ORIGINAL ARTICLE

Morphologic evaluation of dentoalveolar

structures of mandibular anterior teeth during
augmented corticotomy-assisted
decompensation
Hyo-Won Ahn,a Dong-Hwi Seo,b Seong-Hun Kim,c Young-Guk Park,d Kyu-Rhim Chung,e and Gerald Nelsonf
Seoul, Korea, and San Francisco, Calif

Introduction: Our aim in this study was to evaluate the effect of augmented corticotomy on the decompensation
pattern of mandibular anterior teeth, alveolar bone, and surrounding periodontal tissues during presurgical ortho-
dontic treatment. Methods: Thirty skeletal Class III adult patients were divided into 2 groups according to the
application of augmented corticotomy labial to the anterior mandibular roots: experimental group (with
augmented corticotomy, n 5 15) and control group (without augmented corticotomy, n 5 15). Lateral cephalo-
grams and cone-beam computed tomography images were taken before orthodontic treatment and before
surgery. The measurements included the inclination and position of the mandibular incisors, labial alveolar
bone area, vertical alveolar bone height, root length, and alveolar bone thickness at 3 levels surrounding the
mandibular central incisors, lateral incisors, and canines. Results: The mandibular incisors were significantly
proclined in both groups (P \0.001); however, the labial movement of the incisor tip was greater in the experi-
mental group (P \0.05). Significant vertical alveolar bone loss was observed only in the control group
(P \0.001). The middle and lower alveolar thicknesses and labial alveolar bone area increased in the experi-
mental group. In the control group, the upper and middle alveolar thicknesses and labial alveolar bone area
decreased significantly. There were no significant differences in dentoalveolar changes between the 3 kinds
of anterior teeth in each group, except for root length in the experimental group (P \0.05). Conclusions:
Augmented corticotomy provided a favorable decompensation pattern of the mandibular incisors, preserving
the periodontal structures surrounding the mandibular anterior teeth for skeletal Class III patients. (Am J
Orthod Dentofacial Orthop 2016;150:659-69)

a
Assistant professor, Department of Orthodontics, Graduate School, Kyung Hee
University, Seoul, Korea.
b
Postgraduate student, Department of Orthodontics, Graduate School, Kyung
Hee University, Seoul, Korea.
c
Professor and chair, Department of Orthodontics, Graduate School, Kyung Hee
University, Seoul, Korea.
d
Professor, Department of Orthodontics, Graduate School, Kyung Hee University,
Seoul, Korea.
e
Clinical professor, Department of Orthodontics, Graduate School, Kyung Hee
University, Seoul, Korea.
f
Clinical professor, Division of Orthodontics, Department of Orofacial Science,
University of California, San Francisco, Calif.
Hyo-Won Ahn and Dong-Hwi Seo are joint first authors and contributed equally
to this work.
All authors have completed and submitted the ICMJE Form for Disclosure of
Potential Conflicts of Interest, and none were reported.
Supported by the National Research Foundation of Korea, funded by the Korean
government (MEST; no. 2012R1A5A2048310).
Address correspondence to: Seong-Hun Kim, Department of Orthodontics,
Kyung Hee University School of Dentistry, 1 Hoegi-Dong, Dongdaemun-Gu,
Seoul 130-701 Korea; e-mail, bravortho@gmail.com.
Submitted, June 2015; revised and accepted, March 2016.
0889-5406/$36.00
Ó 2016 by the American Association of Orthodontists. All rights reserved.
http://dx.doi.org/10.1016/j.ajodo.2016.03.027
P
resurgical orthodontic treatment is typically
necessary to correct compensated tooth positions
that result from undesirable jaw growth. Correct-
ing the dental compensations allows the most favorable
positioning of the jaw segments during surgery and per-
mits a more accurate and stable occlusion after surgery.
In the correction of Class III malocclusion, decompensa-
tion of the mandibular anterior teeth labially to an ideal
relationship to the supporting bone will allow the best
improvement of facial esthetics after surgery. However,
labial incisor movement can be limited by the alveolar
housing. A previous study has shown that excessive
labial incisor movement is associated with dehiscence
of the labial bone.1 The authors found a high correlation
between the labiolingual inclination of the teeth and the
frequency of dehiscence or gingival recession.1,2
Recently, cone-beam computed tomography (CBCT)
has been an indispensable diagnostic imaging tool for
dentoalveolar evaluation.3 CBCT studies of skeletal
659
660 Ahn et al

