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Periodontal Accelerated osteogenic orthodontics

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REVIEW ARTICLE

Periodontal Accelerated Osteogenic Orthodontics – An Interdisciplinary

Approach

Lynn Johnson1, Sachin B Mangalekar2, Shoba P More3, Priyanka Thakur4, Nandakishore Reddy5,
6
Javed sodawala
1. Post graduate student, Department of Periodontics, Maitri college of dentistry and research center,
Anjora, Durg, Chhattisgarh
2. Professor, Department of Periodontics, Maitri college of dentistry and research center, Anjora, Durg,
Chhattisgarh
3. Professor, Department of Periodontics, Sindbad Dental College and Hospital, Pune
4. Senior lecturer, Department of Periodontics, Maitri college of dentistry and research center, Anjora,
Durg, Chhattisgarh
5. Professor, Department of Orthodontics, Maitri college of dentistry and research center, Anjora, Durg,
Chhattisgarh
6. Senior lecturer, department of orthodontia, Rungta dental college, Bhilai CG
Corresponding address – Sachin B Mangalekar, Professor, Department of Periodontics, Maitri college of
dentistry and research center, Anjora, Durg, Chhattisgarh, email - drsachinbm@yahoo.com

Abstract:
This systemic review is aimed to access the available literature on Periodontal Accelerated Osteogenic Orthodontics (PAOO) a clinical procedure
combining selective alveolar decortications, particulate bone grafting and application of orthodontic forces. The Pubmed electronic database of the US
National Library of Medicine was used to search articles published upto Dec. 2012. A manual search covered the reference lists of the included articles, as
well as of review articles concerning the topic. Furthermore the “related articles” option on the NCBI Website was used as data source. Results were
limited to English articles only. This procedure is theoretically based on Frost’s bone healing pattern known as regional acceleratory phenomenon. In
1990s, Dr. Wilcko discovered that reduced mineralization was the reason behind rapid tooth movement following corticotomies. When combined with
alveolar augmentation, one is no longer strictly at the mercy of the original alveolar volume and osseous dehiscences, and fenestrations can be corrected
over vital root surfaces. As bone is decorticated it goes through a transient phase of osteopenia and braces can move the teeth quickly as bone is softer and
there is less resistance to forces. PAOO results in an increase in alveolar bone width, shorter treatment time, increased post-treatment stability and
decreased apical root resorption. By combining the talents of the periodontist and the orthodontist, a viable and a safe orthodontic treatment can be
completed in a fraction of the time required for conventional orthodontics.

Key-words: regional acceleratory phenomenon, accelerated osteogenic orthodontics, bone grafts, corticotomy.

Introduction: was later adapted to the maxillofacial skeleton and alveolar

An increasing number of adult patients have been seeking ridge.8

orthodontic treatment, and a short treatment time has been a
recurring request. As a result a number of surgical
techniques have been developed to meet their expectations .
Periodontal accelerated osteogenic orthodontics (PAOO) is
The current corticotomy procedures adopted or modified by
most clinicians are based on Henrick Kole’s combined
1
radicular corticotomy/supra-apical osteotomy technique, first
described in 1959. From Kole’s work arose the term bony
4,5

one such clinical procedure that combines selective alveolar blocks to describe the suspected mode of movement after
11,12

decortications, particulate bone grafting and application of corticotomy surgery. Kole believed that teeth were
4,6

orthodontic forces . Dr. William Wilcko and Dr. Thomas

2
embedded and moved in “blocks of bone” connected to each
Wilcko of Erie PA in 1995 developed the phrase Accelerated
3
other by medullary bone only, instead of today’s
Osteogenic Orthodontics (AOO) and more recently as
1,2,4
understanding of how teeth move through alveolar bone.
Periodontal accelerated osteogenic orthodontics (PAOO) 1,2,4,5,6,
Therefore, he postulated that with less resistance from
based on Harold Frost’s (1983) bone healing pattern known
2,5
medullary bone compared with that from the denser cortical
as regional acceleratory phenomenon (RAP) . 2,4,5,6
plate, rapid tooth movement could be achieved. Kole’s 5

