to the relative position of the omy, most likely due to the lack of a palatal

Figure 11. Facial views after removal of the transcutaneous elements of the distractors.
54 Millwaters and Sharma

Figure 12. Right-sided pre- and post-distraction facial views.

retention appliance, fibrous scar retraction, and bone-borne transpalatal distractor has been used
palatal fibromucosal traction.22 successfully in treating congenital as well as
Transpalatal distraction osteogensis (TPDO) acquired transverse maxillary deficiency, with the
is a novel technique for correcting transverse beneficial changes being investigated and
maxillary deficiency. The application of this reported with innovative techniques such as
technique utilizes a bone-borne appliance that computer tomography.23
directs the forces mainly to the palatal shelves The use of TPDO techniques is not without risk,
close to the center of resistance of the maxillary and a number of complications involving the use of
bone with predominantly orthopedic expansion this technique have been reported in the literature.
occurring with elimination of tooth movement.22 They include wound infections, epistaxis, hema-
This negates many of the potential pitfalls of toma, maxillary sinusitis, infraorbital hypoesthesia,
SARPE and Le Fort segmental transverse ulceration, displaced/loose components of the
corrections as no adverse tooth movements distraction device, and fenestration of osteosyn-
occur and soft tissues can adapt with thesis screws.24 Careful planning with respect to the
incremental advancement and new bone type of distractor to be used, meticulous surgical
formation at the osteotomized site with limited technique, and aftercare should help prevent many
scarring. As such, maxillary expansion with a of these complications ensuing.

Figure 13. Left-sided facial views.

 The role of distraction osteogenesis in patients presenting with dento-facial deformity—An overview 55

Figure 14. Frontal pre- and post-distraction facial views.

Mandibular transverse deficiency (MTD) fre- proclination in the majority of cases. Fur-
quently manifests with crowding of the anterior thermore, although the use of mandibular sym-
teeth and may be associated with the presence of physeal osteotomy has been described as a means
scissorbites. Traditional approaches for space to address MTD, this technique has limitations
creation to address mandibular crowding include owing to the lack of rigid fixation, reliance on the
extraction therapy, dento-alveolar expansion, use of bone grafts, and potential risk of perio-
proclination of the anterior segment and use of dontal problems.
interproximal enamel reduction techniques. Application of transmandibular symphyseal
However, it is well established that inadvertent distraction (TMSD) has been described to
expansion in the mandibular arch, particularly manage mandibular transverse deficiency by
the intercanine width, is unstable as is incisor increasing the transverse dimension of the

Figure 15. Skeletal III malocclusion with associated anter-posterior, vertical, and transverse components. The
intra-oral views highlight the v-shaped archform and extent of bilateral buccal crossbites. The patient was treated
with SARPE to address the transverse discrepancy followed by formal orthognathic intervention involving a
differential maxillary impaction and advancement.
56 Millwaters and Sharma

Figure 16. Intra-oral views showing the design of the tooth-borne SARPE device, and the extent of transverse
expansion achieved with development of a significant midline diastema.

mandibular basal bone, overcoming some of the Furthermore, a vertical osteotomy is necessary to
limitations over other alluded to above.25–27 As avoid potential damage to the dentition, and it
with transpalatal distraction, both tooth-borne may be necessary to diverge the roots of the teeth
and bone-borne appliances have been described. surrounding the osteotomy site to facilitate a safe
Bone-borne appliances offer the significant surgical technique. This forms an important
advantage of no tooth tipping with most of the aspect of the pre-surgical planning phase of
mandibular expansion occurring due to skeletal management.
rather than dental change. A number of complications including infec-
A critical consideration in achieving sym- tion, damage to the inferior alveolar nerve and
metrical expansion relates to careful positioning dental structures, hemorrhage, fractures of the
of the distractor by avoiding oblique positioning. jaw, and breakage of distractor device have been

Figure 17. Post-treatment facial and intra-oral views showing corrected occlusion.
 The role of distraction osteogenesis in patients presenting with dento-facial deformity—An overview 57

