-
CASE REPORT
Retreatment of a patient wand severe root resorption
ith Mmets froletal,bularion oharmr lossand
entof
young woman needed orthodontic retreatment
gnathia, down-slanting palpebral fissures and a longlower
anterior facial height. She was unable to close
(Fig 3)a 5-mmy to theClass IIelation-a high-ne wass 6 mm
of mandibular anterior crowding.
premolars. There was extensive root resorption. Most
flected a retropositioned maxilla, and the SNB angle of69
confirmed mandibular deficiency. The FMA was
0889-5406/$36.00
Copyright 2010 by the American Association of
Orthodontists.doi:10.1016/j.ajodo.2007.05.029123teeth showed pulpal
obliteration. The condyles wereworn (resorbed) and flattened.
Surprisingly, there wasminimal mobility of the teeth.
The cephalometric head film and tracing (Fig 5)showed an ANB
angle of 3. The SNA angle of 72 re-
Private practice, Springfield, Va.
The authors report no commercial, proprietary, or financial
interest in the prod-
ucts or companies described in this article.
Reprint requests to: John E. Bilodeau, 6116 Rolling Rd, Suite
201, Springfield,
VA 22152; e-mail, [email protected].
Submitted, February 2007; revised and accepted, May 2007.and
mitral valve prolapse. This disorder weakens theconnective tissue
of the aorta as it enters the heart.She had dural ectasis,
hypermobility of her joints, oste-
The panoramic radiograph (Fig 4) showed that allthird molars
were missing as were the maxillary firstThe patient was a white
woman, aged 28 years 5months, with a history of orthodontic and
orthognathicsurgical treatment that began at age 13 and lasted for5
years, culminating with orthognathic surgery at age18. Her medical
history confirmed that she had Marfansyndrome, a genetic disorder.
She had arachnodactylywith positive wrist (Walker) and thumb
(Steinberg)signs (Fig 1). She was taking a beta-adrenergic
blockerto control blood pressure in hopes of preventing
aorticdissection, because she had evidence of aortic dilatation
her lips without mentalis strain (Fig 2).Intraoral photographs
and dental casts
showed missing maxillary first premolars andopen bite from the
second premolars anteriorlcentral incisors. The molars were in an
Anglerelationship, and the canines were in a Class III rship. The
maxillary arch was constricted witharched palate. The mandibular
dental midli2 mm left of the facial midline, and there waAfor an
open bite, crowded mandibular incisors,and temporomandibular joint
(TMJ) derange-ment with some flattening (resorption) of the
condyles.She had a history of previous orthodontic and
orthog-nathic surgical treatment. She has Marfan syndromeand
extensive root resorption. Did the earlier treatmentcause the
flattening of the condyles and root resorptionor was there a
genetic predisposition, or both? Why didthe first treatment fail?
Was retreatment worth the risk?
HISTORY AND ETIOLOGYJohn E. Bilodeau
Springfield, Va
This case report describes the retreatment of a patient
wsurgical treatment had been unsuccessful. Marfan syndromitted as
an autosomal dominant trait. The disorder resulresponsible for the
impaired structural integrity of the skesought retreatment, the
patient had an open bite, manditemporomandibular joint derangement
with some resorptcluded extractions and surgery, resulted in
balanced andsionwith normal overjet and overbite. Therewas no
furthejoints were asymptomatic. More root resorption on the mwas
evident after the second treatment. (Am J Orthod Dith Marfan
syndrome
arfan syndrome whose earlier orthodontic andis an inherited
connective tissue disorder trans-mmolecular defects in the
fibrillin gene that areocular, and cardiovascular systems. When
sheanterior crowding, severe root resorption, andf the condyles.
