ONLINE ONLY

Dehiscence and fenestration in patients with

Class I and Class II Division 1 malocclusion
assessed with cone-beam computed tomography
Karine Evangelista,a Karla de Faria Vasconcelos,b Axel Bumann,c Edgar Hirsch,d Margarita Nitka,e
and Maria Alves Garcia Silvaf
Goiânia, Goiás, Brazil, and Leipzig and Berlin, Germany

Introduction: The aim of this study was to compare the presence of alveolar defects (dehiscence and
fenestration) in patients with Class I and Class II Division 1 malocclusions and different facial types.
Methods: Seventy-nine Class I and 80 Class II patients with no previous orthodontic treatment were evaluated
using cone-beam computed tomography. The sample included 4319 teeth. All teeth were analyzed by
2 examiners who evaluated sectional images in axial and cross-sectional views to check for the presence
or absence of dehiscence and fenestration on the buccal and lingual surfaces. Results: Dehiscence was as-
sociated with 51.09% of all teeth, and fenestration with 36.51%. The Class I malocclusion patients had
a greater prevalence of dehiscence: 35% higher than those with Class II Division 1 malocclusion (P \0.01).
There was no statistically significant difference between the facial types. Conclusions: Alveolar defects are
a common finding before orthodontic treatment, especially in Class I patients, but they are not related to
the facial types. (Am J Orthod Dentofacial Orthop 2010;138:133.e1-133.e7)