reported.26,28 Despite the aforementioned pos- or their carers being able to manage the dis-
sible complication associated with this technique, tractors and cooperate with the treatment. It is
the stability of transverse skeletal correction with possible in some instances to offer increased
limited deleterious consequences has been support to a patient but essentially they have to
reported.29 understand and carry out the treatment as
directed. If a clinician is not convinced that the
patient comprehends the treatment or has the
Technique and pitfalls
understanding or dexterity to activate the appli-
Osteogenic distraction is an extremely useful and ance, then one should consider an alternate plan.
adaptable technique with a wide range of possi- The other avoidable problems center around
ble uses. However, it requires careful assessment poor planning and delivery of the treatment
and planning together with precise surgical plan. Poor planning of a case can lead to a sub-
technique to ensure optimal outcome. The optimal or poorly controlled vector being
planning will usually include the use of CT scans chosen, which will not deliver the treatment aims.
with stereo-lithographic models and possibly This can occasionally be dealt with via callus
virtual 3D planning. These will allow the selec- molding, but this technique should really be a
tion of a single or multiple vector plans that can planned approach rather than trying to recap-
be modeled or practiced on available skeletal ture a poor treatment plan. Poor planning may
models if required. There is usually a range of also be a contributory factor in distractor failure,
options that one can then choose with regards to although this can be multifactorial as poor
the distractor, but essentially they fall into the patient compliance, incorrect distractor selec-
main groups of external or internal, uni- or multi- tion, and mechanical failure of the components
vector.30 The key point is to plan carefully with can contribute to this. On the other hand,
the available resources and then choose the poor delivery of the plan can lead to premature,
distractor to deliver the chosen treatment plan fibrous, or non-union due to incorrect dis-
and vector. One also has to consider and discuss traction rates being chosen. In addition, there
the post-operative scars that will be created, as are common problems that one may encounter
internal distractors require open operations to such as pain during the distraction and infection.
insert and then remove, whereas external dis- Pain may be reduced or eliminated by using
tractors do not usually require an open place- multiple, small distraction increments, and
ment but will leave scars from the pin placement. patients should be instructed to use analgesics as
Following the surgical procedure and any they are distracting. Infection can be a chal-
latent period, one then has to carefully monitor lenging problem as it can be difficult to eradicate
the distraction, as patients often require support and can damage the developing callus thereby
and advice. In our practice, patients are offered affecting healing. Careful surgical technique
multiple appointments until we are happy that along with good wound care can reduce the
they are able to perform the distraction at home incidence of infection, but the risk cannot be
either themselves or with help. We always keep a entirely removed.
close watch on the patient's progress and will The final problem to consider is that of relapse.
always tend to overcorrect to allow for possible One of the major advantages of distraction is that
relapse. The degree of overcorrection will the soft tissue envelope increases as the bone is
depend on the degree and site of distraction and lengthened, and initial reports suggested that
also on the age of the patient, as one has to relapse should not be a problem. However,
remember to allow for any future growth if this is relapse can be a problem, which one should
being undertaken in children. anticipate and plan for. As above, we would
There is a range of possible complications that advocate overcorrection and consideration of the
one may encounter in distraction, and these have retention period chosen to try to control for this.
been alluded to earlier. Many can be avoided or
minimized with careful case selection, monitoring,
Conclusion
and technique. In the first instance, the treating
clinician should carefully select the patient, as In conclusion, osteogenic distraction is a tech-
satisfactory distraction is dependent on the patient nique that has revolutionized the treatment
58 Millwaters and Sharma

options for a wide range of craniofacial and 16. Molina F, Ortiz Monasterio F. Mandibular elongation and
dento-facial conditions. It can be a time- remodeling by distraction: a farewell to major osteoto-
mies. Plast Reconstr Surg. 1995;96:825–840.
consuming process in terms of planning and 17. Rachmiel A, Potparic Z, Jackson IT, et al. Midface
delivery and does have pitfalls. However, these advancement by gradual distraction. Br J Plast Surg.
are outweighed by the advantages it gives with 1993;46:201–217.
respect to its wide range of clinical applications. 18. Block MS, Cervini D, Chang A, et al. Anterior maxillary
advancement using tooth-supported distraction osteo-
genesis. J Oral Maxillofac Surg. 1995;53:561–565.
References 19. Rachmiel A, Levy M, Laufer D, et al. Multiple segmental
1. Codivilla A. Sulla correzione della deformita de frattura gradual distraction of facial skeleton: an experimental
del femore. Bull Sci Med (Bologna). 1903;3:246–249. study. Ann Plast Surg. 1996;36:52–59.
2. Codivilla A. On the means of lengthening, in the lower 20. Chin M, Toth BA. Distraction osteogenesis in maxillofa-
limbs, the muscles and tissues which are shortened cial surgery using internal devices: review of five cases. J
through deformity. J Bone Joint Surg Am. 1905;s2- Oral Maxillofac Surg. 1996;54:45–53.
2:353–369. 21. Glassman AS, Nahigian SJ, Medway JM, et al. Conservative
3. Abbott JS. Letters to the Editor. Am J Public Health (NY). surgical orthodontic adult rapid palatal expansion:
1927;17(12):1256–1257. sixteen cases. Am J Orthod Dentofacial Orthop. 1984;86:
4. Allan FG. Bone lengthening. J Bone Joint Surg Br. 1948;30B 207–213.
(3):490–505. 22. Mommaerts MY. Transpalatal distraction as a method of
5. Ilizarov GA, Deviatov AA. Surgical lengthening of the shin maxillary expansion. Br J Oral Maxillofac Surg. 1999;37
with simultaneous correction of deformities. Ortop Trav- (4):268–272.
matol Protez. 1969;30:32–37[in Russian]. 23. Garrett BJ, Caruso JM, Rungcharassaeng K, et al. Skeletal
6. Ilizarov GA. The tension-stress effect on the genesis and effects to the maxilla after rapid maxillary expansion
growth of tissues: part I. The influence of stability of assessed with cone-beam computed tomography. Am J
fixation and soft-tissue preservation. Clin Orthop Relat Res. Orthod Dentofacial Orthop. 2008;134:8.e1–8.e11.
1989;238:249–281. 24. Gunbay T, Akay MC, Gunbay S, et al. Transpalatal
7. Ilizarov GA. The tension-stress effect on the genesis and distraction using bone-borne distractor: clinical observa-
growth of tissues: part II. The influence of the rate and tions and dental and skeletal changes. J Oral Maxillofac
frequency of distraction. Clin Orthop Relat Res. Surg. 2008;66:2503–2514.
1989;239:263–285. 25. Weil TS, Van Sickels JE, Payne CJ. Distraction osteo-
8. Ilizarov GA. The principles of the Ilizarov method. Bull genesis for correction of transverse mandibular defi-
Hosp Jt Dis Orthop Inst. 1988;48:1–11. ciency: a preliminary report. J Oral Maxillofac Surg.
9. Ilizarov GA. Clinical application of the tension-stress
1997;55:953–960.
effect for limb lengthening. Clin Orthop Relat Res.
26. Kewitt GF, Van Sickels JE. Long-term effect of mandibular
1990;250:8–26.
midline distraction osteogenesis on the status of the
10. Karp NS, Thorne CH, McCarthy JG, et al. Bone length-
temporomandibular joint, teeth, periodontalstructures,
ening in the cranio- facial skeleton. Ann Plast Surg.
and neurosensory function. J Oral Maxillofac Surg.
1990;24:231.
1999;57:1419–1425.
11. Karp NS, McCarthy JG, Schreiber JS, et al. Membranous
27. Mommaerts M, Polsbroek R, Santler G, et al. Anterior
bone lengthening: a serial histologic study. Ann Plast Surg.
1992;29:2. transmandibular osteodistraction: clinical and model
12. McCarthy JG, Schreiber J, Karp NS, et al. Lengthening the observations. J Craniomaxillofac Surg. 2005;33(5):318–325.
human mandible by gradual distraction. Plast Reconstr 28. Mommaerts MY, Spaey YJE, Soares Correia PEG, et al.
Surg. 1992;89:1. Morbidity related to transmandibular distraction osteo-
13. Rowe NM, Mehrara BJ, Dudziak MD, et al. Rat man- genesis for patients with developmental deformities. J
dibular distraction osteogenesis: part I. Histologic and Craniomaxillofac Surg. 2008;36(4):192–197.
radiographic analysis. Plast Reconstr Surg. 1998;102:2022. 29. Gunbay T, Akay MC, Aras A, et al. Effects of trans-
14. Aro H, Biomechanics of distraction. In: McCarthy JG, ed. mandibular symphyseal distraction on teeth, bone, and
Distraction of the Craniofacial Skeleton. New York: Springer; temporomandibular joint. J Oral Maxillofac Surg.
1999. 2009;67:2254–2265.
15. Snyder CC, Levine GA, Swanson HM, et al. Mandibular 30. Grayson BH, McCormick S, Santiago PE, et al. Vector of
lengthening by gradual distraction. Preliminary report. device placement and trajectory of mandibular distrac-
Plast Reconstr Surg. 1973;51:506–508. tion. J Craniofac Surg. 1997;8:473–480.
Upper incisor trauma and the orthodontic
patient—Principles of management
Monty Singh Duggal, Jay Kindelan, and Hani Nazzal

