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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)

P
a
Assistant professor, Department of Orthodontics, Graduate School, Kyung Hee resurgical orthodontic treatment is typically
University, Seoul, Korea. necessary to correct compensated tooth positions
b
Postgraduate student, Department of Orthodontics, Graduate School, Kyung
Hee University, Seoul, Korea. that result from undesirable jaw growth. Correct-
c
Professor and chair, Department of Orthodontics, Graduate School, Kyung Hee ing the dental compensations allows the most favorable
University, Seoul, Korea. positioning of the jaw segments during surgery and per-
d
Professor, Department of Orthodontics, Graduate School, Kyung Hee University,
Seoul, Korea. mits a more accurate and stable occlusion after surgery.
e
Clinical professor, Department of Orthodontics, Graduate School, Kyung Hee In the correction of Class III malocclusion, decompensa-
University, Seoul, Korea. tion of the mandibular anterior teeth labially to an ideal
f
Clinical professor, Division of Orthodontics, Department of Orofacial Science,
University of California, San Francisco, Calif. relationship to the supporting bone will allow the best
Hyo-Won Ahn and Dong-Hwi Seo are joint first authors and contributed equally improvement of facial esthetics after surgery. However,
to this work. labial incisor movement can be limited by the alveolar
All authors have completed and submitted the ICMJE Form for Disclosure of
Potential Conflicts of Interest, and none were reported. housing. A previous study has shown that excessive
Supported by the National Research Foundation of Korea, funded by the Korean labial incisor movement is associated with dehiscence
government (MEST; no. 2012R1A5A2048310). of the labial bone.1 The authors found a high correlation
Address correspondence to: Seong-Hun Kim, Department of Orthodontics,
Kyung Hee University School of Dentistry, 1 Hoegi-Dong, Dongdaemun-Gu, between the labiolingual inclination of the teeth and the
Seoul 130-701 Korea; e-mail, bravortho@gmail.com. frequency of dehiscence or gingival recession.1,2
Submitted, June 2015; revised and accepted, March 2016. Recently, cone-beam computed tomography (CBCT)
0889-5406/$36.00
Ó 2016 by the American Association of Orthodontists. All rights reserved. has been an indispensable diagnostic imaging tool for
http://dx.doi.org/10.1016/j.ajodo.2016.03.027 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 661

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

American Journal of Orthodontics and Dentofacial Orthopedics 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 with the change in the control group (1.14 mm). When
We looked at the decompensation pattern of the comparing the 2 groups, only the labial movement of
mandibular incisors using lateral cephalograms the incisor crown tip (menton vert-L1) showed a signif-
(Table II). The changes of IMPA were statistically signif- icant difference (P \0.05).
icant in both the experimental and control groups Dentoalveolar changes surrounding the mandibular
(P \0.001). The average changes of IMPA were 7.51 anterior teeth were seen in the CBCT images (Figs 4
(from 78.55 to 86.05 ) in the experimental group and and 5). For the mandibular canines, there was a
5.31 (from 78.57 to 83.87 ) in the control group. statistically significant vertical alveolar bone loss
The variation of menton vert-L1 was also statistically (CEJ-crest) in the control group (P \0.001; Table III).
significant in the groups (both, P \0.001). The average There was a slight vertical alveolar bone gain in the
change of menton vert-L1 was 2.35 mm in the experi- experimental group, although it was not statistically
mental group, which was almost double compared 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 P \0.001). Labial alveolar bone area decreased in the
decreased with statistical significance (P \0.001). The control group and increased in the experimental group
upper alveolar thickness in the experimental group (both, P \0.001). Root length in both groups
also decreased (P \0.05), whereas the middle and decreased with statistical significance (P \0.001).
lower alveolar thicknesses increased (lower thickness, 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- For the mandibular central incisors, there was signif-
ences except for root length and upper alveolar thick- icant vertical alveolar bone loss in the control group
ness (LABA; CEJ-crest, middle and lower alveolar (3.57 mm; P \0.001), whereas it was well maintained
thicknesses; all P \0.001). in the experimental group (Table III). After decompensa-
For the mandibular lateral incisors, there was a sig- tion, the upper and middle alveolar thicknesses in the
nificant vertical alveolar bone loss in the control group control group decreased with statistical significance
(4.24 mm; P \0.001), whereas it was well preserved in (both, P \0.001). In the experimental group, significant
the experimental group (Table III). After decompensa- increases of alveolar thickness were observed in the mid-
tion, the upper and middle alveolar thicknesses in the dle and lower areas (both, P \0.001). Labial alveolar
control group decreased with statistical significance bone area decreased in the control group (P \0.001)
(both, P \0.001). In the experimental groups, the and increased in the experimental group (P \0.01).
change of upper alveolar thickness was negligible, and Root length in both groups decreased with statistical sig-
the middle and lower alveolar thicknesses increased nificance (P \0.001). All measurements showed signifi-
significantly (both, P \0.001).The labial alveolar bone cant differences between groups except root length (all,
decreased in the control group (P \0.001) and increased P \0.001).
in the experimental group (P \0.01). Root lengths In the comparison between the 3 kinds of anterior
decreased in both groups (P \0.001). When we teeth, there were no significant differences in their den-
compared the measurement changes between groups, toalveolar changes in the groups, except for root length
all measurements showed significant differences except in the experimental group (P \0.05; Table IV). The
root length and upper alveolar thickness (LABA; CEJ- length of the canine roots decreased more than did the
crest, middle and lower thickness; all P \0.001). roots of the lateral incisors.