O
rthodontic movement is achieved by biologic
events in bone remodeling (resorption and
apposition) of the alveolar process, which
supports the teeth with involvement of the roots.1 Since
bone resorption occurs in the direction of tooth move-
ment, the reduced volume of the alveolar bone, some-
times with minimal thickness, sometimes even
nonexistent, is a complicating factor for orthodontic
treatment.2
Previous studies and case reports have shown that,
as the roots are displaced and move away from the
a
Private practice, Goiânia, Brazil; Postgraduate student, Federal University of
Goiás, Goiânia, Goiás, Brazil.
b
Postgraduate student, Dental School, Federal University of Goiás, Goiânia,
Goiás, Brazil.
c
Private practice, Berlin, Germany; assistant clinical professor, Department of
Craniofacial Sciences and Therapy, University of Southern California, Los
Angeles, Calif.
d
Assistant professor, Department of DentoMaxilloFacial Radiology, Dental
School, University of Leipzig, Leipzig, Germany.
e
f
Orthodontic office, Berlin, Germany.
Associate professor, Department of Stomatologic Sciences, Dental School,
Federal University of Goiás, Goiânia, Goiás, Brazil.
The authors report no commercial, proprietary, or financial interest in the prod-
ucts or companies described in this article.
Reprint requests to: Karine Evangelista, Rua 3, n 800 sala 502 Ed. Office
tower, Setor Oeste, 74115-050, Goiânia, GO, Brazil; e-mail, karine@
odontologiamaxima.com.br.
Submitted, December 2009; revised and accepted, February 2010.
0889-5406/$36.00
Copyright Ó 2010 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2010.02.021
center of the alveolar bone, there is increased risk of cre-
ating or exacerbating alveolar defects3,4 and producing
consequent mucogingival changes, such as gingival
recession.5-7 The lack of the facial or lingual cortical
plate, which resulted in exposing the cervical root
surface and affecting the marginal bone, represents an
alveolar defect called dehiscence. When there is still
some bone in the cervical region, the defect is called
fenestration.8 The occurrence of dehiscence and fenes-
tration during orthodontic treatment depends on several
factors, such as the direction of movement, the fre-
quency and magnitude of orthodontic forces, and the
volume and anatomic integrity of the periodontal sup-
porting tissues.1,4 To avoid these problems, the
alveolar morphology must be determined before
orthodontic treatment through imaging, which shows
bone topography and anatomy. Currently, cone-beam
computed tomography (CBCT) is the option chosen
for most clinical dental situations, including the alveolar
process, when a cross-sectional examination is indi-
cated, because of its lower dose of radiation,9,10 better
image resolution,11 and lower costs compared with mul-
tislice computed tomography.
To date, no study has been undertaken to compare
the presence of alveolar defects in subjects with various
malocclusions. The hypothesis we tested was that there
is no difference in bone covering between the various
malocclusions. Our aim was to compare the presence
of dehiscence and fenestration between patients with
133.e1
133.e2 Evangelista et al
Table I. Distribution of malocclusions and facial types
Facial type
Malocclusion Brachyfacial Mesofacial Dolichofacial
Class I 32 29 18
Class II 27 30 23
Division 1
Total 59 59 41
Class I and Class II Division 1 malocclusions and differ-
ent facial types by using CBCT.
MATERIAL AND METHODS
This study was approved by the institutional review
board of Medical School Charité, Berlin, Germany.
We used pretreatment CBCT examinations of ortho-
dontic patients from the radiological files of the Mesan-
tis private orthodontic clinic in Berlin, Germany. The
sample was selected by 1 observer, trained in the use
of sectional images, who did not participate in the study.
The following inclusion criteria were considered:
CBCT examinations of patients over 18, with no previ-
ous history of orthodontic treatment; and patient of both
sexes with Class I or Class II Division 1 malocclusions,
mild-to-moderate crowding, and different facial types.
The Class I samples were confirmed by the bilateral
Class I molar and canine relationships: ANB between
2 and 4 , and overjet between 1 and 4 mm. The criteria
for selecting the Class II Division 1 subjects were bilat-
eral Class II molar and canine relationships, ANB $4
and overjet .4 mm. The facial types were divided ac-
cording to NS.GoGn proposed by Reidel,12 with the
mesofacial group measuring from 27 to 37 ; the bra-
chyfacial group, \27 ; and the dolichofacial group,
$37 . All cephalometric measures used in the study
were obtained from the original CBCT images. The ex-
clusion criteria included patients with missing teeth and
agenesis, and images suggesting periodontal disease
such as horizontal or vertical proximal bone loss, furcal
involvement, and calculus. Partial and low-resolution
images were also excluded from the evaluation, as
well as 133 teeth with extensive restorations involving
the cementoenamel junction.
A total of 79 Class I and 80 Class II Division 1 mal-
occlusion patients matched the inclusion criteria, giving
4319 teeth to be evaluated. The power analysis deter-
mined that a sample size of 139 patients would be
sufficient to detect a 5% difference between malocclu-
sion groups. The distribution of the malocclusion and
facial types of all subjects is shown in Table I. Tables
II and III show the sample characteristics according to
malocclusion and facial type.
American Journal of Orthodontics and Dentofacial Orthopedics
August 2010
Mean values (6 standard deviations) for age,
Table II.
ANB, overjet, and NS.GoGn in patients with Class I
Total and Class II Division 1 malocclusions
79 Class I Class II Division 1
80
Age (y) 27.09 (7.46) 26.48 (8.18)
ANB ( ) 2.52 (1.96) 6.66 (1.96)
159
Overjet (mm) 2.61 (0.86) 5.72 (1.13)
NS.GoGn ( ) 29.32 (6.48) 30.98 (6.63)
Table III. Mean values (6 standard deviations) for
NS.GoGn in the facial types
Brachyfacial Mesofacial Dolichofacial
NS.GoGn( ) 23.41 (3.28) 31.07 (1.74) 38.77 (2.86)
The images were obtained by using i-CAT tomogra-
phy (Imaging Sciences International, Hatfield, Pa), with
47.7 mA, 120 kV, 40-second exposure time, and isotro-
pic voxel size of 0.25 3 0.25 3 0.25 mm. The imaging
protocol was performed with a 6-in field of view to in-
clude the entire facial anatomy. The files were exported
to 512 3 512 pixels matrix in DICOM 3 format and pro-
cessed by using InVivoDental software (Anatomage,
San Jose, Calif). The patient’s head was oriented by lo-
cating the Frankfurt plane parallel to the horizontal
plane and in centric occlusion.
Two calibrated examiners (an orthodontist K.E. and
a dentist K.F.V.) visually examined all the sectional im-
ages in a dark room, using a 24.1-in LCD monitor with
resolution of 1920 3 1200 pixels. Both observers eval-
uated the same tomographic views blindly without
knowing either the malocclusion or the facial type, or
each other’s results. First, the mesiodistal and buccolin-
gual axes of each tooth were placed perpendicular to the
horizontal plane. The total length of the root was evalu-
ated in axial and cross-sectional slices at the buccal and
lingual surfaces. Images that showed no cortical bone
surrounding the root in at least 3 consecutive views
were registered as having an alveolar defect. This lack
of bone was classified as dehiscence when the alveolar
bone height was more than 2 mm from the cementoena-
mel junction, based on the value for normal alveolar
height.13 It was classified as fenestration when the de-
fect did not involve the alveolar crest. The root length
was divided into 3 equal parts, from the cementoenamel
junction to apex, to locate the third of the root with the
alveolar defect.
After 20 days, an observer repeated the analysis of
25% of the examinations, randomly selected, to verify
the reproducibility of the method.
American Journal of Orthodontics and Dentofacial Orthopedics Evangelista et al 133.e3
Volume 138, Number 2