A proportion of children referred for orthodontic treatment have a history of

previous trauma to their anterior teeth. Some can suffer trauma whilst
undergoing fixed appliance therapy. The aim of this article is to familiarise the
reader with some common dentoalveolar traumatic injuries that can have
important implications for orthodontic treatment. Multidisciplinary care for
long-term management of such cases with the involvement of orthodontists
and paediatric dentists working in a team is also discussed. (Semin Orthod
2015; 21:59–70.) & 2015 Elsevier Inc. All rights reserved.

Introduction avulsion require interdisciplinary long-term

M
management. Successful outcomes are depend-
any children sustain accidental damage to
ent on close liaison between orthodontists
their incisors, and trauma is reported to
and paediatric dental specialists managing
affect 5–13% of children 8–15 years of age
the case.
according to the latest United Kingdom Child-
ren's Dental Health survey.1 Boys were more
likely to be affected than girls were especially History, examination and diagnosis of
between 12 and 15 years of age. incisor trauma
Almost 10% of children referred for ortho-
dontic treatment had suffered dental trauma to It is crucial to assess the history of dental trauma
one of their anterior teeth.2 These authors including any management provided as part of
reported a significantly higher frequency of an orthodontic assessment. Orthodontists should
dental trauma to anterior teeth in patients with evaluate the anterior teeth for signs of dental
increased overjet, with or without adequate lip trauma even in the absence of such history, as
coverage.2 Systematic review of the relationship children might not recall such events. Clinical
between overjet size and traumatic dental examination should include the following:
injuries concluded that children with an
overjet 43 mm have approximately twice the 1. Hard tissue assessment
risk of trauma to anterior teeth than children a. Crown colour assessment:
with an overjet o3 mm.3 The aim of this article is ● Dark hue might indicate loss of pulp
to discuss some commonly encountered vitality.
traumatic injuries and their implications for ● Yellow colour might indicate pulp canal
orthodontic treatment planning and appliance obliteration.
therapy. The possible effects of orthodontic ● Pink colour might indicate internal
tooth movement of teeth with history of resorption.
previous trauma are also discussed. In addition, b. Transillumination assessment can reveal
severe traumatic injuries such as intrusion and enamel infraction lines and colour changes
in traumatised teeth.
c. Assessment of tooth mobility in both
School of Dentistry, University of Leeds, Leeds, West Yorkshire, horizontal and vertical directions.
UK; York Hospital, York, Yorkshire, UK. d. Percussion tests:
Address correspondence to H. Nazzal, BDS, MFDSRCS (Ireland), ● Tenderness to touching or tapping a
FRCD (Canada), MPaed Dent RCSEng, PhD Paediatric Dentistry,
tooth is suggestive of PDL damage.
School of Dentistry, University of Leeds, Clarendon Way, Leeds,West
Yorkshire LS2 9LU, UK. E-mail: [email protected] ● High metallic percussion note is often
& 2015 Elsevier Inc. All rights reserved.
diagnostic of ankylosis.
1073-8746/15/1801-$30.00/0 ● Dull percussion note may be suggestive
http://dx.doi.org/10.1053/j.sodo.2014.12.006 of a root fracture.