Class III patients after orthodontics and orthognathic

Table I. Demographic data of the patients
surgery have confirmed that mandibular incisors experi-
ence more vertical alveolar bone loss than do maxillary Experimental Control
incisors, and the alveolar bone becomes thin at the group group Total
(n 5 15) (n 5 15) (n 5 30)
root apex area.4 Particularly, labioversion of the mandib-
ular anterior teeth induces decreases of alveolar bone Measurement Mean SD Mean SD Mean SD
and thickness of bone around the mandibular incisors.5 SNA (
) 83.45 3.53 82.01 2.38 82.73 3.04
SNB (
) 86.56 4.50 85.99 2.66 86.27 3.65
Augmented corticotomy has been reported as a
ANB (
) 3.11 2.67 3.98 2.47 3.54 2.56
method to achieve sufficient labioversion of the mandib- SN-MP (
) 32.95 8.72 32.76 4.68 32.85 6.88
ular anterior teeth while minimizing gingival recession FMA (
) 25.98 7.50 25.61 3.47 25.80 5.75
and alveolar bone loss. Before orthodontic forces are Age (y) 23.06 6.16 21.51 3.34 22.29 4.94
applied, the clinician performs selective decortications Treatment 8.73 2.46 10.87 2.45 9.80 2.65
around the target teeth and alveolar bone grafting duration (mo)
with particulate bone grafting material.6 This technique
has been used to achieve the regional acceleratory phe- mandibular central incisor position, according to the
nomenon,7,8 resulting in accelerated tooth movement,9 application of augmented corticotomy: experimental
with the benefit of maintaining sound a periodontium group (with augmented corticotomy; n 5 15 [7 men,
at the end of orthodontic treatment.10,11 8 women]; mean age, 23.06 6 6.16 years) and control
In a preliminary study, we reported using this tech- group (without augmented corticotomy; n 5 15 [7
nique based on the lateral cephalometric analyses of men, 8 women]; mean age, 21.51 6 3.34 years). The
15 skeletal Class III patients who had orthognathic sur- augmented corticotomy was performed when the
gery after decompensation of the mandibular anterior amount of labioversion of the mandibular incisors
teeth.12 The augmented corticotomy provided effective (IMPA changes) was planned to be more than 5
, and
decompensation of the mandibular incisors in skeletal the labial alveolar bone thickness of the mandibular in-
Class III patients while maintaining labial bone thickness cisors was less than 1 mm. Five patients had 1-jaw sur-
and with few periodontal side effects. The pilot study gery, and 10 patients had 2-jaw surgery in the
had a small sample size, and the lateral cephalometric experimental group; 3 patients had 1-jaw surgery, and
x-rays provided compromised evaluations of the den- 12 patients had 2-jaw surgery in the control group.
toalveolar regions of individual teeth. Recent studies The mean periods of presurgical orthodontic treat-
have reported on augmented corticotomy in the ment were 8.7 months in the experimental group and
mandibular anterior regions with CBCT in Class III pa- 10.9 months in the control group, from the first medical
tients.13,14 Although the images are more accurate, the examination to the orthognathic surgery. The study
studies had small sample sizes and no control groups, was performed with the approval of the institutional re-
and evaluated only incisors. Most studies have used view board of Kyung Hee University Dental Hospital
the guided bone regeneration technique with collagen (KHU-IRB-1208-01). The inclusion criteria were bilateral
membranes.13-15 The mandibular canines are the high- skeletal and dental Class III relationships, without severe
risk sites of dehiscence; a comprehensive study of facial asymmetry (\5 mm of lower midline deviation
this problem should include the canines as well as the from the facial midline), mild to moderate crowding in
incisors.16 the mandibular arch (\5 mm), no missing or malformed
The purpose of this study was to elucidate the effect teeth, and no recession of attached gingiva or alveolar
of augmented corticotomy applied in skeletal Class III bone loss on the mandibular anterior teeth.
patients before presurgical orthodontic treatment to All patients had orthodontic treatment with a 0.022-
decompensate the mandibular anterior teeth, including in Roth prescription appliance, fully bonded to the
the central incisors, lateral incisors, and canines. second molars. Augmented corticotomy, with patient
consent, was performed after or right before the attach-
MATERIAL AND METHODS ment of the brackets. Crevicular incision on the labial
The subjects in this retrospective study included 30 side of the gingiva from the mandibular left second pre-
adult patients characterized by skeletal Class III maloc- molar to the mandibular right second premolar preceded
clusion who had orthognathic surgery at the Department the full-thickness flaps. Vertical corticotomy was per-
of Orthodontics at the Kyung Hee University Dental Hos- formed in the cortical plate between the teeth with a
pital in Seoul, Korea (Table I). They were divided into 2 number 2 round bur or a piezoelectric surgical device.
groups, matched for age, sex, and pretreatment The range of vertical corticotomy was from 2 to 3 mm

