|Year : 2021 | Volume
| Issue : 1 | Page : 46-50
A modified protocol for periodontally accelerated osteogenic orthodontics using piezocision and platelet.rich fibrin in accelerating extraction space closure
Jinsa N Joseph1, A Shanaj Doulath1, Aniruddh V Yashwant1, Pratebha Balu2
1 Department of Orthodontics and Dentofacial Orthopedics, Indira Gandhi Institute of Dental Sciences, Puducherry, India
2 Department of Periodontology, Indira Gandhi Institute of Dental Sciences, Puducherry, India
|Date of Submission||26-Apr-2020|
|Date of Decision||13-Aug-2020|
|Date of Acceptance||24-Feb-2020|
|Date of Web Publication||25-Feb-2021|
Aniruddh V Yashwant
Department of Orthodontics and Dentofacial Orthopedics, Indira Gandhi Institute of Dental Sciences, Puducherry - 605 007
Source of Support: None, Conflict of Interest: None
Periodontally accelerated osteogenic orthodontics, a newly evolved technique, involves a combination of corticotomy followed by placement of bone graft and orthodontic force application for the closure of extraction space. This interdisciplinary approach has solved the issue of increased treatment duration by accelerating extraction space closure. The index case describes corticotomy procedure done using piezocision technique along with platelet-rich fibrin placement that has enhanced tooth movement, improved wound healing, and reduced adverse effects including root resorption and damage to periodontium. It was concluded that the orthodontic tooth movement was increased postsurgery, thereby lessening treatment duration and patient discomfort.
Keywords: Malocclusion, orthodontics, platelet-rich fibrin, tooth movement techniques
|How to cite this article:|
Joseph JN, Doulath A S, Yashwant AV, Balu P. A modified protocol for periodontally accelerated osteogenic orthodontics using piezocision and platelet.rich fibrin in accelerating extraction space closure. J Dent Res Rev 2021;8:46-50
|How to cite this URL:|
Joseph JN, Doulath A S, Yashwant AV, Balu P. A modified protocol for periodontally accelerated osteogenic orthodontics using piezocision and platelet.rich fibrin in accelerating extraction space closure. J Dent Res Rev [serial online] 2021 [cited 2021 Apr 21];8:46-50. Available from: https://www.jdrr.org/text.asp?2021/8/1/46/310197
| Introduction|| |
Orthodontics, a specialty in dentistry, deals with repositioning of teeth in order to achieve an esthetically pleasing profile and an efficient functional dentoalveolar complex. Crowding of teeth is one of the major challenges encountered in the routine orthodontic practice. In addition to esthetic problem, they pose a threat to dental hygiene resulting in increased risk of plaque formation and periodontal complications. Either tooth extraction or arch expansion is indicated in cases with moderate-to-severe crowding to gain space for alignment. With improving social standards and awareness, there has been a robust increase in the number of adults undergoing orthodontic treatment. Prolonged duration of the orthodontic treatment has been one of their major concerns. In addition, delay in orthodontic treatment accentuates the risk of root resorption and periodontal damage. Hence, various modalities have been devised to minimize treatment duration without compromising the treatment goal. Broadly, these are categorized into biological, physical, and surgical methods. Biological approach comprises the use of chemical agents to facilitate the tooth movement, whereas physical approach involves the use of magnets, lasers, etc., Among surgical approach, corticotomy and dental distraction deserve special mention.
Corticotomy is a surgical procedure that involves creating a breach in the cortical bone to stimulate osteogenesis and thereby facilitate tooth movement. Alveolar corticotomy accelerates tooth movement nearly 2–3 times as compared to conventional therapy. In addition, it has shown enhanced posttreatment stability and minimal root resorption. Piezocision technique is a minimally invasive technique that makes the use of Piezo surgical tip for creating incisions in the cortical bone. When compared with conventional burs, it provides improved bone healing without any osteonecrotic injury and enhances the maintenance of root integrity due to its precise and selective perforating action.