Seminars in Orthodontics, Vol 21, No 1 (March), 2015: pp 59–70 59

60 Duggal et al

2. Soft tissue assessment: However, the machine is expensive, requires

a. Sinus tracts or swellings indicate loss of pulp patient cooperation and a splint needs to be
vitality and peri-radicular infection. fabricated for a reproducible placement of the
b. Palpation over the tooth apex for tender- probe between visits for accurate longitudinal
ness as it might indicate a periapical assessment.
infection.
3. Radiographic assessment:
Reproducible long-cone periapical radio-
Endodontic management of traumatised
graphs are best for the accurate diagnosis of
anterior teeth
dental trauma. Two radiographs taken at
different angulations are usually required to Pulp necrosis following dental trauma is usually
detect a root fracture. Radiographs are also dependent on the type of injury, root develop-
important to detect any root resorption or ment stage and treatment provided (Table 1). An
pulp canal obliteration due to previous endodontic intervention is required when there
trauma. are clinical and radiographic signs of pulpal
4. Sensibility tests: necrosis and infection associated with traumatised
Sensibility tests should be considered in teeth. Failure of continued root formation and
association with other clinical and radio- presence of external inflammatory (infection
graphic findings but not in isolation. Electric related) root resorption, internal resorption or
pulp testing (EPT) is the most useful test to sinus tract are indicative of either a state of pulp
assess the neurovascular supply to the pulp of inflammation or root canal infection.
a traumatised tooth.4 This is; however, a The choice of endodontic management
subjective measurement tool and relies on technique is dependent mainly on the stage of
patient understanding of and cooperation root development, presence of root fracture and
with the instructions given. The electrode root resorption. Teeth with complete root for-
should be placed as close to the incisal edge mation and no associated root resorption are
as possible to avoid contact with the gingival endodontically treated and obturated using
tissues and hence obtaining false-positive Gutta-percha. The use of calcium hydroxide as
results. The use of the EPT in developing an intracanal medicament is acceptable on short-
teeth is unreliable. The use of laser Doppler term basis as the long-term use of calcium
flowmetry is sometimes indicated especially hydroxide may be detrimental to the dentine
when cooperation is lacking, the patient's making it more brittle and liable to fracture.5
responses are unreliable to cold and EPT Endodontic management of non-vital imma-
testing, or when the results are inconsistent. ture teeth has always been challenging. These
Laser Doppler flowmetry is the only objective teeth have short roots and thin dentinal walls that
measure of pulp vitality available and is shown render these teeth weak and unable to withstand
to be reliable in assessing pulp blood supply. the physiological forces of mastication. This

Table 1. Three-Year Predicted Risks of Healing Complications Following Different Types of Dental Trauma in
Permanent Teeth With Immature (Two-Thirds Root Formation) and Complete Root Formation as per the Trauma
Guide (http://www.dentaltraumaguide.org/Permanent_teeth.aspx)
Type Pulp Necrosis (%) Inflammatory Root Resorption (%) Ankylosis (%) Tooth Loss (%)
ICR CR ICR CR ICR CR ICR CR

E/D fractures 0 5.1 0 0 0 0 0 0

E/D fractures (complicated) 6.2 0 0 0 0 0 0 0
Root fractures 0 30.9 0 0 0 1.5 0 7.2
Concussion 0 0 0 0 0 0 0 0
Subluxation 0 12.5 0 0 0 0 0 0
Extrusion 5.9 56.5 2.9 0 0 0 0 0
Lateral luxation 4.7 72.8 0 33 0 1 0 0
Intrusion 61.1 100 33.3 4.8 5.6 26.1 5.6 5.3
E: enamel; D: dentine; CR: complete root; ICR: incomplete root.
 Upper incisor trauma and the orthodontic patient 61

results in a high fracture rate, and therefore a Observation periods prior to moving
poor prognosis in the medium to long term. Most traumatised teeth orthodontically
studies have shown that over 50% of such teeth
One of the most important factors when plan-
will be lost in the first 10 years following the
ning orthodontic treatment for a patient who has
trauma despite being treated endodontically.6
traumatised their upper incisors is extremely
The preferred current endodontic management
close liaison between orthodontist and paediatric
techniques for such immature teeth favours the
dentist. The potential diversity of injuries that
use of mineral trioxide aggregate (MTA) to
can occur to upper incisors following trauma
physically create a barrier against which the
further emphasises the need for an extremely
root canal filling material can be compacted
close interaction between the specialities of
for obturation of the root canal. However, it has
orthodontics and paediatric dentistry.
been shown recently7 that the prolonged use of
The guidance with respect to managing
calcium hydroxide in the root canal, as is
orthodontically traumatised teeth was summar-
required for apexification, increases the risk of
ised by Kindelan et al.18 For ease of use clinically,
root fractures. This is thought to be due to the
the different times for monitoring traumatised
high alkalinity of calcium hydroxide, which
teeth prior to moving them orthodontically can
denatures the collagen of the dentine,
be split roughly into two categories. Patients
specifically by interfering with the phosphate
receiving milder trauma should be monitored for
and the carboxylate groups within the dentinal
3 months before active tooth movement. Patients
proteins. For this reason, the use of calcium
receiving more severe trauma, which might
hydroxide for a prolonged period of time for the
include root fractures or fractures to the
traditional apexification technique is no longer
alveolus, should be monitored for a minimum
advocated. The use of MTA in the last decade has
of 1 year before starting active tooth movement
improved outcomes,8 but MTA itself is highly
(possibly longer in the case of root fractures to
alkaline and is thought to make the teeth brittle
encourage hard tissue healing).
and more prone to root fractures.9
The current techniques have a fundamental
problem in that although they allow root canal
Observation periods following endodontic
obturation, they do not contribute to any
treatment prior to orthodontic tooth
qualitative or quantitative increase in root
movement
dimensions, and the tooth remains predis-
posed to fracture.6 Further research is In cases where root canal treatment has been
required to improve long-term outcomes for undertaken as a result of pulp necrosis due to
such teeth. caries, orthodontic tooth movement can com-
More recently, there has been a paradigm shift mence immediately.19,20 Where there has been
in the approach to this intractable clinical extensive bone loss, tooth movement should be
problem. Several case reports10–13 and more delayed until there are clinical and radiographic
recently case series14–17 have been published and signs of some healing and an interval of at least 6
shown the regeneration technique to have a months has been suggested.20 Where endodontic
good short-term outcome and continued root therapy has been carried out following dental
development that would indicate that regen- trauma, an interval of 1 year is recommended
eration of the pulp–dentine complex has prior to proceeding with orthodontic treatment
occurred. Although there are several reports, to ensure complete healing and absence of
there are no data based on a systematic evalu- ankylosis.19,20
ation of these techniques or randomised con- de Souza et al.21 histo-morphologically eval-
trolled trials. uated the influence of tooth movement on the
The quality of any existing root canal filling healing of chronic periapical lesions induced in
should be assessed prior to the commencement dogs' teeth. Orthodontic forces applied to root-
of orthodontic treatment. Re-root treatment of filled teeth delayed the periapical healing proc-
teeth with poor unsatisfactory obturation ess in comparison to obturated contralateral
should be considered prior to orthodontic incisors that were not moved. However, they did
treatment. not prevent the periapical healing. This work
62 Duggal et al