October 2016  Vol 150  Issue 4 American Journal of Orthodontics and Dentofacial Orthopedics
Ahn et al
Fig 1. Augmented corticotomy in the mandibular anterior area: A, after a full-thickness flap using a
sulcular incision, with a vertical releasing incision added at the premolar area, circumscribing the cor-
ticotomy cut with low speed (number 2 round bur) or a piezoelectric surgical device; B, bone augmen-
tation by xenograft; C, after suture with 5-0 or 6-0 nylon.
below the crest of the alveolar bone to 2 to 3 mm below
the apex. Then, a horizontal corticotomy was performed
2 to 3 mm below the apices. The horizontal corticotomy
line was connected to the vertical corticotomy lines,
completing a circumscribed corticotomy (Fig 1, A).
When bleeding was sufficient after the corticotomy,
bone augmentation was done between the labial alve-
olar bone and the gingival flap using mineralized and
deproteinized bovine bone mineral (Bio-Oss; Geistlich
Pharma, Wolhusen, Switzerland) (Fig 1, B).17 After the
interdental papillae and flap were repositioned, vertical
everting mattress sutures were placed with 5-0 or 6-0
nylon (Fig 1, C). The sutures were removed a week after
surgery. A 0.016 3 0.022-in rectangular nickel-titanium
wire was engaged to begin decompensation on the same
day. The process of treatment was explained in detail in
our previous article.18
To analyze the lateral cephalometric x-ray, 2 lateral
cephalograms, taken before orthodontic treatment
and before surgery (completion of preoperative ortho-
dontic treatment), were measured with the PiView
STAR program (Infinit Technology, Seoul, Korea). To
evaluate the variations of inclination of the mandib-
ular anterior teeth and the amount of decompensation
of the mandibular incisors, the rater (D-H.S.) set the
baselines and points, and measured IMPA and the
shortest distance between the crown tip of the
mandibular central incisor and the perpendicular line
to the mandibular plane, drawn from menton (menton
vert-L1) (Fig 2).
Two CBCT images, taken before orthodontic treat-
ment and before surgery (completion of preoperative or-
thodontic treatment), were analyzed with the InVivo
Dental program (Anatomage, San Jose, Calif). These
scans were taken with a CBCT device (Alphard-3030;
Asahi Roentgen, Kyoto, Japan) with dosimetry parame-
ters of 10 mA, 80 kV, and 17-second scan time.
American Journal of Orthodontics and Dentofacial Orthopedics
661
I mode (0.15 mm3 voxel size) with a field of view that
included the anterior dentition and the body of
mandible was used. The CBCT raw data of both groups
were gathered without any marks, randomly mixed,
and sequentially numbered before evaluation. When
the second evaluation was performed after 2 weeks,
the data were randomly mixed again and assigned new
numbers. The rater set the baselines and points, and
measured the labial alveolar bone area (LABA), vertical
alveolar bone level, root length, and upper, middle,
and lower alveolar bone thicknesses on the labial side
(Fig 3).
Statistical analysis
All measurements were repeated by the same oper-
ator (S-H.K.) after 2 weeks. The 6 mandibular anterior
teeth were divided into 2 groups. The CBCT measure-
ments of the mandibular left teeth were assigned
numbers from 1 to 15, and the right teeth were as-
signed numbers from 16 to 30. Since there were no
differences in the values of all variables between the
right and left sides, the data were combined to
develop the statistical analysis. The mean of the 2
measurements was used for this study. The differences
ranged from 0.26 to 0.34 mm for linear measure-
ments, from 0.24
to 0.45
for angular measurements,
and from 0.32 to 0.46 mm2 for area measurements,
according to Dahlberg's formula.19 The independent
t test was performed for the comparisons between
the 2 groups, the paired t test was used for the com-
parisons between baseline and after decompensation
in each group, and 1-way analysis of variance with
the Duncan multiple comparison test was used for
the comparisons between the central incisors, lateral
incisors, and canines. The P \0.05 level of signifi-
cance was chosen for all tests.
October 2016  Vol 150  Issue 4
662 Ahn et al