Table IV. Mean values (6 standard deviations) for alveolar defects in Class I and Class II Division 1 malocclusions and
facial types
Alveolar defect Dehiscence Fenestration
†
Number of surfaces P* Number of surfaces P Number of surfaces P*

Malocclusion
Class I 30.01 (9.45) \0.01 22.36 (12.26) \0.01 11.08 (5.62) NS
Class II Division 1 21.78 (10.34) 14.43 (10.63) 9.41 (5.52)
Facial type
Brachyfacial 26.84 (10.78) NS 19.52 (12.19) NS 10.16 (5.49) NS
Mesofacial 24.90 (10.82) 17.31 (12.33) 10.45 (5.91)
Dolichofacial 25.85 (10.56) 18.27 (11.78) 10.05 (5.49)

*Student test and ANOVA; †Mann-Whitney and Kruskal-Wallis tests; NS, not significant.

Table V. Incidence of alveolar defects

Dehiscence Fenestration

Maxilla Mandible Maxilla Mandible

Tooth n % n % n % n %

1 204 9.46 706 24.33 174 10.51 161 21.05

2 288 13.35 508 17.51 302 18.24 194 25.36
3 404 18.73 497 17.13 296 17.87 171 22.35
4 398 18.45 481 16.58 299 18.06 95 12.42
5 226 10.48 266 9.17 124 7.49 68 8.89
6 394 18.27 287 9.90 269 16.24 30 3.92
7 243 11.26 156 5.38 192 11.59 46 6.01
Total 2157 100 2901 100 1656 100 765 100

