Seminars in Orthodontics

EDITOR -IN-CHIEF
Elliott M. Moskowitz, DDS, MSd

EDITORIAL BOARD
EDITOR-IN-CHIEF EMERITUS
P. Lionel Sadowsky, DMD, BDS, DipOrth, MDent

Mani Alikhani, New York, NY (2017) Peter Ngan, Morgantown, WV (2015)

Rolf G. Behrents, St. Louis, MO (2017) Perry M. Opin, Milford, CT (2017)
S. Jay Bowman, Portage, MI (2017) Jae Hyun Park, Mesa, AZ (2017)
James Caveney, Wheeling, WV (2015) Sheldon Peck, Newton, MA (2014)
John Grubb, Chula Vista, CA (2015) William R. Proffit, Chapel Hill, NC (2015)
Greg Huang, Seattle, WA (2014) Eugene Roberts, Indianapolis, IN (2015)
Robert J. Isaacson, Edina, MN (2015) Emile Rossouw, Rochester, NY (2017)
Laurance Jerrold, Brooklyn, NY (2017) David L. Turpin, Federal Way, WA (2017)
Lysle E. Johnston, Jr., Eastport, MI (2015) James L. Vaden, Cookeville, TN (2015)
Donald R. Joondeph, Bellevue, WA (2015) Robert L. Vanarsdall, Jr., Philadelphia, PA (2015)
Robert G. Keim, Los Angeles, CA (2017) Katherine Vig, Columbus, OH (2017)
Richard Kleefield, Norwalk, CT (2015) Christos Vlachos, Homewood, AL (2014)
Steven J. Lindauer, Richmond, VA (2015) Timothy T. Wheeler, Gainesville, FL (2015)
James A. McNamara, Jr., Ann Arbor, MI (2017) Leslie A. Will, Boston, MA (2017)

INTERNATIONAL
Adrian Becker, Jerusalem, Israel (2017) Rakesh Koul, Lucknow, India (2017)
Jose´ Alexandre Bottrel, Rio de Janeiro, Brazil (2015) Birte Melsen, Aarhus, Denmark (2017)
Theodore Eliades, Nea Ionia, Greece (2014) Antony McCollum, Bryanston, South Africa (2015)
W.G. Evans, Johannesburg, South Africa (2017) Eliakim Mizarahi, Ilford, England (2015)
Jorge Faber, Brasilia, Brazil (2017) Bjørn Øgaard, Oslo, Norway (2017)
Joseph Ghafari, Beirut, Lebanon (2017) Nikolaos Pandis, Corfu, Greece (2017)
Vicente Hernandez, Alicante, Spain (2017) Pratik K. Sharma, London, UK (2017)
Nigel Hunt, London, England (2015) George Skinazi, Paris, France (2015)
Haluk Iseri, Ankara, Turkey (2017) John C. Voudouris, Toronto, Canada (2017)
Roberto Justus, Mexico City, Mexico (2015) William A. Wiltshire, Winnipeg, Canada (2015)
Sanjivan Kandasamy, Midland, WA, Australia (2017) Björn U. Zachrisson, Oslo, Norway (2015)
 Seminars in Orthodontics
VOL 22, NO 1 MARCH 2016

Interactions Between Orthodontics and Oral and Maxillofacial Surgery

Jae Hyun Park, DMD, MSD, MS, PhD
Guest Editor

■ Introduction 1
Jae Hyun Park

■ Orthodontic considerations in orthognathic surgery: Who does what, when, where

and how? 2
Jae Hyun Park, Michael Papademetriou, and Yong-Dae Kwon

■ Psychological considerations in orthognathic surgery and orthodontics 12

Won Moon and Jone Kim

■ The airway implications in treatment planning two-jaw orthognathic surgery:

The impact on minimum cross-sectional area 18
Jarom E. Maurer, Steven M. Sullivan, G. Frans Currier, Onur Kadioglu, and Ji Li

■ Surgical exposure of impacted canines: Open or closed surgery? 27

Adrian Becker, Ioannis Zogakis, Ionut Luchian, and Stella Chaushu

■ Primary failure of eruption and other eruption disorders—Considerations for

management by the orthodontist and oral surgeon 34
Sylvia A. Frazier-Bowers, Sonny Long, and Myron Tucker

■ Update on treatment of patients with cleft—Timing of orthodontics and surgery 45

Pradip R. Shetye

■ 3D guided comprehensive approach to mucogingival problems in orthodontics 52

Marianna Evans, Nipul K. Tanna, and Chun-Hsi Chung

■ Implants for orthodontic patients with missing anterior teeth: Placement in growing
patients—Immediate loading 64
Mohamed Bayome, Yoon-Ah Kook, Yoonji Kim, Cheol Won Lee, and Jae Hyun Park

■ Surgical removal of asymptomatic impacted third molars: Considerations for

orthodontists and oral surgeons 75
Sung-Jin Kim, Chung-Ju Hwang, Jung-Hyun Park, Hyung-Jun Kim, and Hyung-Seog Yu
 Seminars in Orthodontics
VOL 22, NO 1 MARCH 2016

Introduction

T o maximize success with orthodontic treat-

ment, cooperation between the orthodon-
tist and other specialties is crucial. This is
focused on an evaluation of the minimum cross-
sectional area of airway passages.
The next three articles discuss the interaction
especially true for patients who need orthog- between the surgeon and orthodontist to treat
nathic surgery, where success depends on a team unique problems in children and adolescents. Dr.
that is led by the orthodontist and surgeon, and Becker and his colleagues from Israel describe a
supported by other specialties such as general closed versus open surgical procedure for expos-
dentists, prosthodontists, and periodontists. This ing impacted canines. Dr. Frazier-Bowers and her
issue of Seminars in Orthodontics addresses various colleagues from University of North Carolina deal
interactions between oral surgeons and ortho- with primary failure of eruption and other erup-
dontists, and it addresses some special challenges tion disorder management by the orthodontist
that orthodontists might face. and oral surgeon. Dr. Shetye from New York
There are nine articles in this issue. The first University describes an update on the timing of
three are related to orthognathic surgery and orthodontics and surgery in treating cleft patients.
orthodontics. In the first one, we discuss the The last three articles look at challenges and
interaction between orthodontists and surgeons critical issues in orthodontic treatment. Dr. Evans
with respect to orthognathic surgical patients; from the University of Pennsylvania describes a
our aim is to improve communication between three-dimensional evaluation of the dentoalveo-
the specialties. Recent advancements in surgical lar anatomy which provides more predictable
orthodontics make cooperation between the treatment outcomes for orthodontists and surgeons.
orthodontist, surgeon, and rest of the inter- I summarize some work done with my colleagues at
disciplinary team more important than ever. the Catholic University of Korea dealing with the
Orthognathic surgery is truly an interdisciplinary potential of implants to restore missing anterior
challenge, and lack of coordination among the teeth in growing patients and the effect of the
team will lead to compromised results. immediate application of orthodontic forces on
Beyond the mechanics of orthognathic sur- newly placed implants. Finally, Dr. Kim and his
gery, clinicians should be aware that patients colleagues from Yonsei University in Korea review
experience various psychological and emotional the potential risks associated with the retention and
challenges in the course of the presurgical, sur- extraction of asymptomatic impacted third molars
gical, and postsurgical stages of treatment. Many and discuss the orthodontic indications and con-
factors can influence the patient’s level of anxi- siderations for their extraction.
ety, emotional instability, and postoperative It is my hope that this issue will provide the reader
satisfaction, so an understanding of the patient’s with useful clinical information that will enable them
state of mind during each stage of treatment is to increase efficiency in their personal practices. It is
important. Drs. Moon and Kim from UCLA my further desire to encourage interdisciplinary
discuss psychological considerations of orthog- communication that is so critical to success in our
nathic surgery and orthodontics. Dr. Maurer and work, both among dental professionals and our
colleagues from the University of Oklahoma patients. I deeply appreciate the opportunity to serve
report on airway implications in orthognathic as the guest editor for this issue and wish to thank
surgery treatment planning. In this study, they the editor-in-chief and Elsevier for their trust in
allowing me to do this.

& 2016 Elsevier Inc. All rights reserved. Jae Hyun Park, DMD, MSD, MS, PhD
http://dx.doi.org/10.1053/j.sodo.2015.10.001 Guest Editor

Seminars in Orthodontics, Vol 22, No 1, 2016: p 1 1

Orthodontic considerations in orthognathic
surgery: Who does what, when, where and how?
Jae Hyun Park, Michael Papademetriou, and Yong-Dae Kwon

Surgical orthodontics to correct severe malocclusions and skeletal deform-

ities involves a considerable amount of treatment planning and coordination
with a multidisciplinary team. The success of the surgery requires an
excellent collaboration between the orthodontist and the surgeon primarily,
and secondarily with other specialties that may be involved during the
diagnostic, treatment, and posttreatment phases. There is a recent move-
ment into the “surgery-first” approach, which eliminates esthetically
undesirable facial changes due to decompensation of the teeth from the
presurgical orthodontic preparation. For both the conventional and “surgery-
first” approaches, careful and detailed creation of a treatment plan is crucial
to produce the most accurate, esthetic, and functional results. Advanced
development and application of cone-beam computed tomography with
three-dimensional models, craniofacial morphology and growth studies, and
virtual orthodontic and surgical treatment planning are changing the
traditional way that orthognathic surgery is being performed. This article
discusses the interaction between orthodontists and surgeons concerning
orthognathic surgical patients to improve communication between both the
specialties. (Semin Orthod 2016; 22:2–11.) & 2016 Elsevier Inc. All rights reserved.

