234

Effects the Periodontium Following

on

Corticotomy-Facilitated Orthodontics.
Case Reports*
Bemard Gantes, Eugene Rathbun, and Milford Anholm

This report describes the corticotomy surgical technique used in conjunction with
orthodontic therapy and its effect on the periodontal status of the involved teeth. The
surgical procedure included intracrevicular incisions and elevation of buccal and lingual
mucoperiosteal flaps. Buccal and lingual vertical grooves penetrating the cortical bone
were then made between the roots. These grooves were extended from just below the
interproximal alveolar bone margin to beyond the apex levels of the teeth. Buccal and
lingual horizontal grooves joined the apical extensions of the vertical grooves. The or-
thodontic appliance was activated immediately upon wound closure. Plaque scores, prob-
ing depths, and probing attachment levels were recorded before the surgical procedure
and after the completion of the orthodontic treatment in 5 patients. The results showed
that the corticotomy procedure caused minimal changes in the periodontal attachment
apparatus. J Periodontol 1990;61:234-238.
Key Words: Flap surgery; corticotomy; orthodontics/corrective; alveolar process/sur-
gery

Reduction of orthodontic therapy treatment time is consid-
ered an important goal in the management of malocclusions
in the adult patient.
Corticotomy-facilitated orthodontic treatment may be
considered an intermediate therapy between Orthognathie
surgery and conventional orthodontics. It has been found
useful in reducing treatment time and allowing for conven-
tional orthodontic measures treating adult patients with se-
vere malocclusion. This treatment consists of a surgical
procedure followed by immediate application of orthodontic
forces heavier than usually used. A technique was first de-
scribed by Kole1 and included partial removal of the cortical
layer of the alveolar bone. This technique has significantly
shortened the orthodontic treatment time and has eliminated
the risk of necrosis of the bone and the dental pulps. Re-
cently, successful correction of severe adult malocculsion
was reported in several patients treated with the corticotomy
procedure.2
The surgical procedure includes elevation of full-thick-
ness flaps and subsequent exposure of the crestal bone of
the teeth with healthy periodontium. It has been reported
that healthy sites with shallow gingival sulcus may lose
approximately 0.5 mm of clinical attachment subsequent to
surgical therapy.3"5 Therefore, the purpose of this report
"Lorna Linda University, School of Dentistry, Loma Linda, Ca.
was to follow the periodontal status of teeth involved in
this combined surgical-orthodontic treatment.
MATERIALS AND METHODS
Subjects
Five adult patients, 21 to 32 years old, were included in
the study. The surgical procedure was described to the pa-
tients. They were informed of the risks related to any form
of major oral surgery and possible after effects including,
but not limited to, permanent deformities of the jaws and
supporting structures of the teeth. Other forms of ortho-
dontic treatment were also explained and discussed, in-
cluding no treatment. The patients consented to the
corticotomy-facilitated orthodontic treatment, which was an
orthodontic research project approved by the Institutional
Human Research Committee.
The patients exhibited different orthodontic problems,
including Angle Class II division 1 and 2 malocclusions
(Table 1). Prior to surgical and orthodontic treatment, the
patients were brought to periodontal health by means of
plaque control, and scaling and root planing as needed. In
addition, crown polishing was performed prior to the place-
ment of orthodontic brackets and bands. The plaque'control
efforts were monitored monthly during the treatment pe-
riod. An age-matched group of adult patients with similar
orthodontic problems was treated simultaneously without
Volume 61
Number 4
Table 1: Initial Diagnosis and Total Duration (Months) of the
Corticotomic Treatment, per Subject
Treatment Duration
Treated With
Subject Diagnosis*
Initial Corticotomy
1 Brachyfacial;
Class II div 2 20
2 same examiner.
Brachyfacial;
Class I (crowding) (17)
3 Brachyfacial;
Class II div 1 (full) 11
4 Brachyfacial;
Class II div 1 12
5 Mesiofacial with
brachyfacial
tendency;
Class II div I (full) 16
Mean 14.8
4.1
S.D.
*
Angle classification.
t No matching control.
X Case presented partially in Figures 1 and 3.
surgery, using conventional fixed appliances and served as
a control group for the orthodontic study. This report does
not include the periodontal status of this control group.
Surgical Procedures
Orthodontic appliances were placed on the teeth prior to
surgery (Figs. l.A and l.B). The surgical procedures were