suggests that tooth movement may be com- A retrospective study by Malmgren et al.29
menced prior to complete radiographic reso- investigated the frequency and degree of
lution of periapical pathology. root resorption in 55 traumatised incisors of
27 patients receiving orthodontic treatment
with fixed appliances, removable appliances
Effects of orthodontic movement on
or a combination. The authors suggested tra-
traumatised teeth
umatised teeth that showed signs of root
Pulp vitality resorption prior to orthodontic treatment may
be more prone to root resorption during
Brin et al.22 looked at the reaction of previously
treatment.
traumatised teeth to the application of
Linge and Linge30 investigated the incidence
orthodontic forces. The traumatised teeth
and extent of apical root resorption in 2451 teeth
undergoing orthodontic tooth movement were
of 719 consecutive orthodontic patients treated
noted to have both the lowest response to
in private practice. The average change in root
sensibility testing and the highest rate of pulpal
length for the trauma group was 1.07 ⫾ 1.19 mm
canal obliteration (PCO) which would, itself,
compared to 0.64 ⫾ 1.04 mm for non-
reduce the response to sensibility tests.
traumatised teeth and was found to be highly
It should be noted that PCO is a sign of
significant.
continued pulpal vitality and that electric pulp
In summary, orthodontic tooth movement is
testing is not a reliable indicator of this. It is
known to cause root resorption in teeth; blunt or
recommended that teeth that have a history of
pipette-shaped roots, jiggling orthodontic forces
dental trauma should be carefully reviewed
and previous tooth trauma may increase the
during the provision of orthodontic treatment.
susceptibility to root resorption. Traumatised
A 3-month assessment of clinical signs including
teeth that display signs of root resorption before
sensibility testing would be considered good
orthodontic tooth movement are at a high risk of
practice, with radiographic investigation
increased root resorption as a result of ortho-
required if other clinical parameters suggest loss
dontic forces. Thus, good clinical and radio-
of vitality and pathology. It should be remem-
graphic assessments are essential prerequisites to
bered that adjacent teeth should also be assessed,
the commencement of orthodontic tooth
as whilst one incisor may sustain the brunt of a
movement.
traumatic incident, 45% of associated teeth will
have experienced some trauma at the same
time.23 Orthodontic tooth movement in
With the evidence available, it is not possible endodontically treated teeth
to say whether orthodontic tooth movement of
Some authors have reported an increased risk of
traumatised teeth increases the risk of pulp
root resorption,31 whilst others have reported
necrosis above that of uninjured teeth under-
equal32 or reduced risk.33,34 More recently, a
going tooth movement.
retrospective study has been carried out evalu-
ating the radiographic findings in 16 patients
Root resorption
from a total of 2500 receiving orthodontic
There are three main types of root resorption: treatment, who concurrently had one endo-
surface resorption, inflammatory resorption and dontically treated maxillary incisor, with the
replacement resorption.24 Detecting ankylosis adjacent incisor tooth available as a control. No
can be difficult, and the clinical sign of a high statistically significant difference in the apical
metallic percussion note is only detectable when root resorption was seen in the root-treated teeth
20% or more of the root surface has been compared to vital control teeth.35
affected by replacement resorption.25,26 Anky- In an animal model, it has been shown that
losis usually occurs initially on the buccal and vital and non-vital teeth moved similar distances
palatal surfaces of the root surface and therefore, when subjected to the same forces.36
whilst the process is present at a cellular level, it is Histologically, root-filled teeth showed greater
not visible on conventional radiographs until loss of cementum after orthodontic tooth
much later.27,28 movement than vital teeth, but there was no
 Upper incisor trauma and the orthodontic patient 63