Introduction surgical-orthodontic treatment (presurgical ortho-

E
dontics, surgery, and postsurgical orthodontics)
arly communication and coordination bet-
became popular because of stability and sat-
ween the orthodontist and the surgeon to
isfaction with posttreatment outcomes. This
correct severe malocclusions and skeletal defor-
success was the product of the development of
mities are essential to the success of surgical
new surgical techniques, orthodontic materials,
treatment and to ensure patient satisfaction. The
and rigid fixation. However, longer treatment
patient is the primary member of the team and
times and transitional detriment to the facial
should be involved in all discussions, noting his
profile has led to a new approach called “surgery-
or her expectations and concerns.1 The success
first,” which eliminates the presurgical ortho-
of a surgery is directly related to the competency
dontic phase.2 The “surgery-first” approach was
and consistency of the surgical team to achieve
first introduced by Nagasaka et al.3 in 2009. Over
predictable, stable, and esthetic results.
time, this approach has gained in popularity
Before the 1960s, most orthognathic surgeries
among orthodontists and surgeons for several
were performed either without orthodontic
reasons.4 First, the esthetic concern for the
treatment, or before any orthodontic treatment.
patient is addressed from the beginning.5,6 Sec-
Later, a three-stage approach to conventional
ond, the length of the orthodontic treatment,
which ultimately affects the total treatment time,
Arizona School of Dentistry & Oral Health, A.T. Still University,
is significantly reduced. This is probably related
Mesa, AZ; Graduate School of Dentistry, Kyung Hee University,
Seoul, South Korea; Department of Oral and Maxillofacial Surgery, to the regional acceleratory phenomenon
School of Dentistry, Kyung Hee University, Seoul, South Korea. (RAP)5,7–9 and a more efficient skeletal position
Address correspondence to Jae Hyun Park, DMD, MSD, MS, in which soft tissue imbalances that can interfere
PhD, Arizona School of Dentistry & Oral Health, A.T. Still with orthodontic movements have been sup-
University, 5835 East Still Circle, Mesa, AZ 85206. E-mail:
JPark@atsu.edu
pressed. Third, when compared to the conven-
tional three-stage surgical-orthodontic approach,
& 2016 Elsevier Inc. All rights reserved.
1073-8746/12/1801-$30.00/0 a “surgery-first” approach does not seem to
http://dx.doi.org/10.1053/j.sodo.2015.10.002 impair the final occlusion.7 However, there has

Seminars in Orthodontics, Vol 22, No 1, 2016: pp 2–11 2

 Orthodontic considerations in orthognathic surgery 3

Figure 1. Mandibular surgical simulation movement using Morpheus3D CT software (Seoul, Korea).

been more instability and the outcome has been 3D virtual technology, we have a tremendously
unpredictable.8,10 Therefore, in order to reduce helpful tool that allows us to more closely replicate
the uncertainty of postsurgical occlusion and the actual patient (Fig. 1). Incorporating 3D
increase the predictability of the results, the use cephalometry is essential, but it is still in the
of minimal presurgical orthodontics has been early stages of development. Even though we have
proposed.11–13 Joh et al.13 concluded that after the ability to measure the right side and the left
treatment, there was no significant difference in side separately, a potentially valuable benefit when
hard and soft tissue measurements between the treating asymmetries,14 we still apply it as we do in
minimal presurgical orthodontic group and the 2D, by using the average measurements of the two
conventional presurgical orthodontic group, but sides.15 Different software programs are available
the total treatment time was significantly shorter for 3D planning and fabrication of splints using
in the minimal presurgical orthodontic group CAD/CAM (computer-aided design/computer-
due to the shorter presurgical orthodontic aided manufacturing) technology.16 The fabri-
treatment time. cation of CAD/CAM surgical wafers has intro-
Another advancement in jaw surgery is the duced a working methodology which is different
utilization of three-dimensional (3D) imaging from conventional clinical practice. Being able to
technology such as cone-beam computed tomo- use computer-aided surgical simulation (CASS), a
graphy (CBCT). The shift from a two-dimensional 3D virtual environment for planning and simu-
(2D) to 3D imaging expands the possibilities for lating surgery, provides surgeons with the best
better diagnosis, surgical simulation, and surgical possible scenario for preoperative treatment plan-
splint construction. This virtual planning allows for ning (Fig. 2).16 Although CBCT scans significantly
a more thorough analysis and surgical planning, reduced the radiation exposure compared with
especially in patients with facial asymmetries.2 With the multi-slice CT scans,17 there are concerns

Figure 2. (A and B) 3D virtual models were constructed and mounted into the virtual articulator. They were
repositioned according to the STO using the 3D Virtual Model Surgery program (Orapix, Seoul, Korea). (C) A 3D
virtual wafer (3D-VIW) was constructed using a stereolithographic technique (Viper2; 3D Systems,Rock Hill, SC).
4 Park et al

about the 3D virtual surgical planning in that there It is essential that the orthodontist and the
is an increase in radiation exposure due to the surgeon have a clear understanding of the path
need for pre- and postsurgical CBCT scans. Fortu- they are going to follow with the case before the
nately, by adjusting the operating parameters, surgical consultation. Issues like third molar
including exposure factors and reducing the extractions, one or two-jaw surgery, genioplasty,
field of view to the actual region of interest, we or other facial plastic surgery should be
can now significantly reduce the radiation addressed in order to avoid patient confusion.
exposure.18,19 Also, the orthodontist should review the patient’s
Recent advancements in surgical orthodontics chief complaint, concerns, family situation, and
make the cooperation between the orthodontist, insurance and monetary issues with the surgeon.
the surgeon, and the whole interdisciplinary The patient should understand that whatever is
team crucial. A successful outcome is derived not covered by the insurance company will be
from teamwork, which is primarily guided by their responsibility for both the orthodontic and
the orthodontist and the surgeon, and could surgical treatments. The surgeon should discuss
include other specialties such as general dentists, hospitalization details and possible options for
prosthodontists, periodontists, radiologists, psy- outpatient procedures. Surgical details, includ-
chologists, anesthesiologists, and nutritionists. ing risks, complications, diet, and eating diffi-
Orthognathic surgery is truly an interdisciplinary culties should be presented to help the patient
challenge, and lack of coordination among the make an educated decision. Medical history and
orthodontist, the surgeon, and the rest of the risk assessment need to be completed early to
team will lead to a compromised result.20,21 allow proper workup.
Therefore, this article, explores the phases that The orthodontist should explain to the patient
are associated with orthognathic surgery, and the the difference between camouflage treatment
roles and collaborative efforts of the members of and surgery. A nonsurgical treatment plan may
the surgical team. provide satisfactory occlusal results, but com-
promised esthetics. A 2D or 3D surgical treat-
ment objective (STO) may help the patient in
Initial evaluation
making a decision. Once the patient understands
The initial orthodontic evaluation should involve and agrees with what was discussed at the surgical
diagnostic records such as those from a thorough consultation, the orthodontist is ready to start
clinical exam, temporomandibular joint (TMJ) presurgical orthodontic treatment.
evaluation, the patient’s medical forms, and chief The surgeon should send all the details of the
complaint, plus photographs, radiographs, surgery and treatment requests in writing, and
articulated study models, and bite registration in the orthodontist must document them in the
centric relation. All photographs and radio- patient’s chart. Complications such as third
graphs should be taken in the natural head molar extractions prior to surgery, particularly in
position. Additional records that could provide the mandible, must be completed at least six
more precise details are 3D photographic months prior to mandibular surgery. Any other
images, CBCT, and video images of the proposed surgical treatment such as other
patient.22,23 When taking these records, it is extractions, surgical expansion, segmented
crucial that they are precise and consistent. They maxilla, genioplasty, or other esthetic augmen-
can easily be shared with the surgical team in tations need to be discussed and documented.
order to minimize the patient’s exposure to Orthodontic considerations such as whether or
further radiation. When establishing an initial not to level the occlusal plane, overcorrections,
diagnosis and treatment plan, a surgical option types of splint and how long they will be used,
should be presented, without giving specific type of fixation, space opening or root diver-
surgical details at this point. It is very important gence to facilitate cuts and follow-up appoint-
that the patient understands that presurgical ments must be discussed from the beginning.
orthodontics will make the problem worse and Any restorative work, permanent or provisional,
facial changes may become more pronounced must be discussed with the general dentist or
temporarily until they are corrected by the prosthodontist and completed, if necessary,
surgery. before presurgical orthodontics. Periodontal and
 Orthodontic considerations in orthognathic surgery 5