The second treatment, which in-onious facial proportions, and a
Class I occlu-of condylar tissue, and the temporomandibularibular
left canine and the left second premolaracial Orthop
2010;137:123-34)
oarthritis of her knees, and scoliosis. She had a Class
IImalocclusion complicated by a 5-mm open bite, 6 mmof mandibular
anterior crowding, and severe root re-sorption. She had a long
lower anterior facial height.Her chief concerns were her crooked
teeth, openbite, and facial appearance. The discomfort she
wasexperiencing in her TMJs had been somewhat relievedwith splint
therapy.
DIAGNOSIS
Facial photographs showed malar hypoplasia, retro-
-
124 Bilodeau American Journal of Orthodontics and Dentofacial
Orthopedics51. The facial height index of Horn1 (posterior
facialheight to anterior facial height) was .50, and it confirmeda
skeletal open bite. The IMPA, a reflection of the rela-tionship of
the mandibular incisor to the mandible, was96. Because the FMAwas
high, 51, the IMPA of 96
confirmed a protrusive mandibular incisor position.
Fig 1. Signs of Marfan syndrome: A, arachnodactyly(spider
fingers); B, positive Walker sign, with the distalphalanges of the
first and fifth digits of 1 hand overlap-ping when placed around
the opposite wrist; C, positiveSteinberg sign, with the thumb
extending beyond the ul-nar border when completely opposed in the
clenchedhand.The Z-angle was 68.2 The Wits measurement of0 mm was
normal.3,4 The symphyseal area was gro-tesquely misshapen from the
previous genioplasty. Theprevious surgical fixation devices were
also evident.
When orthodontic retreatment is needed, it is impor-tant to
review the prior diagnosis and treatment plan todetermine, if
possible, why the treatment failed. Herprior treatment records were
unavailable. However, af-ter studying her cephalometric and
panoramic radio-graphs, it was apparent that orthodontic
treatmentwith maxillary first premolar extractions with a
maxil-lary surgical procedure and a genioplasty had beenperformed.
It is reasonable to speculate that the primaryreason the treatment
failed was that mandibular extrac-tions were not part of the
initial treatment, and that thesurgical manipulations of the
maxilla and the chin wereless than satisfactory.
TREATMENT OBJECTIVES
The following treatment objectives were deter-mined: (1) correct
the open bite, (2) obtain a normal pro-file line to nose
relationship and a normal Z-angle,3 (3)obtain normal canine and
incisal guidance, (4) resolvethe crowding in both dental arches,
(5) reduce the exces-sive lower anterior facial height, (6) reduce
mentalisstrain, (7) eliminate TMJ dysfunction and discomfort,
and(8) guard against further root and condylar resorption.
TREATMENT ALTERNATIVES
No treatment had to be considered an option,because of the
Marfan syndrome, the failure of the firsttreatment, the amount of
root resorption present, and thecondition of the condyles. Further
root and condylarresorption were certainly possible.
The other alternative was extraction of the mandib-ular first
premolars followed by an orthognathic surgicalprocedure to correct
the vertical skeletal imbalance anda redo of the genioplasty to
gain more of an esthetic pro-jection of her chin. This option would
make it possibleto upright the mandibular incisors, reduce vertical
facialheight, provide an esthetic change, and correct thedental
malocclusion.
TREATMENT PLAN
After carefully considering the alternatives, theextraction and
surgical option was chosen. The patientunderstood the risks of
retreatment and was counseledthat teeth could be lost, and implant
placement or splint-ing of her teeth would be necessary because of
the com-plication of further root resorption. She was also
January 2010informed about the condition of her condyles and
thatfurther loss of condylar tissue was possible. Despite
-
American Journal of Orthodontics and Dentofacial Orthopedics
Bilodeau 125
Volume 137, Number 1the risks, she wanted to proceed; in fact,
she was enthu-siastic about retreatment. She said, anything would
bebetter than what I have now, and I know I might losesome
teeth.
Fig 2. Pretreatment facial an
Fig 3. PretreatmenWhen surgical intervention is part of the
treatment,several analyses are used as guidelines to position
thejaw bones both vertically and horizontally to providea pleasing
and harmonious face.
d intraoral photographs.
t dental casts.