Periodontally accelerated osteogenic orthodontics (PAOO) is a term used to describe a procedure which combines both corticotomy and bone grafting for enhanced tooth movement, with special emphasis on the pattern by which bone heals, referred to as regional acceleratory phenomenon (RAP). It is a transient stage where osteoblasts and osteoclasts are recruited for localized tissue remodeling, thereby aiding in healing of injured bone. RAP can be induced by noxious stimulus and is found to be directly proportional to the nature and magnitude of stimulus. The noxious stimuli comprise crushing injuries, infections of bones, joints, and soft tissues, surgical interventions, fractures, etc., Once induced, acceleration of the normally occurring tissue processes occurs, resulting in superior wound healing. Platelet-rich fibrin (PRF) is an example of an autologous platelet–leukocyte concentrate in fibrin matrix that is known to enhance healing and regeneration of bone and soft tissues. PRF, a second-generation platelet concentrate, is rich in numerous growth factors and has gained a lot of popularity in the recent years due to its unique and easier method of preparation by avoiding the usage of an anticoagulant as compared to platelet-rich plasma (PRP). The growth factors include transforming growth factor-β, platelet-derived growth factor, epidermal growth factor, and vascular endothelial growth factor.
In this article, we report a case of successful application of PAOO as an adjunct to orthodontic treatment for premolar extraction space closure.
| Case Report|| |
A 22-year-old female patient without any history of systemic disease presented with a chief complaint of forwardly placed upper and lower front teeth. Extraoral examination revealed mesocephalic head form, mesoprosopic facial form, convex profile with posterior divergence, potentially competent lips, normal chin, and mentolabial sulcus. Intraoral examination showed forwardly placed upper and lower incisors with Class I molar and Class II canine relation bilaterally. Class II incisor relationship was present with an overjet of 7 mm and overbite of 3 mm.
The cephalometric assessment showed a Class II skeletal base with orthognathic maxilla and retrognathic mandible with severe proclination of upper and lower anterior teeth on an average growth pattern. The soft-tissue analysis revealed a protrusive and strained upper lip and an acute nasolabial angle.
The model analysis demonstrated overall maxillary excess by 5.3 mm as in Bolton's analysis, whereas the Carey's analysis showed arch length – tooth material discrepancy of 7 mm in maxilla and 6 mm in mandible suggestive of first premolar extraction [Figure 1] and [Table 1].
The first treatment option involved surgical orthodontics, wherein presurgical orthodontic alignment and levelling (decompensation) followed by bilateral sagittal spilt osteotomy for advancement of the mandible and postsurgical finishing and detailing was planned. Sine the patient was not willing for orthognathic surgery, the second treatment option involving camouflage orthodontic treatment was planned. This camouflage Class II correction involved fixed orthodontic mechanotherapy using MBT 022” prescription with extraction of all first premolars using mini implant-supported anchorage.
Initially, 0.016” nickel–titanium (NiTi) archwires were used for alignment and leveling, followed by 0.016” × 0.022” and 0.017” × 0.025” NiTi archwires, and subsequently, 0.019” × 0.025” stainless steel wires were used. Leveling and alignment were accomplished in 4 months, and thereafter, space closure procedure was initiated. A mini-implant of size 1.4 mm × 10 mm was placed in the interradicular region between second premolar and molar. Elastomeric chain was stretched between implant and crimpable hook that was soldered to the archwire between lateral incisor and canine [Figure 2].
Space closure was found to occur at the rate of 0.05 mm over a period of 2 months which was very minimal. Considering the patient's request for accelerating the space closure, PAOO was suggested. Hence, the patient was referred to the department of periodontology for further opinion regarding the same. A modified PAOO procedure which involved corticotomy followed by placement of PRF was planned. Surgical procedure was explained to the patient in detail. Informed consent was taken from the patient and relative. Before surgery, complete oral prophylaxis was done and the patient was instructed to follow oral hygiene measures.
Preparation of platelet-rich fibrin
Ten milliliters of venous blood was withdrawn from the patient by a phlebotomist, which was then transferred into sterile plain vacutainer tube. The sample was then centrifuged at 3000 rpm for 10 min. The difference in weight of the individual blood components resulted in formation of three different layers, the heavier red blood cells settled at the bottom, an upper layer of cell-free serum, and a middle fraction comprising fibrin clot. The middle fibrin clot was then collected, 2 mm beneath the lower demarcating line so as to procure PRF.
Local anesthesia was administered and a full-thickness mucoperiosteal flap was reflected, extending beyond the mucogingival junction with respect to 13 and 15 regions [Figure 3]a. Piezocision technique (Osada ENAC™, Osada, Inc. LA, USA) was used to place vertical cuts using 0.4 mm piezotip (ST71 SWORD TIP L) in the interradicular region. These cuts were placed 2–3 mm above the alveolar crest to nearly 2 mm below the root apices. A round bur was then used to make perforations over radicular bony surfaces [Figure 3]b. PRF [Figure 3]c was then placed over the decorticated region [Figure 3]d and the flap was approximated using interrupted simple sutures (Ethicon Mersilk 3-0). [Figure 3]e.