temporomandibular disorder (TMD) concerns space or root divergence is needed. It is impor-

must also be addressed before the orthodontic tant that there be no compensations on the teeth
treatment starts. All these will help the ortho- during the presurgical orthodontic treatment,
dontist work his treatment plan and minimize whether it be expansion of the arches, extrusion
presurgical questions and delays. of anterior teeth to close open bite or leveling of
a two-plane occlusion. If a patient has a two-plane
occlusion, it should be maintained that way and
Presurgical orthodontics
be corrected during surgery.
The presurgical phase involves alignment and In Class III cases, Class II elastics are recom-
leveling of the arches, unless there is a two-plane mended to help decompensate the retroclined
occlusion, in which case the treatment goal mandibular incisors and proclined maxillary
becomes maintaining the two-planes and incisors. This will also help to build over cor-
decompensating the teeth to an ideal position rection for Class III relapse (Fig. 3). The opposite
within the arches and coordinating the arches. If should take place in Class II cases with the use of
extractions are necessary to alleviate crowding, to Class III elastics.
decompensate the teeth, to reduce protrusion or Occasional study models can be very helpful for
to help maximize the surgical movements before evaluation of arch coordination, leveling, any
surgery, the extraction spaces should be closed. torque issues (especially on the second molars),
On the other hand, there are situations such as and any Bolton discrepancy. This will also help in a
anterior segmental osteotomy where extraction determination of the time for surgery. A total of six
spaces are closed during surgery to help months prior to surgery, the orthodontist should
decompensate the incisors or correct anterior evaluate alignment of teeth, torque of both ante-
cross bite. If mandibular surgery is planned, rior and posterior teeth, arch coordination using
mandibular third molars should be extracted at stone models, communicate with the surgeon to
least six months prior to surgery to allow healing make sure that insurance and financial arrange-
and bone filling of the extraction site to reduce ments are in order and send the patient to the
the risk of a bad split and to facilitate fixation. surgeon for an evaluation. After that appointment,
The maxillary third molars can be extracted the surgeon and orthodontist should discuss any
during surgery if necessary. If segmental Le Fort I necessary changes or adjustments.
osteotomy is planned, any necessary expansion Approximately 2–3 months before surgery, a
should be done surgically and not orthodonti- presurgical workup appointment should be
cally. To increase stability of the expansion, scheduled with the surgeon. This is an important
clinicians could consider two-stage surgery [first, appointment to review all surgical details, confirm
surgically assisted rapid palatal expansion that the patient is ready for surgery and request
(SARPE), and then Le Fort I surgery].24 If a two- any minor adjustments such as any necessary
or three-piece Le Fort I osteotomy is being spaces or root angulations, equilibrate any inter-
considered, it is critical to verify with the surgeon fering contacts, review the hospitalization or out-
where the cuts are going to be and how much patient process, and reconfirm insurance matters.

Figure 3. (A) Typical compensations of anterior teeth in Class III patents. Proclined maxillary incisors and
retroclined mandibular incisors. (B) The use of Class II elastics in Class III cases helps decompensate the
anterior teeth.
6 Park et al

Before the final surgical workup and at least in order to take the appropriate radiographs at
4–6 weeks before surgery, the orthodontist should the optimal times. The dataset guidelines from
place the final wires to allow any tooth movement the British Association of Oral and Maxillofacial
to take place and the wires to become passive Surgeons (BAOMS) and British Orthodontic
before taking impressions or 3D virtual images for Society (BOS) recommend lateral cephalograms
the construction of the surgical splints. The wires preoperatively, at the end of presurgical ortho-
should be stiff enough to resist any unfavorable dontics, postoperatively 1–3 weeks after surgery,
tooth movements during fixation. For 0.022 slot, a the predebonding stage, and two years post-
0.19  0.25 in stainless steel wire is preferable; for retention. Panoramic radiographs are required
0.018 slot, a 0.16  0.22 in or 0.17  0.25 in before the initial orthodontic treatment, and
stainless steel wire is sufficient. At this time, the immediately postoperatively.27
orthodontist should also check for any loose bands The BAOMS guideline enables clinicians to
or brackets. Immediately before the final surgical minimize unnecessary radiation exposure for the
appointment with the surgeon, the orthodontist patient while still providing adequate data.
should place surgical hooks on the arch wires Panorex should be initiated immediately post-
according to the surgeon’s specifications. operatively to confirm the position of the con-
At the final surgical appointment 2–3 weeks dyles. Not only the surgeons, but also the
prior to surgery, the surgeon should take pre- orthodontists should meticulously review the
surgical records including photos, radiographs radiographs before starting treatment.
(panorex, cephalograms, and tomograms),
impressions, bite registration in centric relation,
Surgery
face-bow transfer for surgical planning and splint
construction. If 3D virtual technology is used Optimal facial harmony and proportions may be
instead, then a CBCT scan is necessary instead of viewed differently by patients, surgeons, and
the 2D radiographs mentioned above. Medical orthodontists. Therefore, open discussion should
imaging, virtual treatment planning, and virtual be mandatory between the treatment team
splint construction could bring an end to members going over the patient’s records
impressions and face-bow transfers.3 All records including 3D computed tomography (CT)
should be taken in the natural head position.25,26 dataset. Understanding the patient’s desires and
If 3D treatment planning is to be used, the expectations are very important in creating the
surgeon and the orthodontist should get together, surgical plan, but care should be taken with
either in person or by other means of commu- patients who have unrealistic expectations; the
nication, and finalize the details of the surgical presurgical consultation with the patient and
movements. At the same time, they should com- his/her guardian is quite important to make sure
municate with the 3D virtual planning company they understand what is possible and what is not
they use to work up the details of the surgery, with the surgery.
finalize the STO and construct the splint. Before Surgery can control all of the dental and
surgery, the surgeon should have the patient skeletal components supporting the facial pro-
come to the office for a final visit to try in the file; therefore, any major discrepancy should be
splints on each arch individually and make sure corrected by surgery. With the advancement of
that there are no interferences with the brackets surgical skills, various surgical options are avail-
or wires and that they are not warped and fit well. able for the patients. Orthodontists should also
Model surgery and surgical splint construction are know the possible surgical options available for
traditionally done by the surgeon, but there are their patients and be actively involved in surgical
some orthodontists who prefer to do it themselves. planning. Having understood surgical options,
This should be communicated and worked out orthodontists can carry out presurgical ortho-
between the orthodontist and surgeon. dontics more efficiently because predicted results
can be stimulated beforehand.
A combination of Le Fort I osteotomy and
Surgical phase
mandibular surgery is the basic option for
An agreement as to the guidelines should be orthognathic patients. For maxillary surgery, Le
made between the surgeon and the orthodontist Fort I is the most commonly used method for
 Orthodontic considerations in orthognathic surgery 7

most dentofacial deformities. Depending on the control bimaxillary protrusion although ortho-
nasomaxillary soft tissue profile, the osteotomy dontic miniscrews are widely used for this purpose.
line can be modified accordingly, so a deficient For mandibular surgery, bilateral sagittal split
soft tissue profile can be improved with Le Fort I osteotomy (BSSO) is the most popular among oral
advancement. Rotation of the maxillomandi- surgeons although other ramus surgeries such as
bular complex can manipulate the occlusal plane intraoral vertical ramus osteotomy (IVRO) can
and control the incisal axis.28 In patients with still be used. BSSO, combined with Le Fort I
prognathic mandibles, maxillary retrusion is osteotomy, is proven to show excellent long-term
often noticed and clockwise rotation of the maxi- postoperative stability in literatures.29,33,34 Some
llomandibular complex can improve depressed studies showed that IVRO may be useful for
paranasal contour and can allow for more mandi- patients with temporomandibular disorder.35,36
bular setback.29 Depending on the wishes of patients or ortho-
Alar base widening, which is considered to be dontists, additional adjunct surgery can be plan-
an undesirable side effect of Le Fort I advance- ned. Surgeons may also recommend some adjunct
ment, can be minimized by using alar cinch suture surgical options such as genioplasty, mandibular
techniques. Segmental surgery has many clinical contouring surgery, or other augmentation
applications and can decrease the duration of techniques. These adjunct surgical options
presurgical orthodontics if the surgical plan has can help the treatment team meet the patients’
been set up at the initial treatment planning. In expectations.
transverse deficiency cases, putting parasagittal Virtual surgical planning and 3D surgical
osteotomy lines in conjunction with Le Fort I planning software are becoming popular and are
osteotomy can widen the maxilla. In most adult very useful tools in surgeons’ armamentarium to
orthognathic surgery patients, maxillary expan- help motivate patients and give them a better
sion during presurgical orthodontics may lead to understanding of the surgical procedure. While
dental tipping rather than true expansion.30 Two- setting up the surgical plan, the surgeon and the
segment and three-segment maxillary osteotomy orthodontist can confirm the detailed movement
are available options, but H-shape osteotomy is the of the jaws by means of surgical simulation
preferred method. Bimolar width can be (Fig. 4). The postoperative occlusion, set by the
expanded to about 5 mm, and SARPE can be orthodontist from the patient’s cast models, may
carried out for larger expansion.31,32 Anterior be optimal from a dental aspect, but the overall
segmental osteotomy is occasionally useful to skeletal harmony of the mandible may not have