performed under local anesthesia and conscious intravenous
sedation. Buccal and lingual vertical incisions were then
extended from the gingival margin towards a level apical
to the apices of the teeth. These incisions were made distal
to the most posterior tooth included in the corticotomy pro-
cedure. The vertical incisions were connected by buccal and
lingual intracrevicular incisions. Mucoperiosteal flaps were
then reflected beyond the level of the apices of the teeth.
The remaining interdental tissue was preserved. Vertical
buccal and lingual grooves were then made through the
cortical layer of the exposed bone with a fissure bur (#556)
mounted in a high speed handpiece, starting 1.5 mm below
the interdental crest. A horizontal groove penetrating the
cortical bone connected all vertical grooves 2 mm to 3 mm
apical to the apices of the teeth (Figs. l.C and l.D). The
horizontal grooves were made by a round bur #4. The teeth
which had been planned for extraction were removed at this
time. The buccal and lingual cortical bone was removed
over the extraction sites (Fig. l.D). The surgical sites were
vigorously irrigated with saline prior to flap repositioning
and suturing using a vertical double mattress technique.
Dexamethasone was injected intravenously in order to re-
duce post-operative edema. Prophylatic antibiotics were
prescribed for 1 week (Penicillin V Potassium 500 mg.
every 6 hours). Orthodontic appliances were activated im-
mediately after completion of the surgical procedures. The
nature and result of the orthodontic treatment will be de-
scribed elsewhere.
PERIODONTAL EFFECTS OF CORTICOTOMY 235
Clinical Parameters
The following parameters were recorded: plaque scores (PS),
probing pocket depths (PPD), and probing attachment lev-
Without els (PAL). Clinical photographs were taken during the treat-
Corticotomy ment. The measurements were repeated throughout the
treatment (Table 2). All measurements were made by the
24
t
28 Plaque Scores: 6 aspects of each tooth were examined:
mesiobuccal, midbuccal, distobuccal, mesiolingual, mid-
35
lingual, and distolingual. Plaque was disclosed with an ery-
throsine dye.+ Areas adjacent to the gingival margin which
exhibited a deep stain that could be easily removed with
26
the side of a probe were scored. Plaque scores were ex-
28.3
4.8
pressed as the % of the total number of surfaces under
evaluation which revealed presence of plaque. Full-mouth
plaque scores were based upon the 6 aspects of all teeth
present.
Probing Pocket Depth and Probing Attachment Levels:
Measurements of probing pocket depth and probing attach-
ment levels were made using an electronic pressure sensi-
tive probe.* A probe tip having 1 mm increments and 0.5
mm in diameter5 and a standardized force of 0.50 was
used. Recordings to the nearest 0.5 mm were made from
the mesiobuccal, midbuccal, distobuccal, mesiolingual,
midlingual, and distolingual sites of each experimental tooth.
A vacuum adapted soft acrylic onlay11 was used to provide
reference points for the probing measurements.6 Pocket depth
was measured from the gingival margin to the bottom of
the pocket. Probing attachment level was recorded from the
margin of the onlay to the bottom of the pocket. The onlays
were sectioned after completion of the orthodontic treat-
ment procedures. The sectioned onlay was then fitted se-
partely on each tooth. Descriptive data analysis will compare
preoperative and posttreatment measurements. The data will
be analyzed by subject, by tooth type, by surface type, and
pooled sites.
RESULTS
Clinical healing was generally uneventful. However, one
patient (subject #2) experienced subcutaneous hematomas
of the face and the neck. All patients reported that discom-
fort levels during and after the surgery were much less than
expected. All teeth stayed vital after the surgical procedures.
Preoperative and post-treatment periapical radiographs are
presented in Figures 2.A and 2.B. The presence of apical
root résorption was noticed after the orthodontic treatment.
Table 1 shows the initial diagnosis and the total duration
Lorvic Co., St. Louis, MO.
Trace,
Electronic Periodontal Probe, Model 200, Vine Valley Research, Mid-
dlesex, NY.
§LL20, Hu-Friedy, Chicago, IL.
Scheu-Dental, Iserlohn, West Germany.
 J Periodontol
236 GANTES, RATHBUN, ANHOLM April 1990

Figure 1 .· Preoperative view, buccal aspect; B: Preoperative view, palatal aspect; C: After flap elevation the grooves are performed
on the buccal cortical bone (see arrows); D: Same on palatal cortical bone, note the extraction site with the cortical plate removed;
E; One week post-surgically after removal of the sutures; F: One month later; G: Seven months later; H: Posttreatment, 16 months.
Volume 61
Number 4 PERIODONTAL EFFECTS OF CORTICOTOMY 237