October 2016  Vol 150  Issue 4 American Journal of Orthodontics and Dentofacial Orthopedics
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.

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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 667

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- alveolar bone volume in the apical third than in the
ever, IMPA does not differentiate between the types of cervical third area. Similarly, histologic findings in an
tooth movement, such as controlled tipping vs uncon- animal study showed that new bone formation and
trolled tipping. Since the anteroposterior position and alveolar bone height in the buccal wall were not
inclination of the mandibular incisors affects the directly affected by the use of the absorbable collagen
amount of mandibular setback in the orthognathic sur- membrane in an augmented corticotomy.23 The 1 posi-
gery, careful analysis is warranted. We used the menton tive effect of the absorbable collagen membrane was to
vert-L1 value to evaluate it. Our results showed that the promote an even surface in the middle and apical areas
changes of IMPA were similar between groups, whereas of buccal bone.23 We also obtained favorable responses
menton vert-L1 was almost double in the augmented on the incisal third area of the alveolus and alveolar crest
corticotomy group. That is because in the experimental without using the barrier membrane. Further study is
group, the incisor movement was controlled tipping necessary to establish the best protocol of augmented
(fulcrum at the apex); in the control group, it was un- corticotomy using the criteria of long-term stability, pa-
controlled (apex moved lingual) (Fig 6). This can allow tients’ convenience, and technique sensitivity.
more mandibular setback movement during the orthog- In regard to root resorption, there was no statistically
nathic surgery in the experimental group than in the significant difference between the groups. In the
control group. Because lingual movement of the root augmented corticotomy group, more root resorption
apex during uncontrolled tipping of the mandibular occurred on the canines than on the incisors, but the
anterior teeth greatly affects mandibular alveolar thick- amount was clinically insignificant. In our study, corti-
ness and LABA, they would be less important to the clin- cotomy was performed only on the labial side (not on
ical outcome than the upper and middle alveolar both labial and lingual sides); this probably did not elim-
thicknesses. inate the hyalinization that occurs when root apices are
One controversial issue in augmented corticotomy is moved against the lingual cortical plate during incisor
whether to place a barrier membrane over the bone proclination. Moreover, some have reported that the
grafts. It is difficult to hold the position of the bone graft use of graft materials such as deproteinized bovine
materials because augmented corticotomy is performed bone mineral or synthetic materials would cause root
on a 1-walled defect area. Without the membrane, bone resorption.17,24 The surgical design of the corticotomy
graft materials gathered at the apical third area of the and the types of graft materials should be considered
experimental group after the decompensation.12 Previ- in further studies.
ous studies have suggested applying the absorbable Up to now, there have been few studies regarding the
collagen membrane combined with augmented cortico- long-term quality of the bone after tooth movement
tomy to improve clinical outcomes.13-15 However, even combined with corticotomy. The graft material used in
with the membrane, the authors observed similar our study is well known for its slow turnover and inte-
changes in alveolar bone morphology: ie, increased gration to become the host's own bone; therefore, the

American Journal of Orthodontics and Dentofacial Orthopedics October 2016  Vol 150  Issue 4
668 Ahn et al