Figure 4. (A) Segmentation of CT dataset was done and scanned images of the dental cast were transferred and
merged to the CT images. (B) Virtual surgery was performed in a software and the final position of the maxilla and
mandible was confirmed (Simplant O&O, Materialise, Leuven, Belgium).
8 Park et al

been taken into consideration. Sometimes the segments. It has enabled patients to begin oral
postoperative mandibular position may be functions such as speaking and eating in the early
unpredictable in the context of 3D spatial postoperative period.
facial harmony. In the mandible, bicortical screws can be
A surgeon can perform simulation surgery applied, but plates and screws are more popular
before he/she goes into the operating room. methods for mandibular fixation. Although
During a simulation surgery with segmented CT bicortical screw fixation seemed stable, fixation
dataset, the surgeon can easily recognize the yaw with miniplates and screws can be assumed to
of the maxilla and the mandible and also can add exert less stress on the temporomandibular joint
yaw correction in the surgical plan. The surgeon and a lower incidence of inferior alveolar nerve
also can detect possible interference between the injury.38,39 Resorbable fixation plates and screws
proximal and distal segment of the mandible, have been introduced by several companies.
allowing for a modified plan to be created to They are getting popular but their stability is still
minimize undesirable interference during BSSO. under clinical validation.40–42 Some researchers
Three-dimensional superimposition is also pos- have shown that conventional fixation with tita-
sible and simulation surgery can be validated by nium miniplates may be more stable in maxillary
the superimposition of pre- and postoperative 3D elongation and mandibular setback.40
CT scan images (Fig. 5).37 Long-term stability can
also be evaluated with this technique.
Splint
The surgical splint is the most important appli-
Fixation
ance during the intraoperative period. Intra-
Rigid fixation, using titanium plates and screws, operative maxillary position is significantly
has enabled us to fix the osteotomized bone dependent on the intermediate or final splints;

Figure 5. Superimposition of the 3D image of the virtual surgery and immediate postoperative image. The real
outcome was able to be validated (Simplant O&O, Materialise, Leuven, Belgium).
 Orthodontic considerations in orthognathic surgery 9

accurate model surgery cannot be over- self-limiting over time but sometimes hypo-
emphasized in every case. In order to check the esthesia may persist.43 Supportive measures for
vertical position of the osteotomized maxilla, K- NSD such as vitamin B12 administration and
wire or a miniscrew can be placed at the nasion neurosensory training might be beneficial.44
point of the patient. Currently, splint fabrication The surgical splint is fixed with wires in the
is possible using 3D technology. Surgical splints maxillary arch and a couple of elastics can be
should be thin and durable since they are usually applied for physiotherapy. The mandible is guided
maintained in the maxillary arch during a post- into the bite indentations on the splint by the
operative period lasting from a few days to elastics (Fig. 6). The surgeon should educate the
several weeks. patient how to perform mouth opening exercises.
They are especially important when IVRO is
carried out because rigid fixation is not being used.
Postoperative course; elastic wear and Before the patients are sent back to the
exercise orthodontist, mouth opening should be achieved
Swelling and bleeding are the most common to recover normal function for postsurgical
postoperative events. Icepacks and elastic facial orthodontic treatment.
bandages are applied for 48 hours starting The orthodontist, following the surgeon’s
immediately after surgery. Steroids are com- instructions, can also remove the surgical splint
monly prescribed postoperatively to reduce when changing the surgical arch wire.
swelling and bruising may sometimes occur.
Neurosensory disturbance (NSD) in the chin and
Diet
the lower lip area is quite a common post-
operative complication so the patient should be Immediate postoperative, parenteral nutritional
specifically advised of it. NSD in the paranasal support is beneficial. In the early postoperative
area and upper lip area, although uncommon, period, a liquid diet is usually provided and some
may also be observed when Le Fort I osteotomy is commercial liquid nutritional supplements are
done. NSD after orthognathic surgery is mostly also available. Nasogastric tubes are rarely used.

Figure 6. Surgical splint in maxillary arch. Mouth opening exercise should be taught for oral function
rehabilitation using some elastics. Mouth opening enough for functional recovery and forthcoming orthodontic
treatment should be obtained.
10 Park et al

Soft diet is usually recommended during the 2. Uribe F, Janakiraman N, Shafer D, et al. Three-
healing phase. Tough and hard food should be dimensional cone-beam computed tomography-based
virtual treatment planning and fabrication of surgical
avoided throughout the surgical-orthodontic splints for asymmetric patients: surgery first approach. Am
treatment period. J Orthod Dentofacial Orthop. 2013;144:748–756.
3. Nagasaka H, Sugawara J, Kawamura H, et al. “Surgery
first” skeletal Class III correction using the skeletal
Postsurgical orthodontics anchorage system. J Clin Orthod. 2009;43:97–105.
4. Quevado LA, Ruiz JV, Quevedo CA. Using a clinical
Right after the surgery, the surgeon should protocol for orthognathic surgery and assessing a
monitor the patient closely and have the patient 3-dimensional virtual approach: current therapy. J Oral
come in for weekly visits. Within a week after Maxillofac Surg. 2011;3:623–637.
surgery, a panoramic radiograph and cephalo- 5. Hernandez-Alfaro F, Guijarro-Martinez R, Molina-Coral
A, et al. “Surgery first” in bimaxillary orthognathic
grams, or CBCT are taken to evaluate the surgical surgery. J Oral Maxillofac Surg. 2011;69:e201–e207.
cuts and to make sure the condyles are seated. It 6. Villegas C, Janakiraman N, Uribe F, et al. Rotation of the
is essential that the surgeon and the orthodontist maxillomandibular complex to enhance esthetics using a
communicate continuously throughout the “surgery first” approach. J Clin Orthod. 2012;46:85–91.
entire process, and any problems should be 7. Hernandez-Alfaro F, Guijarro-Martinez R. On a definition
of the appropriate timing for surgical intervention in
addressed immediately. The orthodontist can orthognathic surgery. Int J Oral Maxillofac Surg. 2014;43:
usually resume the treatment about 2–6 weeks 846–855.
after the surgery upon the advice of the surgeon. 8. Villegas C, Uribe F, Sugawara J, et al. Expedited
At this time, the wires with surgical hooks are correction of significant dentofacial asymmetry using a
removed, any broken brackets are rebonded and “surgery first” approach. J Clin Orthod. 2010;44:97–103.
9. Wilcko MT, Wilcko WM, Pulver JJ, et al. Accelerated
new wires are placed to continue the finishing osteogenic orthodontic technique: a 1-stage surgically
stage of the orthodontic treatment. The earlier facilitated rapid orthodontic technique with alveolar
the surgical splint is removed (ideally within 2 augmentation. J Oral Maxillofac Surg. 2009;67:2149–2159.
weeks), the faster the occlusion will settle because 10. Hong K, Lee J. 2-Phase treatment without preoperative
of the RAP, activated by the osteotomies. orthodontics in skeletal Class III malocclusion. Korean J
Oral Maxillofac Surg. 1999;25:25–48.
The postsurgical orthodontic phase lasts about 11. Ko EW, Hsu SS, Hsieh HY, et al. Comparison of
6–8 months on average. This also applies to the progressive cephalometric changes and post-surgical
“minimal presurgical orthodontics” aproach.13 stability of skeletal Class III correction with and without
During this time, the final detailing and finishing presurgical orthodontic treatment. J Oral Maxillofac Surg.
take place. After debonding, final records are 2011;69:1469–1477.
12. Wang YC, Ko EW, Huang CS, et al. Comparison of
taken and retainers are delivered. The retention transverse dimensional changes in surgical skeletal Class
phase is usually similar to that of conventional III patients with and without presurgical orthodontics.
orthodontics, but it varies from practitioner to J Oral Maxillofac Surg. 2010;68:1807–1812.
practitioner. 13. Joh B, Bayome M, Park JH, et al. Evaluation of minimal
versus conventional presurgical orthodontics in skeletal
Class III patients treated with two-jaw surgery. J Oral
Conclusion Maxillofac Surg. 2013;71:1733–1741.
14. Tai K, Park JH, Ikeda K, et al. Severe facial asymmetry and
Every member of the surgical team should know unilateral lingual crossbite treated with orthodontics and
when, where, and how they are involved in a 2-jaw surgery: 5-year follow-up. Am J Orthod Dentofacial
Orthop. 2012;142:509–523.
surgical case and should be in constant com-
15. Olszewsk R, Zech F, Cosnard G, et al. Three dimensional
munication with the orthodontist and surgeon. cephalometric craniofacial analysis: experimental valida-
An excellent coordination and interaction tion in vitro. Int J Oral Maxillofac Surg. 2007;36:828–833.
between the orthodontist, the surgeon, and the 16. Aboul-Hosn CS, Hernandez-Alfaro F. 3D planning in
rest of the surgical team will lead to a successful orthognathic surgery: CAD/CAM surgical splints and
prediction of the soft and hard tissues results—our
surgery and a desirable outcome.
experience in 16 cases. J Craniomaxillofac Surg. 2012;40:
162–168.
17. Stokbro K, Aagaard E, Torkov P, et al. Systematic review:
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1. Venugoplan SR, Nanda V, Turkistani K, et al. Discharge Maxillofac Surg. 2014;43:957–965.
patterns of orthognathic surgeries in the United States. 18. Bornstein MM, Scarfe WC, Vaughn VM, et al. Cone-beam
J Oral Maxillofac Surg. 2012;70:e77–e86. computed tomography in implant dentistry: a systematic
 Orthodontic considerations in orthognathic surgery 11