Fig 2. Treatment progress in the experimental (augmented corticotomy) group on A, lateral cephalo-
grams and B, cephalometric measurements. 1, IMPA; 2, menton vert-L1 (shortest distance between
the tip of the mandibular central incisor and the perpendicular line to the mandibular plane, drawn
from menton).

Fig 3. Variables in CBCT: A, LABA, the alveolar bone area of the labial side of the sagittal plane of the 6
mandibular anterior teeth); B, vertical alveolar bone level (CEJ-crest, the distance from the cementoe-
namel junction of the 6 mandibular anterior teeth to the labial alveolar bone crest measured on the
sagittal plane); C, root length (distance from the labial cementoenamel junction of the 6 mandibular
anterior teeth to the root apex, measured parallel to the long axis of the tooth on the sagittal plane);
upper (D1), middle (D2), and lower (D3) alveolar thicknesses (labial alveolar thickness on sagittal plane
as a distance from the root surface of the 6 mandibular anterior teeth to the labial surface of the alveolar
bone, measured perpendicular to the long axis of the tooth at 3 evenly divided points).

RESULTS
We looked at the decompensation pattern of the
mandibular incisors using lateral cephalograms
(Table II). The changes of IMPA were statistically signif-
icant in both the experimental and control groups
(P \0.001). The average changes of IMPA were 7.51

(from 78.55
to 86.05
) in the experimental group and
5.31
(from 78.57
to 83.87
) in the control group.
The variation of menton vert-L1 was also statistically
significant in the groups (both, P \0.001). The average
change of menton vert-L1 was 2.35 mm in the experi-
mental group, which was almost double compared
with the change in the control group (1.14 mm). When
comparing the 2 groups, only the labial movement of
the incisor crown tip (menton vert-L1) showed a signif-
icant difference (P \0.05).
Dentoalveolar changes surrounding the mandibular
anterior teeth were seen in the CBCT images (Figs 4
and 5). For the mandibular canines, there was a
statistically significant vertical alveolar bone loss
(CEJ-crest) in the control group (P \0.001; Table III).
There was a slight vertical alveolar bone gain in the
experimental group, although it was not statistically
significant. After decompensation, the upper and

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Ahn et al 663

Table II. Angular and vertical changes of mandibular incisors during presurgical decompensation in lateral cephalo-
grams
Experimental group (n 5 15) Control group (n 5 15) Comparison
between
Before After Before After groups
Mean SD (IQR) Mean SD (IQR) P value* Mean SD (IQR) Mean SD (IQR) P value* P valuey


IMPA ( ) 78.55 4.25 (6.00) 7.51 5.68 (9.90) 0.0002§ 78.57 6.12 (8.00) 5.31 3.67 (8.10) 0.0001z 0.2184
Menton 9.77 2.95 (4.50) 2.35 1.63 (1.98) 0.0001§ 9.77 4.17 (4.60) 1.14 0.76 (1.50) 0.0000z 0.0145z
vert-L1 (mm)
IQR, Interquartile range; IMPA, incisor mandibular plane angle; Menton vert-L1, the shortest distance between the crown tip of mandibular central
incisor and the perpendicular line to the mandibular plane, drawn from menton.
*Paired t test was performed for comparison between before and after decompensation in each group; yindependent t test was performed for
comparing the mean differences between the groups.
z
P \0.05; §P \0.001.