|Figure 3: (a) Full-thickness flap elevated. (b) Vertical cuts with perforations. (c) Platelet-rich fibrin. (d) Placement of platelet-rich fibrin. (e) Placement of sutures|
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Coe-Pak was placed to ensure the protection of the surgical site. Instructions regarding postoperative care were explained. Adequate analgesia was given, and antibiotics were prescribed. Sutural removal was done after 10 days and surgical site exhibited good healing without any complications [Figure 4]. Orthodontic treatment was resumed after 2 weeks, and mild forces of 150–200 g were applied using elastomeric chain between implant and crimpable hook for space closure. Activation of elastomeric chain was done every 2 weeks, and complete space closure was achieved within a period of 3 months [Figure 5].
| Discussion|| |
PAOO is an adjunctive surgical procedure that accelerates the process of space closure. Adequate orthodontic forces and reduced alveolar bone resistance are considered to be the two major factors that contribute toward an ideal orthodontic tooth movement. An increase in bone metabolic rate can result in acceleration of the tooth movement. Studies by Mostafa et al. concluded that corticotomy procedure performed in dogs resulted in twice the rate of tooth movement, which could be attributed to RAP phenomenon and enhanced bone turnover rate. It was shown that following alveolar corticotomies, the divided blocks of bones connected only by trabecular bone could be moved easily when external forces are applied. Hence, the vertical cuts attenuate resistance offered by cortical bone to orthodontic tooth movement.
A surgically induced trauma stimulates bone remodeling and initiates the process of repair. During this process, it passes through a particular phase, known as RAP, which is characterized by temporary and localized surge in metabolism and reduced bone density. Following corticotomy, adjacent trabecular bone also undergoes significant changes in terms of bone volume as well as density similar to that of RAP that occurred during the healing process of long bones, thereby supporting this phenomenon. Corticotomy performed using piezocision technique has better acceptability in terms of patient comfort and also allows placement of hard- and soft-tissue grafts in case of mucogingival defects, bony fenestrations, or bony dehiscence. This technique accesses buccal alveolar bone by means of microsurgical interproximal openings in the gingivae and utilizes the demineralization properties of piezoelectric knife to create bone injury that will initiate RAP effect.
Injury to blood vessels results in extravasation of blood which is followed by hemostasis resulting from platelet aggregation, activation, and formation of fibrin clot. In addition, activated platelets release bioactive proteins that are important for tissue repair and regeneration. These properties make platelets a suitable therapeutic agent in both medical and dental fields. PRP and PRF are two important platelet concentrates. Even though both are equally effective in enhancing healing, PRF is preferred over PRP owing to its lesser cost and ease of use. Tehranchi et al. have shown that placement of PRF in extraction socket enhanced tooth movement with smoother healing as compared to the control group.
In this case, orthodontic treatment was initiated following extraction of first premolars. However, closure of extraction space was found to occur at a very slow rate of 0.5 mm over a period of 2 months on application of forces. Hence, corticotomy was performed using piezocision technique followed by placement of PRF. Rapid wound healing was noted at 2 weeks postoperatively without any complications. Space closure was then initiated by application of orthodontic forces. We were able to achieve complete closure of space within a period of 3 months.
With fixed appliances in the oral cavity, maintenance of oral hygiene becomes difficult, especially in children, which can ultimately lead to plaque accumulation, calculus, and periodontal issues to a more severe extent. This issue is frequently encountered in individuals undergoing orthodontic therapy for a period of 2 years or more. A significant reduction in treatment duration by PAOO technique, as described in the index case, appears to be a promising answer to this problem. Thus, interdisciplinary management of cases gives us a better opportunity to make the use of various resources, thereby providing better results in terms of outcome, treatment duration, and patient compliance.
Being a single case study, the level of evidence is low, and further studies are warranted to affirm these benefits. Invasive nature of alveolar corticotomy is another drawback. Modification of this technique to a less invasive procedure might provide better patient acceptance and even better wound healing.
| Conclusion|| |
A combination of corticotomy and PRF (PAOO), as described in this case, was found to have profound beneficial effects on the treatment outcome. Alveolar corticotomy performed using piezocision technique might improve the resistance of teeth to force application, accelerate tooth movement, and thereby enhance extraction space closure at the cost of an invasive procedure. The addition of PRF treatment might potentially enhance the wound healing process and might avoid complications of delayed healing. PAOO may be considered as an adjunctive therapy in individuals exhibiting a very slow rate of tooth movement and in those patients where treatment duration is a major concern.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]