review focusing on guidelines, indications, and radiation 33. Ueki K, Marukawa K, Shimada M, et al. Maxillary stability
dose risks. Int J Oral Maxillofac Impl. 2014;29:55–77. following Le Fort I osteotomy in combination with sagittal
19. Lundlow JB, Walker C. Assessment of phantom dosimetry split ramus osteotomy and intraoral vertical ramus
and image quality of i-CAT FLX cone-beam computed osteotomy: a comparative study between titanium mini-
tomography. Am J Orthod Dentofacial Orthop. 2013;144: plate and poly-L-lactic acid plate. J Oral Maxillofac Surg.
802–817. 2006;64:74–80.
20. Wirthlin JO, Shetye PR. Orthodontist’s role in orthog- 34. Hoffman GR, Brennan PA. The skeletal stability of one-
nathic surgery. Semin Plast Surg. 2013;27:137–144. piece Le Fort 1 osteotomy to advance the maxilla; Part 1.
21. Proffit WR, White RP, Combining surgery and orthodon- Stability resulting from non-bone grafted rigid fixation.
tics: who does what, when? In: Proffit WR, White RP, Br J Oral Maxillofac Surg. 2004;42:221–225.
Sarver DM, eds Contemporary Treatment of Dentofacial 35. Fujimura K, Segami N, Sato J, et al. Comparison of the
Deformity. St. Louis: Mosby; 2003:245–268. clinical outcomes of patients having sounds in the
22. Lubberts HT, Medinger L, Kruse A, et al. Precision and temporomandibular joint with skeletal mandibular
accuracy of the 3dMD photogrammetric system in cranio- deformities treated by vertico-sagittal ramus osteotomy
maxillofacial application. J Craniofac Surg. 2010;21: or vertical ramus osteotomy. Oral Surg Oral Med Oral Pathol
763–767. Oral Radiol Endo. 2005;99:24–29.
23. Arnett GW, McLaughlin RP. Facial and Dental Planning for 36. Park KR, Kim SY, Park HS, et al. Surgery-first approach on
Orthodontists and Oral Surgeons. St. Louis: Mosby; 93–133. patients with temporomandibular joint disease by intrao-
24. Phillips C, Medland WH, Fields HW, et al. Stability of ral vertical ramus osteotomy. Oral Surg Oral Med Oral
surgical maxillary expansion. Int J Adult Orthodon Orthog- Pathol Oral Radiol. 2013;116:e429–e436.
nath Surg. 1992;7:139–146. 37. Park JH, Tai K, Owtad P. 3-Dimensional cone-beam
25. Lundstrom F, Lundstrom A. Natural head position as a computed tomography superimposition: a review. Semin
Orthod. 2015;21:263–273. http://dx.doi.org/10.1053/j.sodo.
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38. Ochs MW. Bicortical screw stabilization of sagittal split
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minimum dataset of the British Orthodontic Society/
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record keeping for orthognathic patients: retrospective
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comparative multicentre audit. Br J Oral Maxillofac Surg. 40. Ballon A, Laudemann K, Sader R, et al. Segmental
2013;51:639–643. stability of resorbable P(L/DL)LA-TMC osteosynthesis
28. Reyneke JP, Bryant RS, Suuronen R, et al. Postoperative versus titanium miniplates in orthognatic surgery.
skeletal stability following clockwise and counter- J Craniomaxillofac Surg. 2012;40:e408–e414.
clockwise rotation of the maxillomandibular complex 41. Moure C, Qassemyar Q, Dunaud O. Skeletal stability and
compared to conventional orthognathic treatment. Br J morbidity with self-reinforced P (L/DL) LA resorbable
Oral Maxillofac Surg. 2007;45:56–64. osteosynthesis in bimaxillary orthognathic surgery.
29. Bang SM, Kwon YD, Kim SJ, et al. Postoperative stability of J Craniomaxillofac Surg. 2012;40:55–60.
2-jaw surgery with clockwise rotation of the occlusal plane. 42. Ahn YS, Kim SG, Baik SM, et al. Comparative study
J Craniofac Surg. 2012;23:486–490. between resorbable and nonresorbable plates in orthog-
30. Kretschmer WB, Baciut G, Baciut M, et al. Transverse nathic surgery. J Oral Maxillofac Surg. 2010;68:287–292.
stability of 3-piece Le Fort I osteotomies. J Oral Maxillofac 43. Colella G, Cannavale R, Vicidomini A, et al. Neurosensory
Surg. 2011;69:861–869. disturbance of the inferior alveolar nerve after bilateral
31. Vandersea BA, Ruvo AT, Frost DE. Maxillary transverse sagittal split osteotomy: a systematic review. J Oral
deficiency—surgical alternatives to management. Oral Maxillofac Surg. 2007;65:1707–1715.
Maxillofac Surg Clin North Am. 2007;19:351–368. 44. Phillips C, Essick GK, Chung Y, et al. Non-invasive therapy
32. Betts NJ, Vanarsdall RL, Barber HD, et al. Diagnosis and for altered facial sensation following orthognathic surgery:
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Orthodon Orthognath Surg. 1995;10:75–96. vitamin B12 spray. J Maxillofac Trauma. 2012;1:20–29.
Psychological considerations in orthognathic
surgery and orthodontics
Won Moon and Jone Kim

The perceived needs and self-image of patients often differ from those of the
orthodontists and oral surgeons who are treating them. Unfortunately, some
patients may have unreasonable expectations of the treatment outcomes, so
a thorough assessment of patient perception is an important initial step
during the treatment planning stage in order to ensure patient satisfaction.
Clinicians should also be aware that patients experience various psycho-
logical and emotional challenges during the course of the pre-surgical,
surgical, and postsurgical stages of treatment. Many factors can influence the
patient’s level of anxiety, emotional instability, and postoperative satisfac-
tion, so understanding the patient’s state of mind during each stage of
treatment is essential. Numerous studies have suggested ways to minimize
negative feelings and the relationship between surgeon and orthodontist
plays an important role in building patient confidence and trust in the entire
process. The mutual respect and close collaboration between them can
prevent undesirable psychological distress. (Semin Orthod 2016; 22:12–17.) &
2016 Elsevier Inc. All rights reserved.

Introduction disharmony and associated functional problems

V
can be quite different from the parameters that
arious aspects of psychology relative to
the health professionals use to evaluate the
orthognathic surgical procedures have
patient’s skeletal and facial structure. Subse-
already been studied and are well documented. It
quently, the patient’s expectations of the
takes a considerable level of commitment and
surgical outcome may be significantly different
trust for a patient to accept these surgical pro-
from that of the providers and are sometimes
cedures, which can significantly alter masticatory
unrealistic. It is imperative to thoroughly under-
functions and facial appearance. Recently,
stand the patient’s perceptions and expectations
Miguel et al.1 suggested that the current objective
regarding treatment success. In this article, pa-
of orthodontic treatment associated with orthog-
tient psychology through the course of orthog-
nathic surgery consists of not only treating the
nathic surgery will be examined and critical
esthetic and functional components of dento-
considerations will be discussed, and psycho-
facial deformities but also of considering the
logical factors related to interaction between
patients’ psychological factors. Often, while the
surgeons and orthodontists will be explored.
main focus of the care providers is in providing
functional and esthetic improvement objectively,
the patient is focused on subjective expectations Perception
of treatment outcome that can be difficult to
assess.2 The patient’s perception of skeletal Self-perception and an awareness of the need for
functional or esthetic improvement are impor-
tant factors in a patient’s willingness to seek treat-
Section of Orthodontics, UCLA School of Dentistry, Los Angeles, ment. This is especially true when an invasive and
CA; Section of Oral and Maxillofacial Surgery, UCLA School of costly procedure is involved.3 The desire for
Dentistry, Los Angeles, CA. improvement may arise from a patient’s aware-
Address correspondence to Won Moon, DMD, MS, Section of
ness of existing problems, but not all patients may
Orthodontics, UCLA School of Dentistry, Los Angeles, CA 90095-
1668. E-mail: wmoon@dentistry.ucla.edu be initially aware of their problems, so ortho-
& 2016 Elsevier Inc. All rights reserved.
dontists or oral surgeons can play a significant
1073-8746/12/1801-$30.00/0 role in awakening them to the existing problems
http://dx.doi.org/10.1053/j.sodo.2015.10.003 and potential solutions. Orthognathic surgery