Fig 4. CBCT images A, before and B, after decompensation in the control group. 1, Mandibular left
canine; 2, mandibular left lateral incisor; 3, mandibular left central incisor; 4, mandibular right central
incisor; 5, mandibular right lateral incisor; 6, mandibular right canine.

middle alveolar thicknesses in the control group
decreased with statistical significance (P \0.001). The
upper alveolar thickness in the experimental group
also decreased (P \0.05), whereas the middle and
lower alveolar thicknesses increased (lower thickness,
P \0.001). Labial alveolar bone area decreased in the
control group and increased in the experimental group
(both, P \0.001). Root length in both groups
decreased with statistical significance (P \0.001).
When we compared the measurement changes between

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664 Ahn et al

Fig 5. CBCT images A, before and B, after decompensation in the experimental group. 1, Mandibular
left canine; 2, mandibular left lateral incisor; 3, mandibular left central incisor; 4, mandibular right central
incisor; 5, mandibular right lateral incisor; 6, mandibular right canine.

groups, all measurements showed significant differ-
ences except for root length and upper alveolar thick-
ness (LABA; CEJ-crest, middle and lower alveolar
thicknesses; all P \0.001).
For the mandibular lateral incisors, there was a sig-
nificant vertical alveolar bone loss in the control group
(4.24 mm; P \0.001), whereas it was well preserved in
the experimental group (Table III). After decompensa-
tion, the upper and middle alveolar thicknesses in the
control group decreased with statistical significance
(both, P \0.001). In the experimental groups, the
change of upper alveolar thickness was negligible, and
the middle and lower alveolar thicknesses increased
significantly (both, P \0.001).The labial alveolar bone
decreased in the control group (P \0.001) and increased
in the experimental group (P \0.01). Root lengths
decreased in both groups (P \0.001). When we
compared the measurement changes between groups,
all measurements showed significant differences except
root length and upper alveolar thickness (LABA; CEJ-
crest, middle and lower thickness; all P \0.001).
For the mandibular central incisors, there was signif-
icant vertical alveolar bone loss in the control group
(3.57 mm; P \0.001), whereas it was well maintained
in the experimental group (Table III). After decompensa-
tion, the upper and middle alveolar thicknesses in the
control group decreased with statistical significance
(both, P \0.001). In the experimental group, significant
increases of alveolar thickness were observed in the mid-
dle and lower areas (both, P \0.001). Labial alveolar
bone area decreased in the control group (P \0.001)
and increased in the experimental group (P \0.01).
Root length in both groups decreased with statistical sig-
nificance (P \0.001). All measurements showed signifi-
cant differences between groups except root length (all,
P \0.001).
In the comparison between the 3 kinds of anterior
teeth, there were no significant differences in their den-
toalveolar changes in the groups, except for root length
in the experimental group (P \0.05; Table IV). The
length of the canine roots decreased more than did the
roots of the lateral incisors.

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 American Journal of Orthodontics and Dentofacial Orthopedics

Ahn et al
Table III. Alveolar bone changes around mandibular anterior teeth during presurgical decompensation
Comparison
between
Experimental group (n 5 15) Control group (n 5 15) groups

