Supracrestal fiberotomy is a technique for reducing
rotational relapse of orthodontically
aligned teeth. But the procedure is only one aspect
in the total care of the orthodontic patient,
which should include proper root paralleling,
Supracrestal fiberotomy
Ross G. Kaplan, BDS, MSD, P o rtla n d , Ore
D etails o f a su rg ica l te c h n iq u e to d iv id e th e free
g ing ival and transseptal fib e rs aro u n d rotated teeth
th a t have been co rre c te d o rth o d o n tic a lly are o u t­
lined. The rationa le o f th e p ro ce d u re , its a p p lic a ­
tio n s, in d ica tio n s, and c o n tra in d ic a tio n s are d is ­
cussed. S upracrestal fib e ro to m y is not a s u b stitu te
b u t an a d ju n c t to norm al re te n tio n procedures.
complete correction of rotations,
and correction of overbite.
The problem of rotational relapse o f orthodonti­
cally aligned teeth has been well recognized clini­
cally for many years. Reitan1 was the first to
identify an explanation for rotational relapse
when he demonstrated histologically in- dogs the
persistence o f tension in the free gingival
periodontal fibers seven months after teeth had
been rotated. His recommendations for improv­
ing stability were overrotation and early correc­
tion of rotated teeth. Because alignment o f teeth is
the primary aim, overrotation does not seem to be
a logical solution, especially because there is no
way to predetermine how the tooth will stabilize.
Early correction is equally fallible because not all
children are seen early enough by the practitioner,
and its efficacy has not been substantiated. Reitan
also suggested that surgical transection o f the
stretched marginal periodontal fibers might be
advantageous.
The idea of gingival surgery in orthodontic
cases is not new. In 1899, Angle2 advocated sev­
ering the periodontal fibers in the cervical third of
the root to facilitate tooth movement and to
shorten the period of retention.
About the time of Reitan’s study, Thompson3
reported research on monkeys in which a gin-
givectomy was performed on each experimental
animal at the site o f proximation o f the incisors.
Less relapse occurred in this group than in a con­
trol group, and Thompson concluded that the sup-
ra-alveolar fibers do not adapt to new tooth posi­
tions and are in part responsible for relapse. Ewen
JADA, Vol. 95, December 1977 ■ 1127
and Pasternak4 advocated a reverse-bevel surgi­
cal resection to reduce relapse after orthodontic
therapy. T his technique involved removal of a rim
of gingival tissue. They suggested that, after the
procedure, a new system of connective tissue fi­
bers formed that would retain the teeth in their
newly acquired occlusal positions.
Subsequently, research on the efficacy of vari­
ous surgical techniques on rotated teeth was per­
formed by E dw ards5 and Brain6 on animals. The
first report of application o f the technique to di­
vide the supracrestal fibers in hum ans was by
E d w ard s,7 who originated a m ethod of tattooing
the gingiva. He dem onstrated the effectiveness
o f the technique in reducing relapse tendencies
by using contralateral teeth of the same patient to
serve as controls.
O ther reports8 of the application of the tech­
nique in hum ans, though not long-term , tend to
support E dw ards’s initial findings. Clinical expe­
riences have been presented by B oese,9 who be­
lieved that not only is rotational relapse reduced
but postretention crowding of mandibular an­
terior teeth is minimized when the supracrestal
fiberotom y is used in conjunction with judicious
proximal stripping.
In 1975, Campbell and associates10 coined the
term “ circum ferential supracrestal fiberotom y,”
which is an apt designation for the surgical proce­
dure because not only is the intention to transect
free gingival fibers but also transseptal ones.
H ow ever, certain situations do not w arrant a cir­
cum ferential incision as later explained.
T he purpose of this paper is to bring supracres­
tal fiberotom y to the attention o f the dental pro­
fession. A recent survey11 that I conducted has
identified that about 25% of orthodontists pre­
scribe the technique for some of their patients; of
these, 25% refer patients to periodontists for the
surgery, w hereas 7% refer solely to general den­
tists and 15% to general dentists and to spe­
cialists.11 A definite impression gained from the
responses was that prescription of the technique
by orthodontists is likely to increase in the future,
as well as the fact that the technique might prove
helpful to those dentists who perform minor or­
thodontic procedures.
P rocedure in supracrestal fiberotom y
■ A nesthesia: Because the procedure is simple
and can be perform ed in a short period, a local
1128 ■ JADA, Vol. 95, December 1977
anesthetic with vasoconstrictor is adequate. Al­
though infiltration in the vestibular sulcus is effec­
tive, I prefer, after the application o f a topical
anesthetic, adm inistration of an intrapapillary in­
jection (Fig 1). T he needle is inserted from the
facial aspect o f the papilla to the lingual aspect,
and an anesthetic solution deposited as the needle
is withdraw n. Sufficient solution is injected to
produce slight blanching. The local action of the
vasoconstrictor is efficacious, and only slight ooz­
ing of blood occurs. G eneral anesthetic tech­
niques, nitrous oxide analgesia, or intravenous
sedation can be used if available and indicated;
how ever, in most cases it is doubtful if such m eas­
ures are w arranted.
■ Surgical technique: Basically, the technique
consists o f the insertion of a surgical blade
through the depths of the gingival crevice, cutting
through the free gingival and transseptal fibers
circum ferentially around the tooth (Fig 2). H ow ­
ever, in some situations the labial or buccal side
should be avoided (see “ C ontraindications” ).
M ost authors recom m end a no. 11 scalpel blade.*
While this is preferred in the maxilla, it is too thick
(m easuring 0.014 inch) for the m andibular anterior
teeth. I prefer an ophthalm ic blade holder using
fragm ents of a razor blade that are broken off from
a sterile blade to the desired length (Fig 3-5).
T hese are 0.007-inch thick and produce a very
clean incision on the labial aspect of m andibular
anterior teeth. It m ust be em phasized that some
precaution m ust be taken before using the
ophthalm ic blade holder. The spring of the in­
strum ent m ust be adjusted so that the beaks firmly
hold the blade fragm ent to prevent its dislodge-
m ent if it hits against alveolar bone. O ccasionally,
a no. 12 scalpel blade is useful for access to the
lingual aspect o f m andibular anterior teeth.
A nother alternative preferred by some periodon­
tists is a honed-down knife.§ E lectrosurgery, ac-
THE AUTHOR
Dr. Kaplan is associate profes­
sor of o rthod ontics at the Univer­
sity of Oregon Health Sciences
Center, departm ent of orthodon­
tics,'-611 SW Campus Dr, Port­
land, 97201.
KAPLAN