Seminars in Orthodontics, Vol 22, No 1, 2016: pp 12–17 12

 Psychological considerations in orthognathic surgery and orthodontics 13

requires close collaboration between the maxillo- In either of the Class II cases, the main reason
facial surgeon and orthodontist, plus a mutual for seeking orthognathic surgical treatment may
agreement between the patient and the two be an unsatisfactory facial profile with a severe
professionals as to the diagnosis and treatment retrognathic mandible. However, the majority of
plan. Proper objective assessments should be less severe Class II patients are considered to
thoroughly communicated to the patient who is have acceptable appearance. Despite the fact that
contemplating orthognathic surgical procedures; surgical treatment may be recommended by
their understanding of the need for treatment is dental specialists and indicated by cephalometric
imperative. Certain treatments are likely to be measurements, the patient’s self-perception of
more readily accepted than others. their profile are more important factors in their
When comparing Class II and Class III decision regarding surgical correction.3
patients, the desire for functional and esthetic On the other hand, Class III patients may have
improvement is stronger with Class III patients. functional difficulties when anterior crossbite
Class II occlusion is often functional, and patients exists, and patients may experience excessive wear
rarely feel an urgent need for improvements. and chipping of the incisors when they are in an
Patients can chew with posterior dentition in edge-to-edge relationship. Class III patients gen-
Class II occlusal relationship, and they can erally are well aware of their facial disharmony,
function with anterior dentition by simply posi- and socially they are considered to be unattractive.
tioning their mandibles anteriorly unless there Epidemiological analysis of orthognathic surgery
are other compounding problems such as an in a hospital in Curitiba, Brazil, reviewed 195
anterior open bite, deep bite with gingival cases, and mandibular setback was the inter-
impingement on palatal tissue, etc. Maloc- vention most frequently performed.7 Johnston
clusions are often unnoticed by patients until et al.8 explored the self-perception of dentofacial
their dentists inform them of the problem. Even attractiveness among patients requiring orthog-
then, patients may reject treatment, especially nathic surgery, and reported that concerns and
when surgical treatment is the only option. It is awareness about facial profile were more pro-
especially difficult for patients to accept invasive nounced among Class III patients while severe
surgical treatment when they do not perceive the Class II patients exhibited lower levels of happi-
need for correction. However, there are cir- ness with their dental appearance. It is more likely
cumstances where patients may be aware of an for Class III patients to pursue surgical treatment
existing problem. One reason for Class II patients than Class II patients. Even in these Class III
to seek treatment may be an excessively traumatic patients, laypersons are less critical in their eval-
over-bite as with a Class II Division 2 occlusal uation of their profiles than were orthodontists
relationship. Excessive wear and chipping of according to Fabré et al.9 Surgical treatment for
incisors may alert the patient to the need for Class III requires careful persuasion from the
treatment. These patients may also experience orthodontist and surgeon.
painful palatal tissue damage caused by gingival Vertical problems can coexist in both Class II
impingement from extruded lower incisors. and Class III patients, and high angles combined
Visual damage to anterior dentition and pain can with facial concavity are negatively perceived by
motivate patients to accept the surgical treatment laypersons.9 A “long face” or “short faced” is often
if this is the only possible option. Machado et al.4– considered unattractive. Regardless of the true
6
illustrated that the esthetic zone is focused in severity of existing functional problems, the pa-
the area of maxillary central incisors, and they tient’s perception is the main factor in accepting
play a major role in smile esthetics. Excessive orthognathic surgical treatment. Unsatisfactory
overjet in the case of Class II Division 1 can be self-image, pain, and damage to teeth within the
another reason for a patient to seek treatment. In esthetic zone often have more impact in decision-
this case, the patients may have esthetic concerns making than the actual malocclusion.
or they may have had traumatic experiences with
flared incisors. Unsatisfactory self-image and
Pre-surgical orthodontics
damage to anterior dentition can be potent
motivators for patients to seek orthognathic This phase of the treatment can often be difficult
treatment. for the patient to endure both functionally and
14 Moon and Kim

esthetically. In preparation for surgery, decom- movement is critical for a successful result. The
pensation of the dentition is a necessary step in magnitude of surgery required for the best
order to ensure that an adequate amount of skeletal harmony can be easily underestimated,
surgical movement is possible. This procedure because the position where teeth fit best generally
helps in producing a precisely desired final does not produce an optimal jaw position without
outcome. However, this process almost always pre-surgical orthodontic decompensation. Careful
produces a more severe malocclusion and wor- surgical planning for a proper jaw position that
sening of facial esthetics. The patient’s occlusion allows for adequate postoperative orthodontic
often becomes gradually worse as dentition decompensation is crucial for the success of this
moves to a more optimal position within each approach.
jaw, not necessary coordinating well with This technique is favorable for cases requiring a
opposing counterparts. The treatment can take mild to moderate amount of dental decom-
more than one year, and orthodontic movement pensation, but it is not as good for cases requiring
can be difficult when battling an adverse func- major postoperative orthodontic movement.12,13
tional environment. Psychologically preparing More precise estimation of the jaw position and
the patient for these negative changes prior to postoperative dental decompensations are neces-
orthodontic decompensation can help in sary for these cases, and the results are not as
reducing anxiety and uncertainty the patient may predictable. Although this technique has significant
have to endure during the decompensatory advantage in pre-surgical management of patient
period. Even with this prior knowledge, these psychology, it can lead to patient dissatisfaction
changes can adversely affect daily functions and after the surgery when an optimal result is not
cause significant distress. achieved. Communicating the limitations and set-
In order to avoid the negative impact asso- ting a realistic treatment goal with the patient at this
ciated with this part of the treatment, some have stage is critically important for achieving patient’s
promoted a surgery-first procedure in recent satisfaction after the surgical procedure. Although
years.10,11 The obvious advantages are a short it is difficult, accurate prediction of surgical out-
preparation period and a subsequently shorter come can aid in ensuring patient satisfaction.
total treatment duration, rapid creation of a
favorable functional environment for orthodontic
Orthognathic surgery
movement, and psycho-social benefits. This pro-
cedure provides a decisive advantage over the Any surgical experience can be nerve-wracking,
traditional approach for the patient’s psychology. and some patients can experience significantly
Unlike conventional pre-surgical orthodontic increased anxiety as the surgery date approaches.
preparation where the patient’s facial appearance After a long drawn-out preoperative orthodontic
often suffers negative changes, this procedure treatment, patients may have mixed emotions: a
instantly improves facial esthetics. It also reduces desire to complete the surgery promptly but fear of
the pre-surgical anticipation period during which postoperative morbidity. As the oral surgeon pre-
time patients often experience increasing anxiety pares the patient for surgery, the potential surgical
due to a worsening of myofascial functions and complications should be thoroughly discussed days
facial esthetics. These advantages have made the before the operation. At this time the patient must
surgery-first approach increasingly popular, and sign an informed consent form which describes the
this new technique is being accepted by main- risks related to orthognathic surgery. The consent
stream orthodontic disciplines. form is designed to not only inform patients but
However, there are some inherent dis- also to relieve the potential liability for surgeons
advantages with this approach. Without proper should they fail to inform patients of the risk.
orthodontic decompensation prior to surgery, it At this point, some patients may have such
is challenging to match dentition during surgery, heightened anxiety that they get “cold feet” and
especially when dental alignment does not postpone the scheduled procedure. Bertolini
coordinate well between two arches. Since dental et al.14 measured the level of pre-surgical anxiety by
decompensation must be carried out after sur- self-administered questionnaires and reported that
gery, an accurate wafer fabrication based on a all patients experience a medium-to-high level of
precise prediction of postsurgical orthodontic pre-surgical anxiety. This is generally a temporary
 Psychological considerations in orthognathic surgery and orthodontics 15