Statistical analysis 1 malocclusion (P \0.01). No difference was found be-

The levels of interobserver and intraobserver agree-
ment were assessed by kappa statistics. A descriptive
analysis was performed to show the prevalence of the al-
veolar defects and the most teeth, surfaces, and root thirds
affected. Student t and Mann-Whitney tests were applied
to compare the malocclusion groups. Analysis of vari-
ance (ANOVA) and Kruskal-Wallis tests were used to
compare the facial types. The statistical analysis was per-
formed by using an SPSS software package (version 16.0,
SPSS, Chicago Ill) at the 0.05 significance level.
RESULTS
Kappa values for interobserver and intraobserver
agreement varied from 0.7 to 1.00, which represented
good agreement of this method.
The hypothesis tested was not confirmed. Table IV
shows the differences between the Class I and Class II
Division 1 malocclusion and facial types. The samples
with Class I malocclusion had a greater prevalence of al-
veolar defects, specifically dehiscences, which were
35% higher than in the patients with Class II Division
tween facial types.
Tables V, VI, and VII show the incidences of
alveolar defects. There were more alveolar defects
(75.65%) on the buccal root surfaces. Dehiscence was
associated with 51.09% of all teeth, with greater
prevalence in the mandible (57.35%). Dehiscence was
also more predominant on the buccal root surface
(69.43%), with the exception of the mandibular
central incisors, which had equal distributions on the
buccal and lingual surfaces. Large dehiscences
involving the apical root third represented 10.43% of
dehiscence defects and were more related to the
mandibular incisors (32.19%), maxillary (14.77%) and
mandibularr (14.39%) canines, and maxillary first
premolars (8.33%). Figure 1 shows axial and cross-
sectional views of dehiscence in the mandible in a Class
I malocclusion patient. The teeth most affected in man-
dible were the central (24.33%) and lateral (17.51%) in-
cisors, and the canines (17.13%). In maxilla, canines
(18.73%), first premolars (18.45%), and first molars
(18.27%) had more occurrences.
Fenestration was present in 36.51% of the sample.
Different from dehiscence, this type of alveolar defect
133.e4 Evangelista et al
Table VI. Incidence of dehiscence
Buccal Lingual Total
n % n % n %
Maxilla 1450 28.67 707 13.98 2157 42.65
Mandible 2062 40.76 839 16.59 2901 57.35
Total 3512 69.43 1546 30.57 5058 100
occurred with greater frequency in the maxilla (68.4%).
The results showed that the middle third root was the
most associated with fenestration (56.34%). The teeth
most affected in the maxilla were the lateral incisors
(18.24%), first premolars (18.06%), and canines
(17.87%). In the mandible, the lateral incisors
(25.36%), canines (22.35%), and central incisors
(21.05%) had more fenestrations. Figure 2 shows axial
and cross-sectional views of fenestration in the maxilla
of a Class I malocclusion patient. The panoramic distri-
bution of dehiscence and fenestration is shown in
Figure 3.
DISCUSSION
Our results suggest that alveolar defects such as
dehiscence and fenestration are common in the dental
arches; similar data were also found by Rupprecht
et al.14 In our sample, there was more dehiscence
(51.09%) than fenestration (36.51%). Studies have
shown different results for the prevalence of dehiscence
and fenestrations among various ethnic groups, ranging,
respectively, from 0.99% to 13.4% and from 0.23% to
16.9% in the teeth that were analyzed.14-22 It is
difficult to make a correlation with these studies
because of the different methods used, usually based
on analyses of skulls, a method quite different from
our method, which was based on volumetric CBCT
images of live patients. The diagnosis of alveolar
defects using CT, such as dehiscence and fenestration,
depends on length, thickness of the alveolar cortical
plate, and visualization of the periodontal ligament
space.23 Fuhrmann et al24 observed that, when cortical
thickness is less than 0.5 mm, the CBCT scan is rela-
tively accurate. Özmeric et al25 also reported that visual-
ization of the periodontal ligament space, when it is less
than 200 mm, is not detectable by CBCT. These factors
can contribute to false-positive results. Undoubtedly,
these were also limiting factors in this study, since, in
certain regions of the root, the alveolar bone and peri-
odontal ligament are extremely thin. At the same time,
in orthodontics, alveolar thickness less than 0.5 mm rep-
resents a ‘‘quasi defect,’’ because it is extremely thin and
should be considered a defect. This strongly indicates
American Journal of Orthodontics and Dentofacial Orthopedics
August 2010
Table VII. Incidence of fenestration
Buccal Lingual Total
n % n % n %
Maxilla 1431 59.11 225 9.29 1656 68.4
Mandible 697 28.79 68 2.81 765 31.6
Total 2131 87.90 293 12.10 2421 100
caution in orthodontic movement and does not invali-
date our results.2
The analysis of dehiscence and fenestration also de-
pends on the high-resolution image, which is related to
small voxel size in the CBCT.26 The voxel size of 0.25
mm used in this study could have contributed to poor
image resolution when compared using a dimension
of 0.125 mm; this might have compromised the reliabil-
ity of our results.26 However, the smaller voxel size has
greater radiation exposure compared with 0.25 mm.
This technical parameter choice must be balanced be-
tween the clinical objectives of the examination and
the exposure dose, since the higher image resolution im-
plies a higher dose of radiation.
These differences in dehiscence and fenestration be-
tween Class I and Class II Division 1 malocclusions
constitute new evidence. It is thought that tooth inclina-
tion might justify these differences. Patients with Class
II malocclusion have shorter alveolar bases in the ca-
nine, premolar, and maxillary molar regions when com-
pared with patients with Class I malocclusion and
normal occlusion.27,28 This transversal shortness has
greater dental inclination influence than skeletal
reduction because of the lingual orientation of these
teeth, a condition that allows for thicker bone in the
buccal region compared with teeth with a more
perpendicular position in their alveolus.27,28
In addition to dental inclinations, it is also thought
that crowding might be a factor in the differences be-