significant difference in radiographic root but equally of the risk of future episodes of
length. trauma during treatment. This may have an
It should be concluded from the available impact on the prognosis of the teeth and increase
evidence that there is no significant difference in the length of time for orthodontic treatment to
the root resorption of endodontically treated be completed.
teeth when compared to vital teeth subjected to The response of upper incisors to trauma
the same orthodontic forces, assuming that the during orthodontic treatment will largely depend
root canal filling is of good quality. upon the stage of treatment and what sort of arch
wire is in situ. In the initial phases of active
orthodontic treatment, the patients will most
Monitoring root-treated teeth during
likely have flexible nickel–titanium arch wires in
orthodontic tooth movement
place. Episodes of minimal trauma may allow the
Upper incisor teeth that have been root filled arch wire to recover and the tooth repositioned
before the start of orthodontic treatment will automatically. However, as treatment progresses
require very careful monitoring. Close liaison and patients move into stainless steel arch wires,
between the orthodontist and paediatric or then episodes of trauma are most likely to result
restorative dentist who carried out the root canal in distortion of the arch wire and displacement of
treatment is essential. An understanding of the the upper incisor teeth from their normal posi-
severity of injury is important in recognising how tion within the line of the arch.
extensive the damage to periodontal tissues In the end stages of treatment during space
might have been following the episode of closure when rigid rectangular stainless steel
trauma. wires are in place, then this can sometimes
Malmgren et al.19 recommended initial provide a protective element to the incisor teeth,
radiographs prior to the commencement of particularly for episodes of severe trauma where
orthodontic tooth movement followed by otherwise upper incisor teeth may possibly have
radiographic monitoring 6 months after the been avulsed (Fig. 1).
start of orthodontic treatment. Assuming no When a patient presents with a distorted steel
significant change in root length, then arch wire in place, it is desirable to reposition the
treatment can proceed accordingly. If extensive incisor teeth to their pre-trauma position within
resorption is noted then a rest period of the line of the arch. When the displacement of
3 months is recommended, before resuming the teeth has been minimal, this can often be
active tooth movement. In cases where the achieved by placing flexible nickel–titanium arch
degree of root resorption is excessive leading wires as shown in Fig. 2. For cases where the
to potential tooth mobility, a decision will need to degree of displacement is more extensive, then
be taken whether to continue treatment. surgical repositioning may be required prior to
In a long-term follow-up of maxillary incisors replacing an arch wire of normal arch form. It is
with severe apical root resorption, a risk of per- advisable to try and utilise an arch wire that has
manent tooth mobility has been shown to occur if a certain degree of flexibility, i.e., nickel–
the total root length is less than or equal to titanium is usually preferable as that flexibility
9 mm.37 This risk is reduced if more than 9 mm allows movement within the periodontal
of tooth root remains in the presence of a healthy ligament and encourages fibrous periodontal
periodontium. ligament healing rather than the possibility of
bony replacement resorption. Obviously a
contraindication to this would be in cases of
Teeth traumatised during treatment
root fracture where it is preferable to splint the
It has been reported that teeth that experience tooth more rigidly.
one episode of dental trauma are at increased
risk of future episodes of dental trauma.38
Management of intruded teeth
Patients who have experienced dental trauma
prior to orthodontic treatment can thus be Intrusion injuries account for 1.9% of all trau-
warned, not only of the possible increased risk matic injuries.39 The crushing injury of intrusion
of root resorption during orthodontic treatment, produces severe damage to the tooth,
64 Duggal et al

Figure 2. (A) Traumatised tooth 11 mid-treatment

causing palatal displacement and distortion of 0.018-in
SS wire. (B) Tooth 11 realigned with 0.016-in NiTi
wire.

of traumatically intruded permanent incisor

teeth in children (Table 2).
All severely and moderately intruded teeth
with closed apices should be repositioned rapidly
in order to allow access for extirpation of the
non-vital pulp to prevent the high chance of
inflammatory root surface resorption secondary
to pulp necrosis. It may also mean that if ankylosis
does subsequently occur it does so in a more
favourable position. Active repositioning is,
however, a further traumatic event for the
periodontal ligament. If, in a minor or moderate
intrusion injury, an observation period is allowed
for spontaneous re-eruption, active repositioning
should still be considered if there is no change in
Figure 1. (A) Dentoalvelar trauma affecting upper
and lower anterior teeth in a patient with fixed the position of the tooth after a 2-week interval. It
orthodontic appliance, (B) repositioned and splinted should also be remembered that severe intrusion
traumatised teeth using a titanium trauma splint and may lock a tooth in position, and gentle luxation
(C) traumatised teeth a year following trauma. forces may be required before orthodontic
extrusion.
periodontium and pulpal tissues. Although Andreasen et al.41,42 reported on a prospective
periodontal ligament regeneration may occur study of 140 treated intruded incisors collected
in mild intrusions, healing outcomes for more over a 48-year period between 1955 and 2003.
severe intrusion frequently include replacement They claimed that active surgical or orthodontic
resorption, marginal bone loss and pulp necrosis. repositioning had a negative effect upon healing
The British Society of Paediatric Dentistry in terms of pulp necrosis, marginal bone loss
(BSPD) developed guidelines for the treatment and replacement resorption, in contrast to
 Upper incisor trauma and the orthodontic patient 65

