Can we improve atrophic alveolar ridge by surgically ...€¦ · Can we improve atrophic alveolar ridge by surgically-assisted tooth movement? ... Can we improve atrophic alveolar

Associate Professor, Dept. of Orthodontics,

Kyung Hee University School of Dentistry,

Seoul, South Korea

Su-Jung Kim

Can we improve atrophic alveolar ridge

by surgically-assisted tooth movement?

Accelerated tooth movement

Accelerated tooth movement

• Non-invasive Not clinically significant

• Minimally-invasive Not clinically significant enough

• Invasive Can be available, but less than 3 months

• Well-designed prospective clinical study is needed.

Surgically-assisted orthodontics

Osteogenic orthodontics

Corticision

Corticotomy Ridge augmentation

Micro-osteoperforation

osteotomy

Surgically-assisted orthodontics

Minimally-Invasive Cortical Activation

• Corticision

• Piezocision

• Piezopuncture

• Micro-osteoperforation

Osteotomy-assisted orthodontics

• Segmental osteotomy

• Individual tooth osteotomy

• Alveolar distraction osteogenesis

Corticotomy-facilitated orthodontics

• Block / Individual corticotomy

• Selective alveolar decortication

• Periodontally accelerated osteogenic orthodontics

Transient accelerating effect of OTM!

Surgically-facilitated orthodontics

Liem et al. British J Oral Maxillofac Surg 2015

Miles P. Australian Dent J 2017

El-Angbawi et al. Cochrane Database Systematic review 2015

Alfawal et al. Prog Orthod 2016

investigation on overall treatment time

well-controlled prospective clinical study

high level of evidence

Goal I. Reducing treatment time

Goal I. Reducing treatment time

Goal ll. Overcoming anatomical limitation

Surgically-assisted orthodontics

ATM into atrophic alveolar ridge

Part I. Orthodontic root thrusting

Part II. Surgically-assisted TM

Part III. Biomodulation-assisted TM

Residual Ridge Resorption

Part I. OTM into atrophic alveolar ridge

OTM into atrophic ridge in Adults

Zachrisson . J Clin Orthod. 2005

OTM into atrophic alveolar ridge

for prosthetic preparation?

Ridge width around the moved tooth?

looked increased but by the tooth width

not by new bone formation.

Lindskog-Stokland et al. Eur J Orthod. 2013

OTM into atrophic alveolar ridge

with paradental improvement?

OTM into atrophic ridge in adults

1. Impaired tooth movement

2. Dehiscence & attachment loss

3. Lateral root resorption

Lindskog-Stokland et al . Eur J Orthod. 1993

Orthodontic solution for atrophic ridge

Bodily movement in case of a tooth with normal vertical periodontal support

“Orthodontic in vivo tissue engineering”

Root thrusting movement

W. Eugene Roberts. PCSO 2014

Birte Melsen. 2014

Can we improve atrophic alveolar ridge

by root thrusting only?

1

B

No intervention

Group C (n=4)

Root thrusting

Group R (n=6) Group RD (n=6)

Decortication

Hwang DH, Lee WJ, Baek SH, Kim KA, Park YG, Kim SJ. Angle Orthod 2017 in press with or without open-flap decortication

Response of atrophic ridge to Root thrusting

Can we improve atrophic ridge by Root thrusting?

Hwang DH, Lee WJ, Baek SH, Kim KA, Park YG, Kim SJ. Angle Orthod 2017 in press

Reciprocal root thrusting

bone density

bone volume

+ open-flap decortication

• Bone volume: N-S

• Bone density

• Rate of TM

Orthodontic approach for atrophic ridge

1. Growing patient

2. Teeth with normal marginal bone support

3. No severely constricted ridge thickness

4. Root-dominant movement

Surgical approach !

Part II. Surgically-assisted TM into atrophic ridge

Ridge augmentation Segmental osteotomy Flapless decortication

II-1. TM into atrophic ridge

treated by

Ridge augmentation

Bio-Oss collagen graft

Collagen membrane

Decortication

2W after surgery

Ridge augmentation

6M after protraction

12M after protraction

12M after protraction (14M after bone graft)

Can we improve atrophic alveolar ridge by

augmented corticotomy-assisted TM ?