emotional turmoil, and any long-term impact after are also valuable, especially when patients
surgery is uncommon. experience unusual levels of distress or have
Additional assurance and support from the difficulty accepting the postsurgical changes.
surgeon and orthodontist can significantly alle- Drastic facial changes can be alarming to the
viate this anxiety. The preoperative explanation of patient and family if potential changes were not
surgical steps in detail is of paramount importance relayed adequately, or if the results did not meet
in strengthening the patient’s faith in the surgical the patient’s expectations. Properly executed
team and subsequently reducing anxiety and dis- treatment prediction has to be communicated
tress.15 Open communication with the patient can prior to surgery in order to avoid this complica-
build trust and rapport between them and the two tion. The postoperative adaptation of patients to
professionals. Besides a technical explanation of the changes in facial morphology and function
the procedures, a discussion of emotional takes time, even after the predicted outcome has
experience dealing with the facial and been achieved. Psychological preparation mini-
functional changes and postoperative recovery is mizes this difficulty in coping with the post-
recommended. Additional support from family operative body image and surgical distress during
members, friends, and other patients can also the recovery period. As postsurgical facial swelling
help, especially from those who have undergone and other morbidities dissipate over time, most
similar experiences. In the study conducted by patients become acclimated with the changes and
Türker et al.,15 patients who talked to other generally become satisfied with the results.
patients who had previously been through Postsurgical discomfort, pain, paresthesia plus
surgery were better prepared for it. Patients who interpersonal, and oral function problems were
have experienced surgery are generally correlated with the patient’s postsurgery emo-
enthusiastic about sharing their experiences, so tional state. Postoperative pain can increase the
creating a patient support group may be valuable dissatisfaction and anxiety level of patients.20
in assisting patients to overcome preoperative fear. Generally, two-jaw operations precipitate more
pain complaints than single-arch procedures.
Maxillary surgical procedures may produce fewer
Postsurgical orthodontics
complaints of severe pain than mandibular pro-
Although the vast majority of patients are sat- cedures, but this advantage can be off-set by
isfied with surgical results, dissatisfaction, when it complaints of breathing difficulty and sinus
does occur, is largely associated with unantici- problems.21 The common complications or
pated postsurgical events.16 Leading the list of problems in the sequence of postoperative
contributing factors would be unrealistic expec- healing such as facial edema, pain, and
tations, lack of emotional preparation, insuffi- paresthesia should be discussed preoperatively
cient explanation of the surgical experience, in order to prepare the patients to handle such
poor mechanisms for coping with stress, events without distress. Postoperative distress
significant pain, and inadequate support from disappears gradually with the onset of successful
others.17–19 The importance of effective pre- healing, and patients tend to forget postoperative
operative communication and preparation of pain over time.15 As patients recover from surgical
patients cannot be over emphasized. When trauma, enhancement in self-image is common,
patients and families are better informed, post- reflected by improvement in psychological status,
surgical adjustment becomes easier and they are body, and facial images, self-confidence, and
more likely to have a realistic expectation of the interpersonal relationships. These positive changes
surgical outcome. Visual aids and honest com- eventually lead to remarkable satisfaction with the
munication can be helpful in establishing real- surgical outcome through enhancing social
istic goals and reducing false expectations. adjustment, self-confidence, and social life.
Türker et al.15 reported that an explanation of
the treatment steps and postoperative conse-
Interaction between surgeons and
quences prepares patients for surgery and
orthodontists
increases their satisfaction with the surgical
outcome. During the recovery period, It is known that psychological factors between the
assurance, and support from family and friends orthodontist and surgeon come into play during
16 Moon and Kim

planning stages of surgical treatment, but the also cause initial dissatisfaction but will be largely
actual impact of this relationship has not been forgotten as the patient recovers.
closely studied. While it seems logical to assume The relationship between surgeon and
that both parties would participate equally in orthodontist can be tricky. Since any friction or
treatment planning and patient follow up, this disharmony would be detrimental to the patient’s
may not be the case in reality. One party may be confidence and trust, there must be mutual
more dominant in various aspects of patient care respect and a good working relationship with
so the decision-making process can be rather close collaboration between them. This is critical
lopsided. Other than clinical skills, the person- to a successful outcome.
ality traits of providers may play a significant role
in choosing a partner. Generally, the ortho-
dontist spends significantly more time with the
References
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nathic surgery patients: the search for an integral
tionship. Communicating the orthodontist’s full diagnosis. Dental Press J Orthod. 2014;19:123–137.
confidence in the surgeon to patients can greatly 2. Ryan FS, Barnard M, Cunningham SJ. What are orthog-
help establishing a similar trusting relationship nathic patients’ expectations of treatment outcome—a
between patient and surgeon. However, there qualitative study. J Oral Maxillofac Surg. 2012;70:
may be disagreements between the two doctors 2648–2655.
3. Bell R, Kiyak HA, Joondeph DR, et al. Perceptions of
regarding the treatment approach, and these facial profile and their influence on the decision to
issues need to be carefully sorted out. In case an undergo orthognathic surgery. Am J Orthod. 1985;88:
agreement cannot be reached, it may be best to 323–332.
find another provider who might have a more 4. Machado AW. 10 commandments of smile esthetics.
Dental Press J Orthod. 2014;19:136–157.
comparable treatment philosophy. It is imper-
5. Machado AW, Moon W, Gandini LG Jr. Influence of
ative for the two providers to be in sync with both maxillary incisor edge asymmetries on the perception of
their personal relationship and treatment smile esthetics among orthodontists and laypersons. Am J
approach. This intricate balance and teamwork Orthod Dentofacial Orthop. 2013;143:658–664.
are essential parts in achieving success. Estab- 6. Machado AW, McComb RW, Moon W, et al. Influence of
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lishing a good network of providers who are
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Española Cirugía Oral Maxilofac. 2010;32:147–151.
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8. Johnston C, Hunt O, Burden D, et al. Self-perception of
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trusting relationship between all parties is orthognathic surgery. Angle Orthod. 2010;80:361–366.
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laypersons’ aesthetic assessment of Class III subjects
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Conclusion 443–448.
10. Liou EJ, Chen PH, Wang YC, et al. Surgery-first
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before proceeding further. The patient’s pre-
first approach: recent advances in orthognathic surgery.
surgical anxiety can be reduced significantly by J Orthod Sci. 2015;4:9–12.
thoroughly explaining the surgical process with 12. Hernández-Alfaro F, Guijarro-Martínez R, Peiró-Guijarro
additional assurance, utilizing a patient support MA. Surgery first in orthognathic surgery: what have we
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secutive cases J Oral Maxillofac Surg. 2014;72:376–390.
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13. Leelasinjaroen P, Godfrey K, Manosudprasit M, et al.
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emotional recovery. Postsurgical morbidity can Thai. 2012;95:172–180.
 Psychological considerations in orthognathic surgery and orthodontics 17

14. Bertolini F, Russo V, Sansebastiano G. Pre- and postsur- 18. Kiyak HA, McNeill RW, West RA, et al. Personality
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15. Türker N, Varol A, Ögel K, et al. Perceptions of 19. Maslach C, Jackson SE, Leiter MP. Maslach Burnout
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16. Lazaridou-Terzoudi T, Kiyak HA, Moore R, et al. Long- of orthognathic surgery and conventional orthodontics.
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The airway implications in treatment planning
two-jaw orthognathic surgery: The impact on
minimum cross-sectional area
Jarom E. Maurer, Steven M. Sullivan, G. Frans Currier, Onur Kadioglu, and Ji Li

The impact of orthognathic surgery on the pharyngeal airway supported by

cone-beam computed tomography (CBCT) technology has been the topic of
many recent studies. The minimum cross-sectional area (MCA) has also been
evaluated but not with respect to vertical position changes of the MCA with
movement of the facial skeleton. Vertical position changes and shape
changes of 71 patients after orthognathic treatment of Class II and Class III
malocclusions were evaluated with CBCT images and Invivo5 software. The
vertical changes were found not to be significant for Class II and Class III
patients (5.0 mm and 0.2 mm respectively, p ¼ 0.31). In addition, the vertical
changes of the MCA with individual skeletal movement were also not
significant. The shape changes were not consistent relative to individual
Angle classification. Vertical changes of the MCA after orthognathic surgery
could not be associated with Angle’s classification or skeletal movement
while shape changes were not predictable. Orthognathic surgical planning is
a complex process in which the patient’s occlusion, facial balance, and
harmony are considered. The purpose of this article is to provide surgical
insight into obtaining the best possible results when considering the
multifactorial nature of orthognathic surgical treatment planning. Original
research on the changes in MCA will be presented. (Semin Orthod 2016;
22:18–26.) & 2016 Elsevier Inc. All rights reserved.

Introduction difficult to quantify using conventional two- and

A
three-dimensional images. Lateral cephalograms
dvances and availability of cone-beam
do not capture the changes in the lateral airway
computed tomography (CBCT) imaging
that can be seen with CBCT imaging.4 Gonçales
and related software have allowed for the phar-
et al.5 demonstrated an increase in the lateral
yngeal airway to be accurately evaluated. Several
dimension of the airway at three separate vertical
software programs are capable of measuring both
points with maxillary advancement, mandib-
volume and minimum cross-sectional area
ular advancement, and maxillomandibular
(MCA). In addition, several studies1–3 have
advancement. Interestingly, the maxillary
shown the accuracy of the volumetric airway
advancement group with mandibular setback
measurements as well as the accuracy of the
also demonstrated an increase in the lateral
software in evaluating the MCA. It has been
dimensions of the airway at the vertical position
shown that changes in the pharyngeal airways are
of the posterior nasal spine and vellecula with a
small decrease in lateral dimension at the uvula.
Private Practice, 835 3rd Ave SE, Cedar Rapids, IA; Department
of Oral and Maxillofacial Surgery, University of Oklahoma,
Other studies2,4,6–8 have looked at the volu-
Oklahoma City, OK; Department of Orthodontics, University of metric changes associated with orthognathic
Oklahoma, Oklahoma City, OK; Department of Biostatistics and surgery utilizing existing software programs and
Epidemiology, University of Oklahoma, Oklahoma City, OK. have found that there are predictable volumetric
Address correspondence to Jarom Maurer, DMD, Private Practice, increases or decreases of the pharyngeal airway,
835 3rd Ave SE, Cedar Rapidsm, IA 52403. E-mail: jarom@eiofs.
com
depending upon the type of movement that was
& 2016 Elsevier Inc. All rights reserved.
performed surgically. A more recent study9 has
1073-8746/12/1801-$30.00/0 evaluated the changes in airway volume after
http://dx.doi.org/10.1053/j.sodo.2015.10.004 orthognathic surgery as it relates to specific