-
Fig 5. Pretreatment cephalometric andheadfilm tracing.
126 Bilodeau American Journal of Orthodontics and Dentofacial
OrthopedicsMcNamaras nasion Frankfort perpendicular wasused as a
guideline to determine the placement of themaxilla and the
maxillary incisors in the horizontalplane.5 The maxilla should be
positioned so that PointA closely approximates this line, and the
maxillaryincisor is 5 mm 6 2 mm anterior to nasion
Frankfortperpendicular. The maxillary incisor should be placedabout
110 to the palatal plane.
The skeletal position of the mandible can bechecked with the
analysis of Delaire et al,6 which usesa line from the frontal and
maxillary bone intersectionconnected to the posterior clinoid
process and fromthis point to menton. This angular measurement
shouldbe 85 to 90. Also, with a line drawn perpendicular tothis
line, a vertical assessment can be made by measur-ing the upper
facial height from nasion to anterior nasalspine (ANS) and the
lower facial height from ANS tomenton. The distance from ANS to
nasion should be45% of the total facial height, and the distance
from
Fig 4. Pretreatment panoramic radiograph showing rootresorption
and flattening of the condyles.ANS to menton along this line should
be 55% of the to-tal facial height. To determine the ideal facial
height, .45can be divided into the nasion-ANS distance. This is
thetotal hard-tissue height that is ideal for a patient.
Thismeasurement gives guidelines about whether to open orclose a
patient vertically.
In any surgical treatment plan, a soft-tissue evalua-tion is
necessary. Variations in the soft tissues that coverthe face can
produce misleading conclusions if diagno-sis and treatment planning
are based on skeletal mea-surements alone. By using the soft-tissue
analysis ofLegan and Burstone,7 the clinician can evaluate the
hor-izontal and vertical soft tissues of the mandible. Thisanalysis
is used as follows: (1) the SN line is recon-structed 7 upward from
its original position, and (2)a perpendicular is drawn from
soft-tissue glabella tothis line. Soft-tissue pogonion should
closely approxi-mate this line. Vertical soft-tissue proportions
can beJanuary 2010checked by drawing a line perpendicular from
glabellato soft-tissue nasal point and from subnasale to menton.The
ratio of this distance should be 1:1. Another helpfulsoft-tissue
evaluation is Merrifields Z-angle2 and theinterrelationship of the
profile line to the middle of thenose. The profile line should
intersect the nose at the an-terior aspect of the nares, and the
Z-angle, when mea-sured to the Frankfort horizontal, should be
between72 and 78.
Merrifields total space analysis was used to deter-mine space
requirements.8,9 The McNamara analysis5
confirmed that Point A was posterior to the nasionFrankfort
perpendicular, and the maxilla would needto be surgically moved
forward.
A decision was made to extract the mandibular firstpremolars.
This extraction pattern would resolve the
-
American Journal of Orthodontics and Dentofacial Orthopedics
Bilodeau 127
Volume 137, Number 1dental crowding and allow the mandibular
incisors to beuprighted to increase overjet to gain
maximumadvancement of the mandible.
Both the soft-tissue analysis of Legan and Burstone7
and the analysis of Delaire et al6 showed that verticalheight
needed to be reduced. Because of the poor condi-tion of the
condyles, further study and a search of theliterature was done.
Arnett et al10 found that medial or lateral torque ofthe
mandibular condyle associated with sagittal osteot-omy resulting in
medial or lateral condylar compres-sion creates the possibility for
late (9-18 months)condylar resorption and Point B relapse. It was
rea-soned that any surgical manipulation of the proximal(condyle)
segment would have an unpredictable out-come and that a sagittal
split should be avoided.Therefore, after all space closure, only a
LeFort Iosteotomy and a genioplasty were to be performed toreduce
vertical facial height by autorotation of themandible. This type of
surgical intervention wouldbe noninvasive to the mandibular
condyles and wouldprovide a pleasing profile line to nose
relationship anda favorable Z-angle. The genioplasty would also
haveto be redone.