procedure involves the reflection of full thickness flaps to

Historical perspective:
Surgically assisted orthodontic tooth movement has been
used since the 1800s. Corticotomy facilitated tooth
movement was first described by L.C.Bryan in 1893
published in a textbook by S.H.Guilford. A corticotomy is
5
defined as a surgical procedure whereby only the cortical
bone is cut, perforated or mechanically altered. The
medullary bone is not changed. Distraction osteogenesis is
4
a process in which new bone is created in a defect of the
alveolar ridge by stretching existing bone. The process was
originally developed by a Russian orthopedist, Gavriel
Illizarov , for the correction of long bone deformities. It
7,8,9,10
expose buccal and lingual alveolar bone, followed by
interdental cuts through the cortical bone and barely
penetrating the medullary bone (corticotomy style). The
2
subapical horizontal cuts connecting the interdental cuts were
osteotomy style, penetrating the full thickness of the alveolus
approximately 1mm beyond the apices of the roots. Because
of the invasive nature of Kole’s technique, it was never widely
accepted.
Duker used Kole’s basic technique on beagle dogs to
investigate how rapid tooth movement with corticotomy
affects the vitality of the teeth and the marginal periodontium.
The health of the periodontium was preserved by avoiding the

Chhattisgarh Journal of Health Sciences, September 2013;1(1) : 61

AYUSH
marginal crest bone during corticotomy cuts. It was
concluded that neither the pulp nor the periodontium was
damaged following orthodontic tooth movement after
corticotomy surgery. The results helped to substantiate the
belief regarding the health of crestal bone in relation to the
corticotomy cuts. Design of the subsequent techniques has
taken this into consideration; the interdental cuts are always
left at least 2 mm short of the alveolar crestal bone level. In
2,11
1991 Suya replaced subapical horizontal osteotomy with
13
horizontal corticotomy to facilitate luxation of the
corticotimized bone blocks. 2,5,12
Wilcko et al further modified the corticotomy assisted
orthodontic technique with the addition of alveolar
augmentation and patented the procedure as periodontal
accelerated osteogenic orthodontics (PAOO). Wilcko’s
2,11
modification technique used a combination of
demineralized freeze dried bone allograft/ xenograft/ or a
bioabsorbable alloplastic graft. Several reports indicated
5
that this technique is safe, effective, extremely predictable,
associated with less root resorption and reduced treatment
time, and can reduce the need for orthognathic surgery in
certain situations. 2
Biology underlying periodontal accelerated osteogenic
orthodontics (PAOO)
In PAOO technique, cortical bone is scarred surgically on
both labial and lingual side of the teeth to be moved followed
by grafting. The patient is seen every 2 weeks, and the rapid
tooth movement produced after PAOO is substantially
different than periodontal ligament cell-mediated tooth
movement. Recent evidence suggests a localized
osteoporosis state, as a part of a healing event called regional
acceleratory phenomenon (RAP) responsible for the rapid
tooth movement after PAOO. 2
Harold Frost realized that there was a direct correlation
between the degree of injuring a bone and the intensity of its
healing response called as RAP. He recognized that surgical
wounding of osseous hard tissue results in striking
reorganizing activity adjacent to the site of injury in osseous
and/or soft tissue surgery. RAP healing is a complex
physiologic process with dominating features involving
accelerated bone turnover and decreases in regional bone
densities. The term ‘regional’ refers to the demineralization
12
of both the cut site and adjacent bone (Bogoch et al, 1993).
The term acceleratory refers to an exaggerated or intensified
bone response in cuts that extend to the marrow. It is
postulated that osteoclast and osteoblast cell populations
shift in number, resulting in an osteopenic effect (Bogoch et
al 1993; Schilling et al 1998). 10
Norrdin demonstrated that when intraoral cortical bone was
injured by corticotomy, RAP accelerated the normal regional
healing processes by transient bursts of hard and soft tissue
remodeling which rebuilds the bone back to its normal state.
2 3
The theory behind accelerated tooth movement is that the
corticotomy induces a response in the alveolar bone that can
demineralize the bone around the dental roots. Once the bone
has demineralized there is a 3 to 4 months window of
opportunity to move the teeth rapidly through the
demineralized bone matrix before the alveolar bone
remineralizes. Following decorticotomy, RAP potentiates
tissue reorganization and healing by the way of a transient
burst of localized hard and soft tissue remodeling. The bone
goes through a phase known as osteopenia, where its mineral
content is temporarily decreased. The tissues of the alveolar
bone release rich deposits of calcium and a new bone begins
62
to mineralize in about 20-55 days. While the alveolar bone is
in this transient state, the tooth movement will be faster as the
bone is softer and there is less resistance to the orthodontic
forces. This accelerated bone remodeling is influenced by
bone density and the hyalinization of the periodontal
ligament. Pfeifer found increased osteoclastic activity along
314 12
the PDL surface following surgery. There is strong indirect
evidence that the physiologic events associated with RAP
following surgery, i.e. calcium depletion and diminished bone
densities, result in rapid tooth movement. Osteoclasts are
capable of demineralizing bone via a proton pump. 3,15
The best technique consists of punctate and linear
decortication in areas of the alveolus where accelerated and
stable tooth movement is desired. The bone is added ad hoc
where augmentation is needed. As teeth are moved through a
healing wound with or without bone graft, the bone is stressed.
However, the movement of teeth produces tensional stress in
the bone, the maturation and eventual recalcification of the
repair tissue is delayed as long as the bone ‘senses’ tooth
movement. The reaction is similar to bone fracture that
requires immobilization to achieve full development. The
healing callus will be delayed in final calcification when
subjected to tensional stress.
The 2 main features of RAP in bone healing includes
decreased regional bone density and accelerated bone
turnover, which are believed to facilitate orthodontic tooth
movement. 5,2
Case selection:
PAOO can be used to accelerate tooth movement in most of
the cases requiring orthodontic treatment. It has been shown
to be particularly effective in treating moderate to severe
crowding, in class II malocclusions requiring expansions or
extractions, and mild class III malocclusions. 2,16, 17
PAOO can be used in both maxillary and mandibular arches. 2
Surgical technique
The surgical technique for PAOO consists of 5 steps viz. 2
1) Raising of flap, 2) Decortication,
3) Particulate grafting, 4) Closure and
5) Orthodontic force application.
Flap design:
The objectives of flap design are to 1)provide access to the
alveolar bone wherein corticotomies are to be performed
2)provide for coverage of the particulate graft 3)maintain
height and volume of the interdental tissues and 4)enhance
esthetic appearance of gingival form where necessary. 4
A proper flap design is essential for the success of any surgical
procedure. In PAOO also the flap should provide proper
access to the alveolar bone wherein corticotomies are to be
performed. A full thickness periodontal flap is raised on both
sides. The flap should be extended beyond the corticotomy
sites mesially and distally so that vertical releasing incisions
are not required. For esthetic purposes the papilla between the
maxillary central incisors should be preserved on the labial
and palatal aspects (fig 1 a-e). Access to the labial alveolar
bone in this area is achieved by “tunnelling” from the distal
aspect.2
Retention of a palatal or lingual gingival collar of tissue, not
reflected from the underlying alveolar bone is frequently used
to provide a collateral blood supply to the papillary tissue. 4
Decortication
Decortication refers to the removal of the cortical portion of
 Periodontal Accelerated Osteogenic Orthodontics – An Interdisciplinary Approach