T0 T1 T0 T1 At T0 T1-T0

Mean SD (IQR) Mean SD (IQR) P value* Mean SD (IQR) Mean SD (IQR) P value* P valuey P valuey
Central incisors
LABA (mm2) 3.77 1.84 (2.19) 6.61 5.72 (6.12) 0.0068§ 5.23 2.22 (3.17) 2.94 2.84 (4.45) 0.0003k 0.0074§ 0.0000k
CEJ-crest (mm) 4.88 3.75 (6.83) 4.26 2.85 (4.80) 0.4042 2.05 1.71 (0.97) 5.63 3.41 (6.87) 0.0000k 0.0011§ 0.0000k
Root length (mm) 10.86 1.07 (1.79) 10.27 1.08 (1.35) 0.0000k 11.11 0.74 (1.08) 10.41 0.68 (1.22) 0.0000k 0.4289 0.4535
Upper bone thickness (mm) 0.51 0.29 (0.32) 0.45 0.33 (0.64) 0.2477 0.71 0.29 (0.41) 0.26 0.35 (0.55) 0.0000k 0.0133z 0.0000k
Middle bone thickness (mm) 0.31 0.20 (0.19) 0.67 0.41 (0.66) 0.0001k 0.48 0.18 (0.17) 0.26 0.36 (0.49) 0.0002k 0.0001k 0.0000k
Lower bone thickness (mm) 0.31 0.27 (0.38) 1.46 1.18 (1.38) 0.0000k 0.46 0.23 (0.18) 0.46 0.63 (0.65) 0.9771 0.0070§ 0.0000k
Lateral incisors
LABA 5.13 2.67 (3.79) 10.11 7.73 (10.53) 0.0020§ 6.47 2.75 (3.80) 4.04 3.44 (4.84) 0.0003k 0.0617 0.0000k
CEJ-crest 4.46 4.07 (7.77) 4.25 2.80 (4.69) 0.3474 1.79 0.92 (1.51) 6.03 3.52 (7.28) 0.0000k 0.0071§ 0.0000k
Root length 11.96 1.26 (1.63) 11.16 1.14 (1.86) 0.0000k 12.50 1.21 (0.93) 11.77 1.05 (1.47) 0.0000k 0.1624 0.4535
Upper bone thickness 0.64 0.31 (0.41) 0.58 0.51 (0.91) 0.5395 0.72 0.40 (0.37) 0.31 0.43 (0.65) 0.0000k 0.3911 0.0000k
Middle bone thickness 0.33 0.14 (0.15) 0.85 0.64 (0.85) 0.0001k 0.43 0.17 (0.16) 0.22 0.36 (0.36) 0.0002k 0.0065§ 0.0000k
Lower bone thickness 0.40 0.46 (0.41) 1.99 1.15 (1.53) 0.0000k 0.48 0.28 (0.29) 0.56 0.84 (0.85) 0.9771 0.0158z 0.0000k
Canines
LABA 6.86 4.41 (5.17) 11.37 7.04 (9.75) 0.0004k 9.20 5.83 (6.17) 7.09 5.60 (8.21) 0.0657 0.0385z 0.0001k
CEJ-crest 7.43 4.44 (9.15) 6.58 3.04 (4.49) 0.3420 4.37 4.28 (7.83) 8.63 3.60 (4.85) 0.0000k 0.0156z 0.0001k
Root length 13.56 1.81 (3.10) 13.14 1.68 (2.65) 0.0000k 14.40 1.25 (1.70) 13.81 1.37 (2.24) 0.0000k 0.0415z 0.2213
October 2016  Vol 150  Issue 4

Upper bone thickness 0.51 0.39 (0.68) 0.28 0.35 (0.59) 0.0340z 0.60 0.33 (0.30) 0.15 0.31 (0.00) 0.0000k 0.5045 0.0785
Middle bone thickness 0.25 0.25 (0.41) 0.44 0.54 (0.91) 0.1112 0.38 0.24 (0.30) 0.10 0.23 (0.00) 0.0000k 0.0163z 0.0006k
Lower bone thickness 0.53 0.58 (0.90) 1.79 1.12 (1.68) 0.0000k 0.73 0.71 (0.70) 0.93 1.11 (1.68) 0.2893 0.1357 0.0005k

T0, Before treatment; T1, after preoperative treatment; IQR, interquartile range; LABA, labial alveolar bone area; CEJ-crest, distance from the cementoenamel junction of the anterior teeth to the
labial alveolar bone crest.
*Paired t test was performed for comparisons before and after decompensation in each group; yindependent t test was performed for comparison of the mean differences between the 2 groups.
z
P \0.05; §P \0.01; kP \0.001.

665
666 Ahn et al

DISCUSSION

P value
0.9612
0.7154
0.6756
0.8641

0.5734

0.6153
For treatment of mandibular prognathism, decom-
pensation of the mandibular anterior incisors is a crucial
6.04 (6.47)
4.31 (7.39)
0.66 (0.99)
0.34 (0.38)

0.25 (0.46)

1.04 (1.30)
SD (IQR)
element that divides treatment outcomes into
adequately and inadequately treated groups.20 However,
Canines

labial movement of the incisors that exceeds the alveolar

housing is associated with gingival recession or alveolar
2.11
4.26

0.20
0.59
0.45

0.28
Mean

bone loss.4,21 In particular, a hyperdivergent jaw pattern

Control group (n 5 30)

IQR, Interquartile range; LABA, labial alveolar bone area; CEJ-crest, distance from the cementoenamel junction of the anterior teeth to the labial alveolar bone crest.
increases the risk because it is accompanied by a thin
symphysis and vertical elongation of the incisors,
0.74 (0.75)
3.55 (4.81)
3.43 (6.62)
0.75 (1.17)
0.32 (0.56)

0.34 (0.47)
SD (IQR)
Lateral incisors

increasing the likelihood of periodontal side effects.22

Our results proved that augmented corticotomy
increased the continuity of alveolar bone and the peri-
0.08
4.24
2.43