Table 2. BSPD Guidelines for Management of Intruded Permanent Incisor Teeth40

Root Intrusion Severity and Management
Development Tooth Status
Stage

Open apex Mild intrusion, Allow spontaneous eruption

o3 mm
Moderate intrusion, Allow spontaneous eruption or start orthodontic repositioning. If no spontaneous re-
3–6 mm eruption occurs within 2 weeks, orthodontic repositioning must be instigated
Severe intrusion, Surgically reposition
46 mm
Closed apex Mild intrusion, Allow spontaneous eruption or start orthodontic repositioning. If no spontaneous re-
o3 mm eruption occurs within 2 weeks, orthodontic repositioning must be instigated
Moderate intrusion, Orthodontically reposition within 2 weeks to allow access to the pulp chamber
3–6 mm
Severe intrusion, Surgically reposition
46 mm

spontaneous eruption, and concluded that fragment displacement. Healing is worse with
patients with intruded teeth and incomplete root increased separation of the fragments.44 The
formation, spontaneous eruption should be apical root fragment almost always remains vital
allowed to occur. In patients 12–17 years of age, even if the coronal part becomes non-vital.45
spontaneous eruption can still occur, but they
cautioned teeth must be monitored frequently
Orthodontic movement of root-fractured
and with care. In patients older than 17 years,
teeth
they recommended surgical or orthodontic
extrusion should be attempted. In severely It is essential to determine the type of root-
intruded teeth, this technique may be chosen fracture healing before orthodontic tooth
because of the need to gain access to a necrotic movement, as it will affect treatment as follows:
pulp within 2 weeks to institute root canal ther-
apy and prevent inflammatory root resorption. 1. Fracture healing by hard tissue callus forma-
tion: both fragments should move at the
same time.
Management of root-fractured teeth
2. Fracture healing by connective tissue forma-
Root fractures may be horizontal, vertical, single tion or combination of connective and hard
or multiple and complete or incomplete, and tissue formation: the coronal fragment alone
therefore two or more radiographic views are will move, which should be considered as a
required in order to accurately diagnose these tooth with a short root (Fig. 3). This has
fractures. The current International Association profound implications as further surface root
Of Dental Traumatology Guidelines43 for root- resorption due to orthodontic movement
fractured teeth advocates repositioning of dis- could occur thereby shortening the root
placed coronal tooth fragment followed by further (a risk of permanent tooth mobility
physiological splinting for 4 weeks (4 months in has been shown to occur if the total root
the case of cervical root fractures). length is less than or equal to 9 mm37).
As with other traumatic injuries, the aims of
treatment are to preserve pulp vitality and
facilitate periodontal healing. In addition, root- It is also essential to determine the pulp vitality
fracture healing by a hard tissue callus should be of the coronal segment as pulp necrosis can lead
encouraged. Other healing outcomes such as to granulation tissue interposition between the
connective tissue and a combination of bone and fragments. Those teeth would require appro-
connective tissue healing could occur. Pulpal, priate endodontic therapy of the coronal seg-
periodontal and root fracture healing are usually ment prior to orthodontic tooth movement.
dependent on root development stage, with a Complications following root fractures are
better outcome for immature teeth, and coronal usually evident after 1 year, and therefore
66 Duggal et al

Figure 3. (A) Upper standard occlusal radiograph showing tooth 21 with root fracture between apical and middle-
thirds of root. (B) Periapical radiograph of the tooth 21 demonstrating separation of root fragments following
orthodontic treatment.

a minimal review period of 1 year post endodontic Ankylosis of upper incisors

treatment of coronal fragments should precede
Diagnosis
any orthodontic intervention of these teeth.18
Ankylosis is diagnosed either radiographically in
the form of replacement resorption or clinically
Management of avulsed teeth
in the form of a high percussion note, infra-
Avulsion is one of the most severe dentoalveolar occlusion and failure to move teeth orthodon-
injuries where the tooth is completely knocked tically. A high resonant tone heard on percussion
out of the socket and usually requires inter- testing is present only after approximately 20% of
disciplinary management. This injury accounts the root surface area is affected by replacement
for 0.5–3% of dentoalveolar trauma to perma- resorption.26 Early radiographic detection of
nent teeth.46 According to the latest British replacement resorption is often difficult as the
Society of Paediatric Dentistry guidelines,46 the site of initial replacement resorption is usually on
management of these teeth mainly depend on the buccal or palatal root surface.26
the extra-oral dry and wet storage times with a Ankylosis manifests clinically as infra-occlusion
cut-off extra-oral dry time of 30 min and overall causing, mainly in the pre-adolescent life,
extra-alveolar (dry and wet in appropriate stor- noticeable alteration of local growth and devel-
age medium) time of 90 min. This was based on a opment of the alveolus.
thorough review of the literature that revealed The severity of infra-occlusion depends on
ankylosis of more than 90% of avulsed teeth patient's overall growth state as shown by
when replanted outside these time points. Malmgren and Malmgren47 after analysing the
Despite these results, avulsed permanent teeth rate of infra-occlusion of 30 ankylosed incisors in
should be replanted as soon as possible, unless 30 growing subjects over a period of 1–10 years.
contraindicated for reasons such as medical Day et al.48 reviewed the various options of
history or patient cooperation. This would allow management of infra-occluded teeth such as
maintenance of aesthetics, function and alveolar composite buildup in minor cases of infra-
bone height and width facilitating different occlusion (less than 1 mm), decoronation in
future treatment options including premolar order to preserve bone height and width,
auto-transplantation and implant placement. extraction with interim prosthesis and auto-
A referral to a specialist team is essential for transplantation.
management in the short, medium and In severe traumatic injuries, where ankylosis is
long terms. a likely consequence, orthodontists should
 Upper incisor trauma and the orthodontic patient 67

Figure 4. (A) Anterior view with missing teeth 11 and 12. (B) Palatal view shows anterior crowding and sufficient
bone available in a buccopalatal direction for a premolar transplant. (C) Tooth 24 in position of 11. (D) Slight
extrusion of transplanted premolar commenced after 6 months. (E) Temporary composite buildup of premolar
transplant giving final mesiodistal width of 11. (F) Final occlusion showing composite buildup of premolar
transplant, modification of shape of tooth 13 to mimic 12 and good buccal interdigitation. (G) Good left buccal
interdigitation. (Reproduced with kind permission of Maney Publishing, http://maneypublishing.com/index.
php/journals/jor and http://jorthod.maneyjournals.org/content/.)