the alveolar bone. However, it should be just enough to
initiate the RAP response and should not create movable
bone segments. After flap elevation, decortications of bone
adjacent to the malpositioned teeth is performed by using
low-speed round burs under local anaesthesia (Fig 1 f-g). In
the PAOO procedure, decortication is performed at clinical
sites without entering the cancellous bone, avoiding risk of
damage to underlying structures, such as the maxillary sinus
and the mandibular canal. The corticotomies may also be
achieved with a piezoelectric knife. The corticotomies are
placed on both the labial and lingual (palatal) aspects of the
alveolar bone. 2
By the use of a no.1 or no. 2 round bur in either a high speed
handpiece or dental implant drill, decortications are made in
aspect of PAOO is performed. However, if complex
mucogingival procedures are combined with the PAOO
surgery, the lack of fixed orthodontic appliances may enable
easier flap manipulation and suturing. After flap
repositioning, an immediate heavy orthodontic force can be
applied to the teeth and in all cases initiation of orthodontic
force should not be delayed more than 2 weeks after surgery.
A longer delay will fail to take full advantage of the limited
time period that the RAP is occurring. The orthodontist has a
limited amount of time to accomplish accelerated tooth
movement. This period is usually 4 to 6 months, after which
finishing movements occur with a normal speed. Given this
limited “window” of rapid movement, the orthodontist will
need to advance arch wire sizes rapidly, initially engaging the
largest arch wire possible. 2,4

the alveolar bone. Typically a vertical groove is placed in the

inter-radicular space, midway between the root
prominences in the alveolar bone. The groove extends from
a point 2 to 3mm below the crest of bone to a point 2mm
beyond the apices of the root. These vertical corticotomies
are then connected with a circular shaped corticotomy. Care
is taken not to extend the cuts near any neuro-vascular
structures. If the alveolar bone is of sufficient thickness,
solitary perforations may be placed in the alveolar bone over
the radicular surface. However if the bone is estimated to be
less than 1 to 2mm in thickness, these perforations are
omitted to ensure damage to the radicular surface. 4