Fig 1 ■ Needle is inserted into interdental papilla to lingual aspect.
Local anesthetic solution is deposited as needle is slow ly w ith­
drawn until tissue blanches.
Fig 2 ■ Insertion of blade into gingival crevice, through crevicular
epithelium , and free gingival periodontal fibers to crest of alveolar
bone. Reprinted w ith perm ission from Am erican Journal o f Or­
tho don tics.6
Fig 3 ■ T w o types of ophthalm ic blade breakers and holders. Top,
Castroviejo’s blade breaker and h o ld e r.f Bottom, Barraquer’s
blade breaker and holder.^
Fig 4 ■ Fragm ent of blade broken off from sterile razor blade
(0.007-inch thick).
Fig 5 ■ Use of blade holder and blade fragm ent in m andibular
a nterior region.
cording to W alters,12 is definitely contraindicated
because it invariably produces gingival recession.
E dw ards7 has suggested that the blade should
penetrate 2 to 3 mm apically to the alveolar crest.
T here is no evidence that this is necessary or
feasible in some cases. As long as the incision is
made down to the alveolar crest, division of the
supracrestal fibers is ensured. T he type o f inci­
sion illustrated in Van der Linden’s pap er13 is an
alternative m ethod, but it presents some serious
disadvantages if incorrectly perform ed (Fig 6). If
the blade m isses the crest of the alveolar bone
(this is possible if there has been some resorption
or if the blade is angled too much) and the incision
is made down to root cem entum , then the tissue
rim will be severed from the underlying tissue and
the blood supply may be prejudiced. A lterna-
Kaplan: SUPRACRESTAL FIBEROTOMY ■ 1129