Table 2: Schedule of Treatment and Measurements Table 4: Means and Standard Deviations of Probing Pocket Depth
and Attachment Level Changes (Patient Means)
Time Frame Treatment
Patient PPD* PAL*
Prior selection, oral hygiene instruction (OHI), seal-
to treatment ing, root planing, and crown polishing Subject Initial Final Difference Difference
0 week Preopcrative measurements: PS, PPD, PAL, photos, 1 2.7 2.4 -0.3 0
surgery, photos 2 2.3 2.1 -0.2 0
1 week Removal of sutures and postop treatment, photos 3 2.3 2.3 0 -0.3
2 weeks PS 4 2.6 2.2 -0.4 + 0.1
1 month PS 5 2.2 2.0 -0.2 0
3 months PS
6 months PS Mean 2.4 2.2 -0.2 -0.1
X months Orthodontic treatment completed PS, PPD, PAL, photos S.D. 0.2 0.2 0.2 0.2
*
in mm.

Table S: Means and Standard Deviations of Probing Pocket Depth

and Attachment Level Changes per Tooth Type (Tooth Means)

PPD* PAL*
Tooth Type Initial Final Difference Difference
Maxillary incisors 2.3 2.1 -0.2 -0.1
Mandibular incisors 2.4 2.0 -0.4 +0.2
Maxillary cuspids 2.3 2.4 +0.1 -0.4
Mandibular cuspids 2.4 2.3 -0.1 +0.1
Maxillary bicuspids 2.6 2.6 0 -0.2
Mandibular bicuspids 2.7 2.3 -0.4 -0.1
Mean 2.4 2.3 -0.2 -0.1
S.D. 0.1 0.2 0.2 0.2

Table 6: Means and Standard Deviations of Probing Pocket Depth

and Attachment Level Changes per Surfaces (Surface Means)

Figure 2 A: Preoperative radiographs; Bv Post treatment radiographs. PPD* PAL*

Surfaces Initial Final Difference Difference
Table 3: Mean-Full Mouth Plaque Scores (Patient Mean) and Buccal 1.9 1.5 -0.4 + 0.1
Standard Deviation Lingual 2.0 1.9 -0.1 + 0.2
Proximal 2.7 2.5 -0.2 -0.1
Post
0 2 4 3 6 orthodontic Mean 2.2 2.0 -0.2 + 0.1
week weeks weeks months months treatment S.D. 0.4 0.5 0.2 0.1
Mean % 27 28 27 13 14
S.D. 16 13 28 10 14

was reduced by 0.2 mm. Patient #3 experienced 0.3 mm

of the orthodontic treatments for both experimental and
control groups. The mean treatment time was 14.8 months
for the experimental group and 28.3 months for the control
group. The treatment time of patient #2 was not used in
the mean calculation because his matching control was not
identified. Figures l.E through l.H show the postsurgical
orthodontic phases. Note that after 7 months most of the
orthodontic movement of the canine had been accomplished
(Fig. l.G).
Table 3 shows the mean plaque scores
experimental period. The mean full mouth plaque scores
were 27% prior to surgery, remained unchanged for 1 month,
then decreased throughout the observation period.
Table 4 presents the mean and standard deviation of in-
itial and final probing pocket depths and attachment level
changes for the 5 subjects. The total mean pocket depth
of mean attachment loss.
Table 5 presents the mean and standard deviation of in-
itial and final probing pocket depths and attachment level
changes per tooth type. The mean pocket depth changes
ranged from +0.1 to -0.4 mm. The maxillary cuspids
showed a mean attachment loss of 0.4 mm. The other teeth
showed mean attachment change of 0.2 mm or less.
Table 6 presents the mean and standard deviation of in-
itial and final probing pocket depths and attachment level
throughout the changes per tooth surface. The mean pocket reduction was
0.4 mm for the buccal surfaces. The lingual and proximal
surfaces had fewer changes. The mean attachment level
changes were less or equal to 0.2 mm.
Figure 3 shows the frequency of sites with loss or gain
of probing attachment; 88% of the sites had an attachment
level which stayed within 1 mm of the original value.