0.73
0.41

0.20
Mean

One-way analysis of variance with the Duncan multiple comparison test for the comparisons between central incisors, lateral incisors, and canines.

odontal support that surrounds the labial root surface;

these would contribute to reducing the possibility of
periodontal side effects during decompensation.
0.63 (0.68)
3.19 (5.99)
3.02 (3.27)

0.47 (0.62)
0.29 (0.37)

0.29 (0.45)
SD (IQR)
Central incisors

Augmented corticotomy has the additional benefit of

Table IV. Comparison of alveolar bone changes around mandibular anterior teeth according to tooth type

accelerating tooth movement by the regional accelera-

tory phenomenon while maintaining a structurally intact
0.00
3.57
2.29

0.69
0.45

0.22
Mean

periodontium. The most encouraging point was that

buccal crestal bone height and upper alveolar bone
thickness were well preserved despite the stress concen-
0.0403* (3,1).(1,2)

tration during labial tipping. Some clinical studies have

comparison
Multiple

shown that vertical alveolar bone loss still occurs in an

P value

0.3313
0.4205
0.6163

0.1144
0.2899

augmented corticotomy group, although it was reported

to be less than in the control group.13,15 Animal studies
using histologic examinations of the periodontal
reaction to augmented corticotomy combined with
1.18 (1.37)
6.14 (6.41)
4.85 (6.32)

0.66 (1.06)
0.42 (0.75)
0.57 (0.75)
SD (IQR)

significant buccal tipping have confirmed reformation

of the buccal bone crest in the coronal direction along
Canines
Experimental group (n 5 30)

the root surface.23,24

This is the first study to evaluate the alveolus sur-
1.26
4.52

0.20
0.86
0.41
0.23
Mean

rounding all anterior teeth including the central incisors,

lateral incisors, and canines after augmented cortico-
8.00 (8.03)

1.24 (1.38)
0.62 (0.77)
5.12 (7.19)
0.69 (0.81)
0.52 (0.82)

tomy. Nimigean et al16 noted that dehiscence occurred

SD (IQR)
Lateral incisors

more frequently in the mandibular canines in the 138

dry skulls ranging from 21 to 54 years of age. Since
the position and root morphology of canines are quite
4.97
0.21
0.80

0.51

1.59
0.06
Mean

different from those of incisors, we wondered whether

the effect of augmented corticotomy is similar between
5.34 (5.40)
4.03 (4.27)
0.58 (0.98)
0.30 (0.40)

0.44 (0.75)

1.16 (1.07)

incisors and canines. Our results showed that the favor-

SD (IQR)
Central incisors

able response attributed to augmented corticotomy was

observed in all anterior teeth, and there was little differ-
ence in the dentoalveolar changes between the incisors
2.84
0.62
0.59
0.06

0.37

1.15
Mean

and the canines. In the canines, the upper alveolar thick-

ness slightly decreased, but the vertical height of the
Middle bone thickness

alveolar crest was preserved, and the middle and lower

Lower bone thickness
Upper bone thickness

alveolar thicknesses increased; this was also true for

Root length (mm)
CEJ-crest (mm)

the incisors.
LABA (mm2)

IMPA and menton vert-L1 values were used to quan-

*P \0.05.
(mm)

(mm)

(mm)