Fig 6. PresurgicalTREATMENT PROGRESS
Because of mitral valve prolapse, and on the adviceof her
physician, this patient was premedicated with 2 gof amoxicillin to
prevent bacterial endocarditis beforeall appointments. The
mandibular teeth only werebanded or bonded sequentially with the
10-2 systemof Merrifield.9,11 A .022-in standard nontorqued,
non-angulated edgewise appliance was used. The maxillary
dental casts.
Fig 7. Presurgical panoramic radiograph.
-
128 Bilodeau American Journal of Orthodontics and Dentofacial
Orthopedicsteeth would remain without appliances until the man-
dibular incisors were uprighted and the mandibular
arch stabilized. It was reasoned that this approach
would protect the maxillary incisors from further root
resorption until they absolutely had to be aligned and
leveled. The patient was instructed to wear a high-
pull J-hook headgear directly against the mandibular
canine brackets to retract these teeth into the first pre-
molar extraction sites. After canine retraction, the man-
dibular anterior teeth were carefully and slowly
retracted with a .020 3 .025-in closing loop archwire.
The J-hook headgear was worn against the canine
brackets to support anterior retraction. After space clo-
sure in the mandibular arch, a .0213 .025-in stabilizing
archwire was placed.
At this juncture, the maxillary teeth were banded
Fig 8. Presurgical cephalometric headfilm and tracing.and
bonded. Reproximation of the maxillary anteriorteeth was necessary
to create enough space to resolvethe maxillary crowding.
Impressions were taken atevery appointment, and the dental casts
were hand-articulated to assess the postoperative occlusion.
Preop-erative records were taken to plan the orthognathicsurgical
procedure (Figs 6-8).Fig 9. Computerized visual treatment
objectives.
January 2010PREOPERATIVE DIAGNOSIS
The presurgical cephalometric tracing (Fig 8)showed that the FMA
remained at 51. The facial heightindex of Horn1 remained the same
at .50. The IMPAof 71 confirmed that the mandibular incisors had
beenuprighted over basal bone. The Z-angle remained at 68.
Point A and the maxillary incisors were 13 mmposterior to nasion
Frankfort perpendicular.
The analysis of Delaire et al6 showed that themandible could
come forward because the posteriorclinoid-FMA-menton angle was 80
and could bepositioned between 85 and 90. The vertical analysisof
Delaire et al showed an upper facial height of 57mm; therefore, the
lower facial height should be 69mm. It was actually 88 mm or 19 mm
more than whatit should be for a harmonious facial balance.
Reducingthe vertical dimensionwith a LeFortmaxillary impactionwould
produce a large autorotation of the mandible (per-haps asmuchas
10-12mm); thiswould cause forward po-sitioning of pogonion. Because
mandibular surgery wasto be avoided, a large advancement of the
maxilla wouldbe necessary to maintain a Class 1 molar
relationship.
-
Fig 10. Posttreatment facial and intraoral photographs.
Fig 11. Posttreatment dental casts.
American Journal of Orthodontics and Dentofacial Orthopedics
Bilodeau 129Volume 137, Number 1
-
would be redone to further project pogonion anteriorly
130 Bilodeau American Journal of Orthodontics and Dentofacial
Orthopedicsto more closely satisfy the soft-tissue projection of
theanalysis, reposition the infrahyoid muscles, and achievea normal
Z-angle.
A computerized visual treatment objective was cre-ated with the
DFplus software (Dentofacial Planner,Toronto, Ontario, Canada) (Fig
9).