238 GANTES, RATHBUN, ANHOLM
TOTAL NUMBER OF SITES
=
-3 -2 2 3
Figure 3: Histogram offrequency of attachment level changes.
DISCUSSION
The results obtained in this study should be interpreted with
care, as initial recordings were taken after the placement of
brackets and bands while the final recordings were taken
with no appliances on the teeth, after completion of the
orthodontic treatment. The plaque scores were initially high.
After the placement of the orthodontic appliance, the pa-
tients experienced some difficulties in reaching optimal plaque
scores. This had a definite influence on the bleeding scores
which were meaningless and, therefore, not presented. The
data on the pocket depth and attachment changes demon-
strate that the surgical procedure was not excessively dam-
aging to the periodontal tissues. Gingival recession was
minimal and the interdental papillae were preserved, insur-
ing a good post-treatment esthetic result. The vertical mat-
tress suturing technique as well as the attempt to preserve
the interproximal soft tissue during the surgery seem to be
successful in retaining the papilla architecture (Fig. l.E).
Longitudinal studies have shown that shallow sites lose
approximately 0.5 mm of probing attachment after peri-
odontal surgery.3 In our study, we could not observe any
attachment loss of clinical significance. Possible explana-
tions for this difference could be that initial pocket depth
and attachment measurements were recorded with the or-
thodontic appliances on the teeth and that the final record-
ings were taken without the orthodontic appliances in place.
Furthermore, we had to cut the onlays after the orthodontic
movements of the teeth in order to get the final recordings.
In addition, the orthodontic treatment had improved the
clinical attachment of some teeth which were out of alig-
ment prior to the treatment. This has possibly influenced
the mean values.
The osteotomy restricted to the cortical bone layer min-
imized the injury of the vital structures. Kole1 showed the
importance of preserving an intact spongiosa using this
technique, while a total alveolar osteotomy may impair the
intraosseous and intrapulpal blood circulation.7
Rapid orthodontic treatment using heavy forces in com-
bination with corticotomy does not affect tooth vitality but
induces histological changes in the periodontal ligament.
J Periodontol
April 1990
These short-term changes seem to be of no clinical
importance.8
The observation of the post-operative periapical radio-
435
graphs revealed that apical root résorption took place during
the treatment. However, this type of phenomenon can be
observed after non-surgical orthodontic treatment also.
The treatment time was reduced by approximately 50%.
Furthermore, during the orthodontic treatment, due to the
increased appliance complexity and the frequency of patient
visits, the total chair time for these patients was estimated
to be approximately the same as for conventional ortho-
dontic treatment.
Considering the surgical access of the bony structures,
this procedure was designed primarily for anterior teeth
movement. However, it may be possible to apply this tech-
nique to posterior segments as well when anatomical con-
siderations permit.
This procedure should be avoided on patients having any
form of periodontal pathology or deformity including gin-
gival recessions, teeth having buccal or lingual bony de-
hiscences, and teeth with reduced periodontium. Before such
treatment, we advise the surgeon to review carefully the
health history of the patient, request the routine laboratory
analysis, and examine a complete set of radiographs in or-
der to pinpoint and, therefore, to foresee any anatomical
obstacle for the surgical procedure. Risks and possible after
effects should be explained and discussed with the patient.
In conclusion, in these 5 cases, the corticotomy proce-
dure reduced the orthodontic treatment time. The descrip-
tive statistics of these 5 cases indicate that no periodontal
adverse effects were clinically noticeable. The increasing
number of adults seeking correction of teeth and jaw mal-
positions may be a group of patients for this procedure.
Acknowledgment
The authors wish to thank Dr. Hajime Suya for his instruc-
tions in the corticotomy technique.
REFERENCES
1. Kole H. Surgical operations on the alveolar ridge to correct occlusal
abnormalities. Oral Surg 1959; 12:277.
2. Anholm M. Corticotomy facilitated orthodontics. Calif Dent Assoc J
December 1986:7.
3. Kohler CA, Ramfjord SP. Healing of gingival mucoperiosteal flaps.
Oral Surg Oral Med Oral Path 1960; 13:89.
4. Persson P. The regeneration of the marginal periodontium after flap
operation. Acta Odont Scand 1962; 20:43.
5. Chamberlain AD, Garrett S, Renvert S, Egclberg J. Healing after treat-
ment of periodontal intraosseous defects. IV. Effect of a non-rcsective
versus a partially resective approach. / Clin Periodontol 1985; 12:525.
6. Badersten A, Nilveus R, Egelbcrg J. Effect of nonsurgical therapy. II.
Severely advanced Periodontitis. J Clin Periodontol 1984; 11:63.
7. Bell W. Revascularization and bone healing after maxillary osteotomy.
/ Oral Surgery 27:249, 1969.
8. Duker J. Experimental animal research into segmental alveolar move-
ment after corticotomy. J Maxillofac Surg 1975; 3:81.
Send reprint requests to: Dr. Bernard Gantes, Graduate Periodontics,
School of Dentistry, Loma Linda University, Loma Linda CA 92350.