tify the amount of decompensation of the mandibular

anterior teeth in this study. IMPA was deemed relevant

October 2016  Vol 150  Issue 4 American Journal of Orthodontics and Dentofacial Orthopedics
Ahn et al
Fig 6. Decompensation pattern of the mandibular incisors: A, control group; B, experimental group.
Although the changes of IMPA values in the 2 groups were similar, the labial movement of the incisal
tip in the experimental group was greater than that of the control group. There was a significant vertical
bone loss in the control group.
because it is not affected by mandibular rotation. How-
ever, IMPA does not differentiate between the types of
tooth movement, such as controlled tipping vs uncon-
trolled tipping. Since the anteroposterior position and
inclination of the mandibular incisors affects the
amount of mandibular setback in the orthognathic sur-
gery, careful analysis is warranted. We used the menton
vert-L1 value to evaluate it. Our results showed that the
changes of IMPA were similar between groups, whereas
menton vert-L1 was almost double in the augmented
corticotomy group. That is because in the experimental
group, the incisor movement was controlled tipping
(fulcrum at the apex); in the control group, it was un-
controlled (apex moved lingual) (Fig 6). This can allow
more mandibular setback movement during the orthog-
nathic surgery in the experimental group than in the
control group. Because lingual movement of the root
apex during uncontrolled tipping of the mandibular
anterior teeth greatly affects mandibular alveolar thick-
ness and LABA, they would be less important to the clin-
ical outcome than the upper and middle alveolar
thicknesses.
One controversial issue in augmented corticotomy is
whether to place a barrier membrane over the bone
grafts. It is difficult to hold the position of the bone graft
materials because augmented corticotomy is performed
on a 1-walled defect area. Without the membrane, bone
graft materials gathered at the apical third area of the
experimental group after the decompensation.12 Previ-
ous studies have suggested applying the absorbable
collagen membrane combined with augmented cortico-
tomy to improve clinical outcomes.13-15 However, even
with the membrane, the authors observed similar
changes in alveolar bone morphology: ie, increased
American Journal of Orthodontics and Dentofacial Orthopedics
667
alveolar bone volume in the apical third than in the
cervical third area. Similarly, histologic findings in an
animal study showed that new bone formation and
alveolar bone height in the buccal wall were not
directly affected by the use of the absorbable collagen
membrane in an augmented corticotomy.23 The 1 posi-
tive effect of the absorbable collagen membrane was to
promote an even surface in the middle and apical areas
of buccal bone.23 We also obtained favorable responses
on the incisal third area of the alveolus and alveolar crest
without using the barrier membrane. Further study is
necessary to establish the best protocol of augmented
corticotomy using the criteria of long-term stability, pa-
tients’ convenience, and technique sensitivity.
In regard to root resorption, there was no statistically
significant difference between the groups. In the
augmented corticotomy group, more root resorption
occurred on the canines than on the incisors, but the
amount was clinically insignificant. In our study, corti-
cotomy was performed only on the labial side (not on
both labial and lingual sides); this probably did not elim-
inate the hyalinization that occurs when root apices are
moved against the lingual cortical plate during incisor
proclination. Moreover, some have reported that the
use of graft materials such as deproteinized bovine
bone mineral or synthetic materials would cause root
resorption.17,24 The surgical design of the corticotomy
and the types of graft materials should be considered
in further studies.
Up to now, there have been few studies regarding the
long-term quality of the bone after tooth movement
combined with corticotomy. The graft material used in
our study is well known for its slow turnover and inte-
gration to become the host's own bone; therefore, the
October 2016  Vol 150  Issue 4
668
long-term status of the labial augmented bone site
should be evaluated in further studies. Recently, Wilcko
et al25 reported long-term stability of augmented corti-
cotomy with orthodontic treatment by evaluating the
keratinized gingiva. The keratinized gingival height
increased after augmented corticotomy at 1.5 years after
debonding. With regard to orthodontic retention, Makki
et al26 reported that orthodontic therapy combined with
augmented corticotomy enhanced the stability of the
postorthodontic mandibular irregularity index for at
least 10 years. We have been gathering the retention
CBCT data of the corticotomy group, and further study
will include the long-term bone quality after augmented
corticotomy.
The limitation of this retrospective study was a statis-
tically significant difference in alveolar bone quality at
pretreatment between the 2 groups. The experimental
group showed more vertical bone loss and a smaller alve-
olar bone area than did the control group at the initial
stage. Another limitation was that there has been no es-
tablished CBCT resolution for examination of alveolar
bone morphology. Although many studies showed that
CBCT renders anatomic measurements reliably and is
an appropriate tool for linear measurements,27,28 there
is still controversy regarding which voxel size is
appropriate to evaluate alveolar bone.29,30
CONCLUSIONS
In a comparison of 2 Class III malocclusion samples
matched for age, sex, and pretreatment mandibular cen-
tral incisor position, augmented corticotomy provided a
favorable outcome after decompensation of the
mandibular anterior teeth. In skeletal Class III patients
undergoing orthognathic surgery, the integrity of the
periodontal structures surrounding all mandibular ante-
rior teeth was preserved and, by some measurements,
improved. Augmented corticotomy can be a good
adjunctive procedure for skeletal Class III patients with
any risk factors that might contribute to periodontal
side effects as a result of presurgical orthodontic decom-
pensation.
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