Particulate grafting
Grafting is done in most areas that have undergone
corticotomies. The materials most commonly used for
grafting after decortication are deproteinized bovine bone,
autogenous bone, decalcified freeze-dried bone allograft, or
a combination thereof. Grafting is done in most areas that
have undergone corticotomies (fig 2.b). The volume of the
graft material used is dictated by the direction and amount of
tooth movement predicted, the pre-treatment thickness of
the alveolar bone, and the need for labial support by the
alveolar bone. A typical volume used is 0.25 to 0.5 ml of
graft material per tooth. 2,4

No objective data exist comparing one grafting material
with another in terms of superiority. The use of barrier
membrane is not suggested. The decorticated bone acts to
retain the graft material. The use of platelet-rich plasma or
calcium sulfate has been reported to increase the stability of
the graft material.4
Fig 1- a to e showing (a) preoperative view with localized
gingival enlargement with 31,32,33,41,42,43, (b) straight
surgical hand piece with carbide round bur (c) exposed bone
surface after full thickness mucoperiosteal flap elevation on
the buccal side along with gingivoplasty (e) 31,32,41,42

showing dehiscence osseous defect

Closure techniques
Primary closure of the gingival flaps without excessive
tension and graft containment are the therapeutic endpoints
of suturing. The flap should be closed using non resorbable
interrupted sutures without creating excessive tension. No
packing is required. The sutures are usually left in place for 1
to 2 weeks (fig.2 a to d).
The specific suture used is determined by the thickness of
the tissue. The sutures that approximate the tissue at the
midline are placed first to ensure proper alignment of the
papilla. The remaining interproximal sutures are placed
next, followed by closure of any vertical incisions. No
packing is required. 2,4

