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Associate Professor, Dept. of Orthodontics,
Kyung Hee University School of Dentistry,
Seoul, South Korea
Su-Jung Kim
Can we improve atrophic alveolar ridge
by surgically-assisted tooth movement?
Accelerated tooth movement
• Non-invasive Not clinically significant
• Minimally-invasive Not clinically significant enough
• Invasive Can be available, but less than 3 months
• Well-designed prospective clinical study is needed.
Surgically-assisted orthodontics
Osteogenic orthodontics
Corticision
Corticotomy Ridge augmentation
Micro-osteoperforation
osteotomy
Surgically-assisted orthodontics
Minimally-Invasive Cortical Activation
• Corticision
• Piezocision
• Piezopuncture
• Micro-osteoperforation
Osteotomy-assisted orthodontics
• Segmental osteotomy
• Individual tooth osteotomy
• Alveolar distraction osteogenesis
Corticotomy-facilitated orthodontics
• Block / Individual corticotomy
• Selective alveolar decortication
• Periodontally accelerated osteogenic orthodontics
Transient accelerating effect of OTM!
Surgically-facilitated orthodontics
Liem et al. British J Oral Maxillofac Surg 2015
Miles P. Australian Dent J 2017
El-Angbawi et al. Cochrane Database Systematic review 2015
Alfawal et al. Prog Orthod 2016
investigation on overall treatment time
well-controlled prospective clinical study
high level of evidence
Goal I. Reducing treatment time
Goal I. Reducing treatment time
Goal ll. Overcoming anatomical limitation
Surgically-assisted orthodontics
ATM into atrophic alveolar ridge
Part I. Orthodontic root thrusting
Part II. Surgically-assisted TM
Part III. Biomodulation-assisted TM
Ridge width around the moved tooth?
looked increased but by the tooth width
not by new bone formation.
Lindskog-Stokland et al. Eur J Orthod. 2013
OTM into atrophic alveolar ridge
with paradental improvement?
OTM into atrophic ridge in adults
1. Impaired tooth movement
2. Dehiscence & attachment loss
3. Lateral root resorption
Lindskog-Stokland et al . Eur J Orthod. 1993
Orthodontic solution for atrophic ridge
Bodily movement in case of a tooth with normal vertical periodontal support
“Orthodontic in vivo tissue engineering”
Root thrusting movement
W. Eugene Roberts. PCSO 2014
Birte Melsen. 2014
B
No intervention
Group C (n=4)
Root thrusting
Group R (n=6) Group RD (n=6)
Decortication
Hwang DH, Lee WJ, Baek SH, Kim KA, Park YG, Kim SJ. Angle Orthod 2017 in press with or without open-flap decortication
Response of atrophic ridge to Root thrusting
Can we improve atrophic ridge by Root thrusting?
Hwang DH, Lee WJ, Baek SH, Kim KA, Park YG, Kim SJ. Angle Orthod 2017 in press
Reciprocal root thrusting
bone density
bone volume
+ open-flap decortication
• Bone volume: N-S
• Bone density
• Rate of TM
Orthodontic approach for atrophic ridge
1. Growing patient
2. Teeth with normal marginal bone support
3. No severely constricted ridge thickness
4. Root-dominant movement
Surgical approach !
Part II. Surgically-assisted TM into atrophic ridge
Ridge augmentation Segmental osteotomy Flapless decortication
Demineralization; therapeutic osteopenia
Osteoid transportation
+
Osteoconduction
Remineralization; at the end of TM
“Bone matrix transportation”
Healing after augmented corticotomy
Shoreibah et al. J Int Aca Periodontol 2012
Wilcko, JOMS 2009
Amit et al. J Clin Exp Dent 2012
• Bone volume
• Bone density
; as long as TM is accompanied
1. Need high skill for flap surgery
2. Need waiting time before initiating TM
3. Risk of impaired TM & root resorption
4. Risk of graft failure (only-graft type)
Clinical efficacy for orthodontists?
Ru et al. Am J Orthod Dentofacial Orthop 2016
Healing after Flapless decortication
Microdamage
ATM
Transient Osteopenia
Less Hyalinization
Activation
Resorption
Formation
RAP
B
OTM OTM+ MOP
Group C (n=6) Group MOP (n=6)
Lee JW, Lee JH, Cha JY, Kim SJ. AJODO 2017 in review
Response of atrophic ridge to flapless MOP
Can we improve atrophic ridge by Decortication-TM?
Flapless decortication
• Bone volume: N-S
• Bone density
• Rate of TM
Post-surgical TM into osteotomy gap
Protraction of posteriors Retraction of anteriors
Midline correction
Wang et al, 2009
Osteotomy-assisted TM
- Fracture or DO-like healing
- No paradental osteopenia
Corticotomy-facilitated TM
- Transient local osteopenia
around roots by RAP
Healing after Osteotomy / Corticotomy
2015
Initiating TM at 0, 2, 12 weeks post-op.
Osteotomy + Graft +TM Osteotomy +TM
O-0 O-2 O-12 OG-0 OG-2 OG-12
TM at 2W post-osteotomy
• Bone volume: N-S
• Bone density
• Rate of TM
Immediate TM to grafted-osteotomy
Can we improve Osteotomy gap with ATM?
Can we improve Osteotomy-TM with biostimulation?
TM into Lased-grafted-osteotomy
• Bone volume N-S
• Bone density
• Rate of TM
Healing-based Orthodontics
1. Optimal timing to initiate post-surgical TM depends on
defect healing state: Target woven bone!
2. Biomodulation of healing state is promising to develop
a novel ATM procedure with periodontal regeneration.
Horizontal constriction
Marginal bone support
Surgically-assisted TM Orthodontic
root thrusting
Augmented
corticotomy Flapless
decortication
Segmental
osteotomy
Healing-based TM into atrophic ridge
Ex
pre
ss
ion
ch
an
ge
s
C D2 D6 DT6
-1.5
-0.5
0.5
1.5
Cluster 8
-1.5
-0.5
0.5
Cluster 1
C D2 D6 DT6
-1.0
0
1.0 Cluster 3
C D2 D6 DT6
-1.0
0
1.0 Cluster 2
C D2 D6 DT6
-1.0
0.0
1.0 Cluster 4
C D2 D6 DT6
-1.5
-0.5
0.5
1.5
Cluster 5
C D2 D6 DT6
-1.5
-0.5
0.5
1.5
Cluster 6
C D2 D6 DT6
-1.5
-0.5
0.5
1.5
Cluster 7
C D2 D6 DT6
8 clusters of differentially expressed genes
Mature lamellar bone
-
Delaying maturation
Immature woven bone Granulation tissue
+
Accelerating formation
Biomodulation of woven bone healing
SPP1
DMP1
MMPs
TNFSF11
CTSK
ACP5
Accelerated tooth movement (ATM)
ATM into alveolar defect
Controlled TM with periodontal regeneration
Further studies for tissue-regenerative ATM