TREATMENT RESULTS
The posttreatment photographs (Fig 10) show thebalance and
harmony of facial proportions that wasachieved with the orthodontic
and surgical approach.The midline is in the center of the patients
face. SheThe Legan-Burstone soft-tissue analysis confirmedthat the
mandible needed to come forward, and verticalfacial height needed
to be reduced 15 mm to achievea 1:1 ratio and a well-balanced
facial profile. Dependingon the amount of autorotation achieved,
the genioplasty
Fig 12. Posttreatment panoramic radiograph.can close her mouth
without mentalis strain.Theposttreatment dental casts (Fig11)
showaClass I
occlusion with normal overjet and overbite. Theocclusion
exhibits canine and incisal guidance. Theopen bite was corrected.
The maxillary second molarsare still settling and will eventually
come into occlusion.
The posttreatment panoramic radiograph (Fig 12)shows that the
level of root length was maintained,except for the mandibular left
canine and second premo-lar, which had decreases in root length.
Therewas no fur-ther loss of condylar tissue. The TMJs
wereasymptomatic. The mandibular incisors were uprightedover basal
bone to an IMPA of 79. Because of theLeFort impaction of the
maxilla, the mandible wasautorotated 11 mm. This rotation allowed
the FMA todecrease to 41. The genioplasty projected pogonion
far-ther anteriorly to approach the Legan-Burstone
glabellaperpendicular. The Z-angle improved to a normal 75.January
2010All skeletal cephalometric measurements showedimprovement. With
the analyses previously described,the McNamara analysis5 and that
of Delaire et al6 illus-trate the postsurgical position of the
teeth. Themaxillaryincisor was positioned 4 mm closer to nasion
Frankfortperpendicular at 110 to the palatal plane. The mandiblewas
at 83 according to Delaire et al, and the verticalhard-tissue
relationship was reduced by 10 mm. TheLegan-Burstone analysis7
showed that vertical soft-tissue glabella to soft-tissue subnasale
and soft-tissuesubnasale to soft-tissue menton were in a 1:1
relation-ship. Soft-tissue pogonion was slightly behind soft-tissue
glabella perpendicular. The composite cephalo-metric tracings (Fig
13) show mandibular incisor
Fig 13. Posttreament cephalometric headfilm andsuperimposed
tracings.
-
raph
American Journal of Orthodontics and Dentofacial Orthopedics
Bilodeau 131uprighting,maxillary anteriormovement and
impaction,mandibular autorotation and forward movement, andfacial
profile improvement.
Fig 14. Periapical radiogVolume 137, Number 1The periapical
radiographs show the severe rootresorption (Fig 14).
Treatment time was 24 months. A .030-in mandibu-lar lingual
retainer was bonded to each anterior tooth toproduce a splinted
anterior segment. A removablemaxillary circumferential retainer was
also placed.
DISCUSSION
There is no doubt that the retreatment of this patientwas
clinically challenging and not without risk. Treat-ment was
undertaken with much trepidation. Thisauthor had treated this
patients adoptive mother withorthodontics and a mandibular
advancement with a suc-cessful result several years earlier; this
encouraged thepatient to seek retreatment. She had not
consideredretreatment before because her first treatment wasdone at
a dental school, and she accepted her first out-come as all that
could be done. It was reasoned thateven if she lost teeth,
prosthetic replacements wouldhave a better prognosis with the jaws
in an optimalposition and the open bite corrected. As mentioned,the
maxillary teeth were not banded until the mandibu-lar arch was
stabilized to try to minimize further rootresorption. Patients with
Marfan syndrome have anincreased risk of root resorption and pulpal
necrosiswith orthodontic treatment.12 TMJ dysfunction and con-
dylar resorption can be important aspects of the disor-
der,13 as can obstructive sleep apnea and upper airway
s show root resorption.resistance.14 Severe periodontitis has
also been reported
by Straub.15
Marfan syndrome is an autosomal dominant hered-
itary connective-tissue disorder. The incidence is esti-
mated to be at least 1 case per 5000 to 10,000 people.