Fig 2- a to d showing a-corticotomy done in between 42,43

Timing of orthodontic treatment
and 32,33, (b) perioglass bone graft placed in dehiscence
The placement of orthodontic brackets and activation of the
defect (c) suturing done (d) coepack placed
arch wires are typically done the week before the surgical
Chhattisgarh Journal of Health Sciences, September 2013;1(1) : 63
AYUSH
Patient management
The PAOO surgical procedure can take several hours to
complete when treating both the arches. Because of the
length of this procedure, sedation of the patient is suggested.
The use of short term-steroids, given either IV or orally also
enhances patient comfort and clinical healing. Antibiotics
and pain medications are administered at the clinician’s
preference. However the long-term post-operative
administration of NSAIDS is discouraged, because they
may theoretically interfere with the regional acceleratory
phenomenon. The application of ice packs to the affected
area also is suggested to decrease the severity of any
possible post operative swelling or edema.
Most commonly reported post surgical complications are
edema and ecchymosis both of which are self limiting. The
patient will return for post surgical evaluation and gentle
prophylaxis every week for the first month and then
monthly thereafter. 4
Complications and side effects:
Although PAOO may be considered a less-invasive pro-
cedure than osteotomy-assisted orthodontics or surgically
assisted rapid expansion, there have still been several
reports regarding adverse effects to the periodontium after
corticotomy, ranging from no problems to slight interdental
bone loss and loss of attached gingiva, to periodontal defects
observed in some cases with short interdental distance.
Subcutaneous hematomas of the face and the neck have
been reported after intensive corticotomies. In addition,
some post-operative swelling and pain is expected for
several days.
No effect on the vitality of the pulps of the teeth in the area of
corticotomy was reported. Long-term research on pulpal
vitality after rapid movement has not been evaluated in the
literature. In an animal study, Liou et al demonstrated
normal pulp vitality after rapid tooth movement at a rate of
1.2 mm per week. However, pulp vitality deserves
additional investigation.
It is generally accepted that some root resorption is expected
with any orthodontic tooth movement. An association
between increased root resorption and duration of the
applied force was reported. The reduced treatment duration
of PAOO may reduce the risk of root resorption. Ren et al.
reported rapid tooth movement after corticotomy in beagles
without any associated root resorption or irreversible pulp
injury. Moon et al reported safe and sufficient maxillary
18
molar intrusion (3.0 mm intrusion in two months) using
corticotomy combined with a skeletal anchorage system
with no root resorption. Long-term effect of PAOO on root
resorption requires further study. 2,13
Indications and clinical applications : 2,13
1. Resolves crowding and shortens the treatment time.
2. Accelerated canine retraction after pre-molar
extraction 2,4,13,17
3. Enhance post orthodontic stability 2,11,13
4. Facilitate eruption of impacted teeth 2,13
5. Facilitate slow orthodontic expansion 2,4,11,13
6. Molar intrusion and open bite correction
7. Manipulation of anchorage 2,13
Contraindications and limitations:
1. Patients with active periodontal disease or gingival
recession. 2,11,13
2. Patients with insufficient attached gingiva, dental caries,
uncontrolled diabetes mellitus, compromised immune
64
system and patient incompliance. 17
3. PAOO should not be considered as an alternative for
surgically assisted palatal expansion in the treatment of
severe posterior cross-bite.2,13
4.
Osteoporosis or other bone diseases 17
5. PAOO should not be used in cases were bimaxillary
protrusion is accompanied with a gummy smile, which
might benefit more from segmental osteotomy. 2,13
6. Long term use of medication (anti-inflammatory,
immunosuppressive, bisphosphonates or steroids) 17
Technique modifications
Significant acceleration in orthodontic tooth movement has
been extensively reported following a combination of
selective alveolar decortication and bone grafting surgery,
with the latter being responsible for the increased scope of
tooth movement and the long-term improvement of the
periodontium. Although quite effective, the trauma generated
by the necessity to raise large flaps and the extensive nature of
the corticotomies have met with some resistance in patients
and the dental community.
An alternative approach has been recently introduced by Park
et al, consisting of incisions directly through the gingiva and
bone using a combination of blades and a surgical mallet.
While decreasing the surgical time (no flaps or sutures; only
cortical incisions), this technique did not offer the benefits of
bone grafting to increase periodontal support in the areas
where expansive tooth movement was desired. In addition,
the extensive hammering in office to perform the cortical
incisions appears to certain patients to be somewhat
aggressive. Moreover, dizziness and benign paroxysmal
positional vertigo have been reported, following the use of the
hammer and chisels in the maxilla. 16
Dibart et al developed Piezocision a minimally invasive
procedure combining microincisions, minimal piezoelectric
osseous cuts to buccal cortex only and bone and soft tissue
grafting concomitant with tunnel approach. 11,16
PAOO can be successfully combined with gingival
augmentation procedures. This is particularly important to the
adult patient who presents with significant gingival recession.
In these situations a sub-epithelial connective tissue graft is
placed over the denuded root surface in addition to particulate
graft placement. The graft is harvested by removing a 1 to
2mm thickness of gingival connective tissue from the
elevated palatal flap.
4
Discussion
The fact that the teeth can be moved more rapidly, thus
resulting in shortened treatment times, is certainly advan-
2,11,13,17
tageous to the patient’s periodontal health because less time in
fixed appliances reduces patient “burnout” and substantially
reduces the time available for relatively benign commensal
bacterial biofilms to assume qualitative changes and convert
to a destructive cytotoxic potential often seen when fixed
appliances have remained on the teeth for more than 2 to 3
2,11,13,18,19
years. The significance of the increase of the rate of tooth
movement, however, pales in comparison to the fact that the
teeth can be moved two to three times further than would be
possible with traditional orthodontics alone, and that the cases
can be completed with an increased alveolar bone volume .
This increased alveolar volume can provide for a more intact
periodontium, a decreased need for extractions, a degree of
facial reshaping, and an increase in the bony support for both

the teeth and the overlying and soft tissues.
The ability to increase the post treatment alveolar volume
and cover vital root surfaces can result in the repair of
preexisting alveolar dehiscences over root prominences and
lessen the likelihood of new dehiscence formation, which
can be a contributing factor to gingival recession. 6
Conclusion
PAOO is an effective treatment approach in adults to
decrease treatment time and reduce the risk of root
resorption. From an esthetic perspective the PAOO
technique not only addresses tooth alignment, but also facial
features and as such is truly in vivo tissue engineering. With
a combination of both in-office periodontal surgery and
orthodontic treatment, we can now more routinely address
the esthetics of the entire lower face. 2,6
By combining the talents of the periodontist and the
orthodontist a viable and a safe orthodontic treatment can be
completed in a fraction of the time required for conventional
orthodontics. 3
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