Fig 6 ■ Van der Linden's13 method of surgical severance of sup-
racresfal periodontal fibers to reduce relapse tendency of rotated
teeth. P osition of instrum ent in relation to too th and alveolar stru c­
ture (a, b). Details of fibers to be cut (c, d). Reprinted with perm is­
sion from van der Linden, Frans P.G.M. Theoretical and practical
aspects o f cro w d ing in the human dentition. JADA 89:139 July
1974.
tively, if the blade contacts the facial aspect o f the
alveolar bone, below the crest, then all supracres-
tal fibers will not be severed.
Because the incision is so superficial and swell­
ing is minimal, there does not appear to be any
indication for sutures or periodontal packs.
■ T im ing o f the procedure: M oderate hyperplas­
tic gingivitis is a common occurrence in patients
who w ear fixed orthodontic appliances. This con­
dition subsides to a great extent after removal of
the appliances. Orthodontic bands that extend
subgingivally, coupled with plaque accum ulation,
are responsible. These factors as well as the fact
that band attachm ents do present obstacles to the
surgery make it expedient to perform the surgical
procedure after band removal. Wellesley H.
W right, D D S , M S, director of graduate periodon-
Fig 7 ■ M andibular arch before (left) o rthod ontic treatm ent and after (m iddle) and ten years after removal of retainers.
1 1 3 0 ■ JADA, Vol. 95, December 1977
tology at the U niversity of Oregon H ealth Sci­
ences C enter, recom m ended (oral com m unica­
tion, M arch 1976) that the teeth to receive surgery
be immobilized during the healing period. He
suggested the placem ent of retainers immediately
after surgery: a canine-to-canine retainer in the
mandibular arch, and in the maxillary arch, a re­
movable Hawley appliance with palatal acrylic
resin cut away from the marginal gingiva of the
teeth in which surgery was perform ed. If the ging­
ival condition is unsatisfactory, the procedure can
be delayed until sufficient resolution has o c­
curred. A t that time it might be necessary to re­
move a canine-to-canine retainer and recem ent it
after surgery.
■ Indications: The m ost obvious situation for
use of supracrestal fiberotom y is the rotated
tooth. H ow ever, the noticeable tendency for
m andibular anterior teeth to relapse into pre­
treatm ent patterns of crowding, in some cases,
seems to point to a possible inherent tissue factor
(Fig 7-9). Supracrestal fiberotom y might be ef­
ficacious in these cases too, although long-term
studies have yet to substantiate this.
Cam pbell and associates10 recom m ended the
use o f circum ferential supracrestal fiberotom y in
cases with median diastem as. O thers have rec­
om m ended it for palatally blocked maxillary lat­
eral incisors—especially on the palatal aspect—to
relieve possible fiber tension on that side, which
could produce palatal relapse (Fig 10).
R esults o f the survey11 previously referred to
showed that over 50% of respondents who pre­
scribe the procedure believed that it im proved
stability of rotated teeth, 23% believed that it was
too early for them to assess their results, while 4%
reported only limited success and 4% did not be­
lieve that the procedure made any difference.
Although it has been clearly dem onstrated that
tension on supracrestal fibers is a factor in relapse
of rotated teeth, it should be m entioned that gingi­
val tissue pile-up on the side to which a tooth has
Fig 8 ■ M andibular arch before (left) and after (m iddle) orth o d o n tic treatm ent and 111/2 years after removal of retainer (right).

Fig 9 ■ M andibular arch before (left) o rthod ontic treatm ent and after (m iddle) and seven years, fou r m onths after removal of retain­
ers (right). Severance o f lingual fibers, tensed during treatment, m ight have reduced relapse.

Fig 10 ■ Maxillary arch before (left) o rthod ontic treatm ent and after (middle) and ten years after removal of retainers (right).
Severance of lingual fibers, tensed during treatment, might have reduced relapse.