tween the malocclusions. In a Class I malocclusion,
crowding is a common feature, resulting in the misalign-
ment of crowns and roots. We did not intend to determine
the influence of crowding on alveolar defects. Other
studies with this methodologic approach on patients
with normal occlusion might confirm this assumption.
Some studies have reported that dolichofacial pa-
tients have thinner alveolar bone than do patients with
other facial types.2,4 So, in this study, the expectation
of finding dolichofacial types with higher prevalences
of alveolar defects was not confirmed, since there
were no statistically significant differences between
facial types. These data suggest that the high
prevalences of dehiscence and fenestration are
common anatomic findings, affecting different facial
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 138, Number 2
Fig 1. Axial and cross-sectional views of dehiscence
(yellow arrows) in the mandible of a patient with Class I
malocclusion.
types, and that the vertical position of the jaws does not
influence the presence of dehiscence or fenestration.
The clinical relevance of our results is to alert ortho-
dontic specialists about orthodontic movement in Class
I malocclusion patients. Their orthodontic treatment re-
quires less extensive tooth movement compared with
patients with Class II malocclusion. However, the mag-
nitude of tooth movement should be just as well planned
in Class I patients as in other malocclusions. At the
same time, these results guarantee greater reliability in
the treatment planning of patients with Class II maloc-
clusion because of the need for further extensions of
the dental displacement.
Another clinically important fact is related to the di-
rection of orthodontic movement and the groups of teeth
with higher risks of dehiscence and fenestration. Ac-
cording to the literature, dehiscence is more frequently
found in the mandible, whereas fenestration is more fre-
quent in the maxilla.14-23 Many studies have also found
alveolar defects on the buccal surfaces, a feature we also
found.14,15,19,20 This happens because the bone at the
buccal surface narrows, where the amount of marrow
bone is less dense than in the lingual region.23 These
Evangelista et al 133.e5
Fig 2. Axial and cross-sectional views of fenestration
(yellow arrows) in the maxilla of a patient with Class I mal-
occlusion.
data suggest greater caution about tooth proclination
in the mandibular arch, especially in the incisor region;
this has been emphasized by other authors.4-7,29-31 In
addition, this study showed many alveolar defects in
the lingual faces of the mandibular incisors; this
means that greater care is needed in planning
treatment for patients who need extraction of
mandibular premolars and retraction of incisors. The
maxillary canines and first premolars also showed
high prevalences of dehiscence in this study. This
offers an important clue to procedures involving rapid
expansion of the maxilla, since the first premolars,
and sometimes the canines, are the supporting teeth
for orthopedic devices. Because of the considerable
force needed to break the median palatine suture, an
evaluation of the periodontal structures, including
alveolar bone and gingival biotype, is an important
approach for the procedure. This is so because an
increase in alveolar bone height associated with
gingival recession,32 caused by the effects of dental in-
clination, has been observed.33
The prevalence of alveolar defects is interesting in-
formation for orthodontists, who can alert patients that
dehiscence and fenestration are probably common find-
ings in the population and are not caused by orthodontic
133.e6 Evangelista et al
Fig 3. Distributions of dehiscence and fenestration in A, Class I and B, Class II Division 1 malocclu-
sion (B, buccal surface; L, lingual surface).
movement alone. At the same time, the great prevalence
of alveolar defects found in this study cannot explain the
low prevalence of gingival recession before orthodontic
treatment. In the literature, gingival recession associ-
ated with orthodontic treatment is a controversial issue.
Studies about the role of the gingival phenotype as a pro-
tective factor in gingival recession have found that,
when thickness is more than 0.5 mm in the attached gin-
givae, the risk of gingival recession is reduced.7 A
thicker attached gingiva probably plays a decisive role
in preventing gingival recession even when the alveolar
bone is reduced or absent. Thus, for patients with a thin
attached gingiva, a correct diagnosis of bone support in
the periodontal evaluation is necessary. A diagnosis of
the relationship of the craniofacial structures should
also be made to moderate the tooth movement and con-
sequently reduce the risk of gingival changes.
With this in mind, the indication of tomographic im-
ages should be considered for orthodontic patients. The
American Journal of Orthodontics and Dentofacial Orthopedics
August 2010
European guidelines on radiation protection in dental
radiology recommend starting orthodontic treatment
in Class I malocclusion by using only panoramic radio-
graphs.34 Considering the ALARA principle, the indica-
tion for an imaging method should be based on the
patient’s clinical needs and obtaining maximum image
quality while maintaining a lower radiation dose. This
is worth considering, since orthodontic patients are be-
ing exposed to more and more radiation.35 However, in
patients needing more extensive orthodontic move-
ments, and those who have a less favorable gingival bio-
type such as thin attached gingiva, a 3-dimensional
diagnosis of alveolar bone is recommended to preserve
periodontal health during and after treatment.
CONCLUSIONS
Alveolar defects are a common finding before ortho-
dontic treatment, mainly in Class I patients, and are not
related to the facial types. Since 51.09% of all teeth are
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 138, Number 2
associated with alveolar defects prior orthodontic treat-
ment, a CBCT is especially recommended in cases of
buccal tooth movement, such as protrusion and arch
expansion.
Special thanks to Mesantis Berlin, Heilbronn,
Mayen, München and Wiesbaden for appropriation of
anonymerized CBCT data.
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