The syndrome is caused by gene coding for fibrillin-1,
an extracellular matrix glycol-protein. It was first
described by Dr Bernard Marfan in 1896 and was sub-sequently
included among the hereditary disorders ofconnective tissues. The
gene responsible for the muta-tion was identified in the region of
chromosome15q21.1.16 This patient was adopted, and her
familialhistory was unknown. Clinical features of the disordercan
include tall stature, ectopia lentis, mitral valve pro-lapse,
aortic-root dilation, aortic dissection, joint hyper-mobility,
arachnodactyly, dural ectasis, highly archedpalate, dental
crowding, down-slanting palpebralfissures, and retrognathia. This
patient exhibited allthese features except aortic dissection and
ectopialentis.
At the onset of treatment, some questions came tomind. Is the
TMJ sensitive to changes in mechanicalloads? Can the amount of root
resorption be controlled?What about retention and the need for
future prosthetictreatment?
-
132 Bilodeau American Journal of Orthodontics and Dentofacial
OrthopedicsMongini17 showed condylar changes after
occlusalequilibration. Peltola18 found radiographic changes
inpatients treated with orthodontics when compared withcontrols.
Arnett et al19,20 concluded that the TMJ isnot immutable and that
changes in occlusion (lost teeth,orthodontic or orthognathic
manipulations), excessiveparafunctional habits, and articular
disc-condyle rela-tionships could contribute to remodeling of the
articularstructures of the TMJ. They noted that 1 patient
canexperience dysfunctional remodeling (ie, condylysis)whereas
another subjected to a similar insult might adaptto the mechanical
stress with functional remodeling.
Internal derangement can occur with21-25 and with-out23,24,26-28
remodeling. DeBont et al29 showed thatosteoarthrosis of the
mandibular condyle can occur inthose with a normal articular
disc-condyle relationship.
Furstman30 described the phenomenon that severeosteosclerotic
changes of the mandibular condyle havebeen associated with the loss
of occlusal stability. Gazitet al31 and Ehrlich et al32 found
structural changes in theTMJ associated with unstable occlusion,
including boneresorption and fibrocartilage calcification.
Posteriorization of the mandibular condyle sec-ondary to
occlusal changes might lead to postglenoidspine and posterior
condylar resorption.10,27,33 Arnettet al,10 Arnett and
Tamborillo,33 and Arnett34 observedcondylar resorption when the
condyles were displacedposteriorly after orthognathic surgery.
Wolford andCardenas35 described some characteristics that appearto
make a patient most susceptible to idiopathic condy-lar resorption.
These factors include (1) female sex(approximately 9:1 female to
male ratio), (2) age rangeof 10 to 40 years with a strong
predominance for teen-agers in their pubertal growth phase, (3)
high occlusalplane angle and mandibular plane angle, and (4)
ClassII skeletal pattern with or without open bite. They foundthat
condylar resorption rarely occurs in patients withlow mandibular
plane angle or those with a Class IIIskeletal relationship.
A number of systemic disease states can lead tocondylar
resorption.36 These include rheumatoid orjuvenile rheumatoid
arthritis, systemic lupus erythema-tosus, familial Mediterranean
fever, Sjogrens syn-drome, Marfan syndrome, psoriatic arthritis,
andidiopathic condylysis. Arnett et al20 concluded that con-dylar
resorption is multifactorial and based on the hostsadaptive
capacity and mechanical stimuli. They stated,when predisposing host
factors are not present, occlu-sal treatments normally result in
functional remodeling.However, dysfunctional remodeling from low
level me-chanical stress (orthodontics, orthognathic surgery,
prosthetics) may occur subsequent to an inadequatehost adaptive
capacity, coincidental internal derange-ment of the joint,
excessive parafunction, macrotrauma,or unstable occlusion.