been rotated or moved could be another factor.
A therton14 has dem onstrated the consequences
of gingival tissue pile-up after orthodontic closure
of spaces remaining after tooth extraction.
■ C ontraindications: Any general contraindica­
tions to surgery or anesthesia apply, of course.
Specific contraindications relate to teeth showing
gingival recession or lack o f attached gingiva. The
presence of poor oral hygiene, gingivitis, or any
periodontal pocketing are contraindications. Any
tooth with excessive labial root prom inence with
the distinct possibility o f a dehiscence should not
have any labial incision. E dw ards15 warned
against incising the m idportion of the labial ging­
iva of m andibular incisors and canines because
this might precipitate gingival recession. He also
warned against incising the gingiva while the tooth
is being rotated (written com m unication, Sept 25,
1975). In other words, teeth that are going to
receive surgery should be examined carefully
first.
In the survey of orthodontists,11 89% of those
who prescribe the technique reported that they
had not observed any undue sequela of the proce­
dure. O f those respondents who do not prescribe
the procedure, a few stated that the reason they
did not prescribe it was that they were concerned
with the possibility of periodontal dam age. The
procedure, how ever, is basically simple and
atraum atic and, if it is perform ed on carefully
selected cases, prognosis is excellent. T he ques­
tion of healing and reattachm ent should be more
correctly directed to oral surgeons and periodon­
tists who routinely reflect full-thickness muco-
periosteal flaps.

Kaplan: SUPRACRESTAL FIBEROTOMY ■ 1131


Conclusion
It should be emphasized that supracrestal fi-
berotomy procedure is not a substitute for total
care of orthodontic patients, which should include
proper root paralleling, complete correction o f
rotations, and correction o f overbite.
*Bard-Parker scalp el blade, Bard Parker, Div. of B ecton Dickin­
son and Co., Rutherford, N J 07070.
fM iltex G-F Periodontal Instruments, Miltex Instrument Co., New
York City, 10 0 10 .
tD ixey and C o., London. Also, Miltex Instrument Co.
§Orban knife, Hu-Friedy Mfg. Co., Inc., C hicago, 60618.
1. Reitan, K. T issu e rearrangem ent during retention of or-
thodontically rotated teeth. A ngle Orthod 2 9 :10 5 April 1959.
2. Angle, E.H. Section of peridental m em brane and frenum labli.
Dent C osm os 4 1 : 1 1 4 3 Nov 1899.
3. Thom pson, H.E. O rthodontic relap ses analyzed in a study of
connective tissu e fibers. Am J Orthod 4 5:9 3 Feb 1959.
4. Ewen, S .J., and Pasternak, R. Periodontal surgery— an ad­
junct to orthodontic therapy. Periodontics 2 :16 2 July-A ug 1964.
1132 ■ JADA, Vol. 95, December 1977
5. Edw ards, J.G . A study o f the periodontium during orthodontic
rotation of teeth. Am J Orthod 5 4 :4 4 1 Ju n e 1968.
6. Brain, W.E. The effect o f surgical tran ssection of free gingival
fibers on the regression of orthodontically rotated teeth in the dog.
Am J Orthod 5 5 :5 0 Ja n 1969.
7. Edwards, J.G . A surgical p roced ure to eliminate rotational
relapse. Am J Orthod 5 7 :3 5 Ja n 1970.
8. Crum, R.E., and A ndreasen, G .F. T he effect of gingival fiber
surgery on the retention of rotated teeth. Am J Orthod 65:626 Ju n e
1974.
9. B oese, L. Transection and reproxim ation without lower reten­
tion. Read before the University of W ashington Orthodontic Alumni
M eeting, Seattle, Aug 4-8, 1974.
10 . Cam pbell, P.M.; Moore, J.W .; and M atthews, J.L . O rthodon­
tically corrected midline d iastem as. A histologic study and surgical
procedure. Am J Orthod 6 7 :13 9 Feb 19 7 5.
1 1 . Kaplan, R.G. Clinical ex p e rie n ce s with circum ferential sup ­
racrestal fiberotom y. Am J Orthod 7 0 :14 6 Aug 1976.
12 . Walters, M. Electro-surgery: a problem solver. Read before
the 39th m eeting of the P acific C oast So cie ty of Orthodontists,
Seattle, Sept 14 -18 , 19 7 5.
13 . Van der Linden, F.P.G.M. T heoretical and practical asp ects
of crow ding in the hum an dentition. JAD A 8 9 :13 9 Ju ly 1974.
14 . Atherton, J.D . The gingival resp o n se to orthodontic tooth
movement. Am J Orthod 5 8 :17 9 A ug 1970.
15 . Edwards, J.G . Surgical p roced u res to eliminate rotational
relapse. Read before the O rthodontic Periodontal C on feren ce, St.
Louis, March 25-26, 1974.