long-term status of the labial augmented bone site 4. Kim Y, Park JU, Kook YA. Alveolar bone loss around incisors in
should be evaluated in further studies. Recently, Wilcko surgical skeletal Class III patients. Angle Orthod 2009;79:
676-82.
et al25 reported long-term stability of augmented corti-
5. Lee KM, Kim YI, Park SB, Son WS. Alveolar bone loss around lower
cotomy with orthodontic treatment by evaluating the incisors during surgical orthodontic treatment in mandibular
keratinized gingiva. The keratinized gingival height prognathism. Angle Orthod 2012;82:637-44.
increased after augmented corticotomy at 1.5 years after 6. Murphy KG, Wilcko MT, Wilcko WM, Ferguson DJ. Periodontal
debonding. With regard to orthodontic retention, Makki accelerated osteogenic orthodontics: a description of the surgical
technique. J Oral Maxillofac Surg 2009;67:2160-6.
et al26 reported that orthodontic therapy combined with
7. Frost HM. The biology of fracture healing. An overview for clini-
augmented corticotomy enhanced the stability of the cians. Part I. Clin Orthop Relat Res 1989;248:283-93.
postorthodontic mandibular irregularity index for at 8. Frost HM. The biology of fracture healing. An overview for clini-
least 10 years. We have been gathering the retention cians. Part II. Clin Orthop Relat Res 1989;248:294-309.
CBCT data of the corticotomy group, and further study 9. Lee W, Karapetyan G, Moats R, Yamashita DD, Moon HB,
Ferguson DJ, et al. Corticotomy-/osteotomy-assisted tooth move-
will include the long-term bone quality after augmented
ment microCTs differ. J Dent Res 2008;87:861-7.
corticotomy. 10. Wilcko MT, Wilcko WM, Pulver JJ, Bissada NF, Bouquot JE. Accel-
The limitation of this retrospective study was a statis- erated osteogenic orthodontics technique: a 1-stage surgically
tically significant difference in alveolar bone quality at facilitated rapid orthodontic technique with alveolar augmenta-
pretreatment between the 2 groups. The experimental tion. J Oral Maxillofac Surg 2009;67:2149-59.
11. Wilcko WM, Wilcko MT, Bouquot JE, Ferguson DJ. Rapid ortho-
group showed more vertical bone loss and a smaller alve-
dontics with alveolar reshaping: two case reports of decrowding.
olar bone area than did the control group at the initial Int J Periodontics Restorative Dent 2001;21:9-19.
stage. Another limitation was that there has been no es- 12. Ahn HW, Lee DY, Park YG, Kim SH, Chung KR, Nelson G. Accel-
tablished CBCT resolution for examination of alveolar erated decompensation of mandibular incisors in surgical skel-
bone morphology. Although many studies showed that etal Class III patients by using augmented corticotomy: a
preliminary study. Am J Orthod Dentofacial Orthop 2012;142:
CBCT renders anatomic measurements reliably and is
199-206.
an appropriate tool for linear measurements,27,28 there 13. Wang B, Shen G, Fang B, Yu H, Wu Y, Sun L. Augmented
is still controversy regarding which voxel size is corticotomy-assisted surgical orthodontics decompensates lower
appropriate to evaluate alveolar bone.29,30 incisors in Class III malocclusion patients. J Oral Maxillofac Surg
2014;72:596-602.
14. Wang B, Shen G, Fang B, Yu H, Wu Y. Augmented corticotomy-
CONCLUSIONS assisted presurgical orthodontics of Class III malocclusions: a
In a comparison of 2 Class III malocclusion samples cephalometric and cone-beam computed tomography study. J
Craniofac Surg 2013;24:1886-90.
matched for age, sex, and pretreatment mandibular cen-
15. Coscia G, Coscia V, Peluso V, Addabbo F. Augmented corticotomy
tral incisor position, augmented corticotomy provided a combined with accelerated orthodontic forces in Class III orthog-
favorable outcome after decompensation of the nathic patients: morphologic aspects of the mandibular anterior
mandibular anterior teeth. In skeletal Class III patients ridge with cone-beam computed tomography. J Oral Maxillofac
undergoing orthognathic surgery, the integrity of the Surg 2013;71:1760.e1-9.
16. Nimigean VR, Nimigean V, Bencze MA, Dimcevici-Poesina N,
periodontal structures surrounding all mandibular ante-
Cergan R, Moraru S. Alveolar bone dehiscences and fenestrations:
rior teeth was preserved and, by some measurements, an anatomical study and review. Rom J Morphol Embryol 2009;50:
improved. Augmented corticotomy can be a good 391-7.
adjunctive procedure for skeletal Class III patients with 17. Araujo MG, Carmagnola D, Berglundh T, Thilander B, Lindhe J.
any risk factors that might contribute to periodontal Orthodontic movement in bone defects augmented with Bio-
Oss. An experimental study in dogs. J Clin Periodontol 2001;
side effects as a result of presurgical orthodontic decom-
28:73-80.
pensation. 18. Kim SH, Kim I, Jeong DM, Chung KR, Zadeh H. Corticotomy-assis-
ted decompensation for augmentation of the mandibular anterior
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