2

Demineralization; therapeutic osteopenia

Osteoid transportation

+

Osteoconduction

Remineralization; at the end of TM

“Bone matrix transportation”

Healing after augmented corticotomy

Shoreibah et al. J Int Aca Periodontol 2012

Wilcko, JOMS 2009

Amit et al. J Clin Exp Dent 2012

• Bone volume

• Bone density

; as long as TM is accompanied

1. Need high skill for flap surgery

2. Need waiting time before initiating TM

3. Risk of impaired TM & root resorption

4. Risk of graft failure (only-graft type)

Clinical efficacy for orthodontists?

Ru et al. Am J Orthod Dentofacial Orthop 2016

II-2. TM into atrophic ridge

treated by

flapless decortication

Highly resistant TM

Micro-osteoperforations (MOP)

2W post-MOP 3 M post-MOP

Before MOP

3M post-MOP

Healing after Flapless decortication

Microdamage

ATM

Transient Osteopenia

Less Hyalinization

Activation

Resorption

Formation

RAP

Can we improve atrophic alveolar ridge

by flapless decortication-TM ?

3

B

OTM OTM+ MOP

Group C (n=6) Group MOP (n=6)

Lee JW, Lee JH, Cha JY, Kim SJ. AJODO 2017 in review

Response of atrophic ridge to flapless MOP

Can we improve atrophic ridge by Decortication-TM?

Flapless decortication

• Bone volume: N-S

• Bone density

• Rate of TM

II-3. TM into atrophic ridge

treated by

Segmental osteotomy

Asymmetric ASO

Post-surgical TM into osteotomy gap

Protraction of posteriors Retraction of anteriors

Midline correction

Can we improve osteotomy gap

on the preexisting atrophic ridge with ATM?

4

Wang et al, 2009

Osteotomy-assisted TM

- Fracture or DO-like healing

- No paradental osteopenia

Corticotomy-facilitated TM

- Transient local osteopenia

around roots by RAP

Healing after Osteotomy / Corticotomy

0W: Fresh wound 2W: Woven bone Hypermaturation 12W: Non-union

Healing-based TM into osteotomy gap

Healing of osteotomy- preexisting atrophic ridge

9M after ASO

2015

Initiating TM at 0, 2, 12 weeks post-op.

Osteotomy + Graft +TM Osteotomy +TM

O-0 O-2 O-12 OG-0 OG-2 OG-12

TM at 2W post-osteotomy

• Bone volume: N-S

• Bone density

• Rate of TM

Immediate TM to grafted-osteotomy

Can we improve Osteotomy gap with ATM?

Part III. Biomodulation-assisted TM

2015

Can we improve Osteotomy-TM with biostimulation?

TM into Lased-grafted-osteotomy

• Bone volume N-S

• Bone density

• Rate of TM

Healing-based Orthodontics

1. Optimal timing to initiate post-surgical TM depends on

defect healing state: Target woven bone!

2. Biomodulation of healing state is promising to develop

a novel ATM procedure with periodontal regeneration.

Horizontal constriction

Marginal bone support

Surgically-assisted TM Orthodontic

root thrusting

Augmented

corticotomy Flapless

decortication

Segmental

osteotomy

Healing-based TM into atrophic ridge

Can we modulate the healing period

to maximize the woven bone state?

5

2017

A

Natural healing model OTM-related healing model

B

C D

Microarray gene profiling

Hierarchial clustering heatmap

D-2 D-6 DT-6

Ex

pre

ss

ion

ch

an

ge

s

C D2 D6 DT6

-1.5

-0.5

0.5

1.5

Cluster 8

-1.5

-0.5

0.5

Cluster 1

C D2 D6 DT6

-1.0

0

1.0 Cluster 3

C D2 D6 DT6

-1.0

0

1.0 Cluster 2

C D2 D6 DT6

-1.0

0.0

1.0 Cluster 4

C D2 D6 DT6

-1.5

-0.5

0.5

1.5

Cluster 5

C D2 D6 DT6

-1.5

-0.5

0.5

1.5

Cluster 6

C D2 D6 DT6

-1.5

-0.5

0.5

1.5

Cluster 7

C D2 D6 DT6

8 clusters of differentially expressed genes

Verification of critical DEGs by Real time RT-PCR

Mature lamellar bone

-

Delaying maturation

Immature woven bone Granulation tissue

+

Accelerating formation

Biomodulation of woven bone healing

SPP1

DMP1

MMPs

TNFSF11

CTSK

ACP5

Accelerated tooth movement (ATM)

ATM into alveolar defect

Controlled TM with periodontal regeneration

Further studies for tissue-regenerative ATM