observe these teeth for at least 12 months prior to respond to orthodontic forces) and subsequently
orthodontic movement,18 monitor traumatic monitor the teeth for 8 weeks as temporary
teeth for signs of ankylosis (mainly failure to ankylosis had been reported in the literature.26
68 Duggal et al

Auto-transplantation to review these teeth clinically and radio-

graphically at 1, 3 and 12 months and then
Auto-transplantation has been successfully used
annually.
in replacement of traumatised teeth with poor
long-term prognosis such as ankylosed teeth,
Summary
non-vital immature teeth following cervical
resorption and teeth with uncontrolled internal Dentoalveolar trauma to anterior teeth in chil-
or external inflammatory resorption. This treat- dren and adolescents has important implications
ment modality, however, is only recommended that require the orthodontist to have an intricate
for motivated patients with good oral hygiene knowledge of the implications of such injuries on
and good compliance in addition to orthodontic treatment planning. Careful monitoring of such
needs dictating extraction of at least one pre- teeth for both pulp vitality and root resorption
molar. The prognosis of these teeth is shown to during active tooth movement is required. For
be excellent with success rates of between 87% this reason, a close liaison with paediatric dentists
and 93%, while survival rates are reported to be is essential. Multidisciplinary care, especially in
between 90% and 98%.49 cases where there is severe trauma resulting in
This biological treatment promotes bone irreversible root resorption or tooth loss, ensures
generation and allows orthodontic tooth move- that clinicians can work with growth and devel-
ment of transplanted teeth (Fig. 4). Careful opment. This will give the child not only an
interdisciplinary management is essential for excellent long-term aesthetic outcome but also
the successful management of these cases. The one that is founded in biological management of
orthodontic team should do the following: the child. Auto-transplantation is one such
example where multidisciplinary care can result
1. Consider the patient's overall orthodontic in working with biological processes that ensures
needs and decide on the best treatment plan an excellent long-term outcome for the child as
for that patient. they grow into young adults.
2. Decide which teeth to extract. The mandib-
ular first and second premolars are partic-
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 Seminars in Orthodontics
Future Issues
Vol 21 No 2 (June 2015)
JUVENILE IDIOPATHIC ARTHRITIS
Bjørn Øgaard, DDS

Recent Issues
Vol 20 No 4 (December 2014)
ALL ROADS LEAD TO ROME: NEW DIRECTIONS FOR CLASS II
S. Jay Bowman, DMD, MSD, FACD, FICD, Guest Editor
Vol 20 No 3 (September 2014)
PERIODONTAL-ORTHODONTIC INTERACTIONS
Ramzi V. Abou-Arraj, DDS, MS, Guest Editor
Vol 20 No 2 (June 2014)
AGE-APPROPRIATE ORTHODONTIC TREATMENT, PART II
Gerry Samson, DDS, and Elliott M. Moskowitz, DDS, MSd, Guest Editors
Vol 20 No 1 (March 2014)
AGE-APPROPRIATE ORTHODONTIC TREATMENT, PART I
Elliott M. Moskowitz, DDS, MSd, and Gerry Samson, DDS, Guest Editors
Vol 19 No 4 (December 2013)
THE VERTICAL DIMENSION IN ORTHODONTICS
Nada M. Souccar, DDS, MS, Guest Editor
Vol 19 No 3 (September 2013)
EVIDENCE-BASED ORTHODONTICS
Katherine Vig, BDS, MS, FDS, DOrth, and Greg Huang, DMD, MSD, MPH, Guest Editors
Vol 19 No 2 (June 2013)
PROGRESSIVE CONDYLAR RESORPTION AND DENTOFACIAL DEFORMITIES
Chester S. Handelman, DMD, and Charles S. Greene, DDS, Guest Editors
Vol 19 No 1 (March 2013)
INTERDISCIPLINARY TREATMENT OF ADOLESCENTS WITH MISSING ANTERIOR TEETH
Mark R. Yanosky, DMD, MS, Guest Editor
Vol 18 No 4 (December 2012)
UPDATES ON THE BIOLOGICAL FOUNDATIONS OF ORTHODONTIC TOOTH MOVEMENT
Vinod Krishnan, BDS, MDS, M Orth RCS D, PhD, and Ze’ev Davidovitch, DMD, Cert Ortho, Guest Editors
Vol 18 No 3 (September 2012)
AN OVERVIEW OF FACIAL ATTRACTIVENESS FOR ORTHODONTISTS
Margaret Collins, BDS, FDSRCPS, DOrth, MSc, MOrthRCS, MA, Guest Editor
Vol 18 No 2 (June 2012)
MAXILLARY EXPANSION AND MANDIBULAR WIDENING: TREATMENT METHODS AND STABILITY
Haluk İ şeri, DDS, PhD, Guest Editor
Vol 18 No 1 (March 2012)
FUNCTION AND DYSFUNCTION OF THE TEMPOROMANDIBULAR JOINT
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Vol 17 No 4 (December 2011)
PRACTICE MANAGEMENT AND MARKETING
Peter M. Sinclair, DDS, MSD, and Ellen M. Grady, BA, Guest Editors
Vol 17 No 3 (September 2011)
CRANIOFACIAL ORTHODONTICS II
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Vol 17 No 2 (June 2011)
TREATMENT OF CLASS III MALOCCLUSIONS WITH SKELETAL ANCHORAGE
Peter W. Ngan, DMD, Guest Editor