Dysfunctional remodeling pro-voked by the treatment of
dentoskeletal deformities is,to some extent, dependent on the
presence of these hid-den factors. However, it seems likely that
excessivetreatment compression is capable of initiating
substan-tial condylar resorption and resultant occlusal
changeswithout contribution of other stimuli. Arnett et al20
described a 3-fold treatment for condylar resorption:(1) control
or eradicate the etiologic factors, (2) stabi-lize the unstable
occlusion and the TMJs, and (3) correctthe resulting occlusal
deformity.
Recommended treatment options for condylarresorption include (1)
splint therapy to minimize jointloading, (2) arthroscopic lysis and
lavage, (3) condylarreplacement with a costochondral graft if
resorptionrecurs or cannot be controlled, and (4) maxillary
surgeryto correct the occlusal deformity.19, 20,28,37,38
In this patient, maxillary surgery was chosen toreduce the load
on the condyles. She was informedthat a costochondral graft was
possible if the condylesresorbed completely. A case report showed
that a patientwith virtually no condyles treated with the same
regi-men of orthodontics and surgery experienced noadverse
sequelae.39 The genioplasty was redone witha cortical osteotomy to
suspend the mentalis muscle toachieve optimal facial balance and
harmony.
External apical root resorption (EARR) is the loss ofroot
structure in the apical region that can be seen onradiographs. It
is an unpredictable phenomenon, andits etiology is unknown.
Hartsfield et al40 found thatthe degree and severity of EARR are
multifactorial,involving host and environmental factors.
Geneticfactors account for at least 50% of the variation inEARR.
Variation in the interleukin 1 beta gene in ortho-dontically
treated patients accounts for 15% of thevariation in EARR. Those
authors found historical andcontemporary evidence that the earliest
event leadingto EARR is injury to the periodontal ligament (PDL)and
supporting structures at the site of root compressionafter
orthodontic force.40
Multinucleated cells called odontoclasts responsiblefor the
resorption of the dental tissues cementum anddentin share many
cytochemical and morphologic char-acteristics with osteoclasts that
are responsible for boneresorption. Odontoclasts and osteoclast
precursors orig-inate from hemopoietic cells in the bone
marrow.41
Brezniak and Wasserstein41,42 reported that loss of api-cal root
material is unpredictable, and, when it extendsinto the dentin, it
is irreversible. Orthodontic force leadsto microtrauma of the PDL
and activation of many cel-
January 2010lular events associated with inflammation. Root
resorp-tion begins adjacent to hyalinized zones and occurs
-
orthognathic surgery. J Oral Surg 1980;38:744-51.
American Journal of Orthodontics and Dentofacial Orthopedics
Bilodeau 133during and after elimination of hyaline
(necrotic)tissues. In their review of the literature, Brezniak
andWasserstein41,42 found that EARR is classified into3 types:
surface resorption, involving small areasfollowed by spontaneous
repair from intact parts of thePDL; inflammatory resorption when
resorption hasreached the dentinal tubules; and replacement
resorptionwhen bone replaces the resorbed tooth material andleads
to ankylosis. Brudvik and Rygh43 found that rootresorption
continued in the area where hyalinized tissuepersisted even after
active force had ended. They hy-pothesized that the determinants of
resorption and repairgenerally seem to be associated with the
persistence andremoval of necrotic tissue and a process of repair
startedfrom the periphery in the resorbed lacunae where thePDL had
been reestablished, whereas ongoing resorp-tion was observed
beneath existing hyalinized tissue.
EARR is the bane of orthodontists and a commonsequela associated
with orthodontic treatment.Although EARR is a frequent iatrogenic
outcome asso-ciated with orthodontics, Harris and Butler44 and
Harriset al45 found that it can also occur without
orthodontictreatment, presumably as a function of occlusal
forces.DeShields,46 Sharpe et al,47 and Parker and Harris48
reported that the amount of tooth movement is posi-tively
associated with the extent of EARR. McNab etal49 found extraction
patterns can influence EARRbecause of the increased tooth movement
required toclose extraction spaces. Sameshima and Sinclair50
found that patients whose 4 first premolars wereextracted had
more EARR than those treated withoutextractions or extractions of
only the maxillary first pre-molars. Tainthongchai et al51 found
that the amount oftime spent in orthodontic treatment can be a
factor inEARR. Lee et al,52 in a clinical study, showed that
expo-sure of the roots to 2 sequential orthodontic procedures,1 in
adolescence and the other during adulthood,actually decreased the
extent of EARR.
This patients EARR at the beginning of treatmentwas probably
caused by many factors, including theduration of the first
treatment (5 years), perhaps the useof vertical elastics to control
the open bite, and certainlythe genetic influence ofMarfan
syndrome. EARRdid notappreciably increase during the second
treatment exceptfor themandibular left canine andfirst premolar.
This canbe attributed to careful and slow leveling and retractionof
the mandibular incisors and by not having applianceson the
maxillary teeth until the mandibular arch was sta-bilized. No
elastics were used except for those used bythe surgeon during the
surgical care phase of treatment.
Several anecdotal reports have demonstrated the
Volume 137, Number 1stability of teeth with severe root
resorption.53-55
Parker53 showed that severely resorbed maxillary8. Merrifield
LL. Differential diagnosis with total space analysis.
J Charles H. Tweed Int Found 1978;6:10-5.
9. Vaden JL, Dale JG, Klontz HA. The Tweed-Merrifield
philoso-
phy. In: Graber TM, Vanarsdall RL, editors. Orthodontics:
current
principles and techniques. St Louis: C.V. Mosby; 1994. p.
627-84.
10. Arnett GW, Tamborillo, Rathbone JH. Temporomandibular
joint
ramifications of orthognathic surgery. In: Bell WH, editor.
Mod-
ern practice in orthognathic and reconstructural surgery.
Philadel-
phia: W.B. Saunders; 1992. p. 523-93.
11. Merrifield LL. Edgewise sequential directional force
technology.
J Charles H. Tweed Int Found 1986;14:22-37.
12. Bauss O, Sadat-Khonsari R, Schwestka-Polly R. Dental hard
tis-
sue abnormalities in patients with Marfan syndrome.
Proceedings
of the European Orthodontic Society 80th Congress; 2004 June
7-11; Aarhus, Denmark. Available at:
www.ejo.oupjournals.org.
13. Bauss O, Sadat-Khonsari R, Fenske C, Engelke W,
Schwestka-
Polly R. Temporomandibular joint dysfunction in Marfan syn-
drome. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
2004;97:592-8.
14. Cistulli PA, Richards GN, Palmisano RG, Unger G,
Berthon-
Jones M, Sullivan CE. Influence of maxillary constriction
and
nasal resistance and sleep apnea in patients with Marfans
syn-incisors after orthodontic treatment were still function-ing
well after 33 years. Roberts56 suggested that retain-ing teeth with
fixed appliances should be done withcaution because occlusal trauma
to the fixed teeth orsegments might cause further EARR. A fixed
mandibu-lar retainer was bonded from canine to canine, and
thepatients occlusion was adjusted to provide optimalfunction in
all excursive movements. She will be fol-lowed in the long term in
retention.
Certainly, the long-term prognosis of her dentition isguarded.
Technology and research are constantly evolv-ing. If she retains
her teeth for another 10 to 15 years, thetissue and bone support
can remain viable for futureesthetic implant placement that will
maintain soft-tissuecontours and papillae forms. The early
detection andmedical management of Marfan syndrome has
signifi-cantly increased her life expectancy. Was the risk worththe
reward? The patient thinks it was.
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Retreatment of a patient with Marfan syndrome and severe root
resorptionHistory and etiologyDiagnosisTreatment
objectivesTreatment alternativesTreatment planTreatment
progressPreoperative diagnosisTreatment
resultsDiscussionReferences