Seminars in Orthodontics, Vol 22, No 1, 2016: pp 18–26 18

 The airway implications in treatment planning two-jaw orthognathic surgery 19

skeletal movement, with certain movement in the and voxel size of 0.3 mm or a ProMax 3D CT
horizontal mandible and vertical position of the scanner (Planmeca, Roselle, IL) with a field of
posterior nasal spine (PNS) causing significant view of 17  20 cm2 and a voxel size of 0.2 mm.
differences in airway volume and MCA. The images included the entire oropharynx,
Similarly, there have been numerous pub- extending at least to the inferior border of C3.
lications10–13 concerning both the position of Exclusion factors included those without suffi-
the MCA and the changes in area following cient preoperative or postoperative records,
orthognathic surgery. However, the vertical open bites, craniofacial anomalies, and patients
position of the MCA has not been evaluated with not in intercuspation at either time when the
respect to the millimetric skeletal changes with scans were made. The same surgeon performed
orthognathic surgery. Such evaluation is impor- the orthognathic surgery for all patients.
tant because airway obstruction tends to occur at The postsurgical CBCT images were taken
two vertical areas, either at the level of the soft from 4 to 14 months postsurgery to allow for
palate or at the tongue base.13,14 If specific decrease of soft tissue inflammation. All scans
skeletal movement changes are found to predict were performed at 3.8 mA for 40 s at 120 kV
the vertical position of the MCA, the orthodontic (Iluma), or a variable 1–14 mA for 27 s at 90 kV
setup and surgical movement can be planned to (Planmeca). The patients were instructed to
improve upon or at least minimize negative breathe lightly without swallowing while in
effects on the airway. maximum intercuspation with their head posi-
tions standardized (held in the Frankfort Hori-
zontal (FH) plane, parallel to the floor) while
Materials and methods
they either sat (Iluma) or stood (Planmeca).
IRB approval was obtained from the University of The scans were reconstructed at 0.3 mm and
Oklahoma (OU). The patient pool obtained exported in the Digital Imaging and Communi-
from the OU Oral and Maxillofacial Surgery cations in Medicine (DICOM) format.
Department used in this study was also used in a The DICOM files were then loaded into Invivo
recently published article on the pharyngeal 5 software for evaluation. The same examiner
airway and orthognathic surgery.9 This performed all CBCT data analysis for bony
retrospective study included 71 total subjects measurements pre- and postoperatively,9 and a
that met the inclusion criteria of 35 Class II second examiner performed the data analyses for
patients and 36 Class III patients as determined measurement of MCA and vertical position of the
cephalometrically. The patients’ preoperative MCA as well as changes in its shape. The patient’s
lateral cephalograms were used for classifica- 3D images were oriented to FH utilizing the
tion. Class II patients had positive overjet and software’s orientation widget. This served as a
ANB and Class II posterior buccal segments. reference plane as previously described (Fig. 1).9
Class III patients had negative overjet and ANB Once oriented, skeletal measurements were
and Class III posterior buccal segments. Positive performed. For the maxilla, Point A was
overjet was defined as the anterior maxillary measured vertically and horizontally. The
dentition anterior to the mandibular anterior transverse maxilla was measured from the
dentition and negative overjet defined as the inner most curvature as well as the vertical
mandibular anterior dentition anterior to the position of the PNS. The mandible included
maxillary anterior dentition. Class II buccal both horizontal and vertical measurements at
segments were defined as any maxillary molar Point D, which is the midpoint of the mandibular
position anterior to a Class I designation. Class III symphysis. Point D more accurately represents
buccal segments were defined as the maxillary the vertical and sagittal movement of the bony
molar position posterior to a Class I designation. chin than does Point B, which may not change
The average age of the 31 male and 40 female with rotational movement of the mandible. For
patients was 18 years 8 months. Preoperative and the nine patients that underwent genioplasty,
postoperative CBCT scans were taken on them Point B was used due to the difficulty in
after two-jaw orthoganthic surgery using either determining Point D after this procedure.
an Iluma Ultra Cone Beam CT scanner (IMTEC, The airway volume measurement option in
Ardmore, OK) with a 19  22 cm2 field of view the Invivo software was used to calculate the MCA
20 Maurer et al

Figure 1. (A) Submental view showing orientation through right and left porion and orbitale. (B) Left lateral view
showing orientation through right and left porion and orbitale. (For interpretation of the references to color in
this figure legend, the reader is referred to the web version of this article.)

(Fig. 2A). Vertical measurements from FH to the the final vertical position of MCA to FH
most superior limits of the MCA were then (Table 1).
measured (Fig. 2B and C). A vertical reference
plane perpendicular to FH at porion was used for
Results
anterior or posterior measurements. A positive
value was assigned to any skeletal movement that The MCA vertical position changes were not
was anterior or inferior while a negative value was found to be statistically significant in pre- and
assigned to skeletal movements posterior or postoperative pooled data (Table 2). Similarly,
superior. The superimposition option in the there were no statistically significant differences
software provides simultaneous views of the in the MCA vertical positions when the Class II
axial, sagittal, and coronal sections of the and Class III patients were separated (Table 3).
CBCT as well as the three-dimensional skeleton Also, there were no significant changes in vertical
and three-dimensional airway. It was used to position of the MCA as related to changes in
scroll through the axial sections of the CBCT bony skeletal position pre- and postoperatively
until the level of the MCA was reached in order to (Table 4).
record the shape of the axial section of the airway The vertical position changed in 68 of the 71
(Fig. 3). subjects postoperatively, but none of the eval-
In order to evaluate potential error in the uated data showed statistical significance. A wide
measurements of MCA and vertical position, 17 range was noted in the vertical position from FH
of the 71 patients were randomly selected and re- of the MCA from 16.2 mm to 87.0 mm with a
measured by the same examiner. The Dahlberg mean of 58.6 mm in the postsurgical sample
formula was used to obtain an intra-rater corre- (Table 2). This was expected considering the
lation of 0.97 for the initial vertical position anatomical differences in male and female
measurements from FH to the MCA and 0.99 for patients, their skeletal classification, and their

Figure 2. (A) Generated lateral cephalogram from 3D CBCT with airway volume and minimum cross-sectional
area defined. (B) Vertical measurement from Frankfort Horizontal to the most superior aspect of the minimum
cross-sectional area (MCA—red arrow). (C) Class III patient showing an increase in the MCA (red arrow) after two-
jaw orthognathic surgery. (For interpretation of the references to color in this figure legend, the reader is referred
to the web version of this article.)
 The airway implications in treatment planning two-jaw orthognathic surgery 21

Figure 3. (A) The superimposition tab of Invivo5 software was used to locate the minimum cross-sectional area.
(B) Axial view of the MCA (red arrow). (C) Class II patient after counterclockwise rotation with mandibular
advancement. (D) Axial view showing MCA (red arrow) change compared to (B). (For interpretation of the
references to color in this figure legend, the reader is referred to the web version of this article.)

ages. The mean change for the entire sample was that became more circular in appearance while
2.6 mm with a large standard deviation of six changed from more circular to more ovoid
17.1 mm. There was no statistical significance lateral. Of all, nine of the patients exhibiting
associated with any skeletal movement in the shape changes were Class II while the remaining
vertical position of the MCA which is consistent patients were Class III.
with the findings of other authors 8,10 (Table 4).
The shapes were also evaluated. For ori-
entation, the shape of the MCA in the axial Discussion
section was termed either circular or ovoid lat- The Class II patients had an average vertical
eral. A total of 20 of the 71 patients had a clearly change of 5.0 mm in the MCA position while the
visible shape change postoperatively (Fig. 4); 14 Class III patients exhibited an average change of
of the 20 had a preoperative ovoid lateral shape only 0.2 mm (Table 3). Although these values
were not statistically significant, it did show that
Table 1. Measurement error.
Table 2. Summary statistics for MCA-pooled groups
Measurement time N Dahlberg’s measurement Intra-rater (units: mm).
error correlation
Variable N Minimum Maximum Mean Median SD
Vertical MCA 17 2.291 0.97
initial Vertical MCA 71 16.22 83.46 56.03 59.03 16.82
Vertical MCA 17 0.998 0.99 initial
final Vertical MCA 71 16.16 87.04 58.59 63.22 17.09
qffiffiffiffiffiffiffiffiffiffi final
P d2
Dahlberg’s formula, S ¼ was used to calculate the error Vertical MCA 71 61.72 48.10 2.56 1.92 20.13
2n
change
of measurement with d as the difference between the first and
the second measures. Intra-rater correlation was also Negative value denotes superior change while positive an
calculated. inferior change.
22 Maurer et al

Table 3. ANOVA analysis to compare the means between Class II and Class III (units: mm).
Variable Class N Minimum Maximum Mean Median SD p Value

Vertical MCA initial II 35 20.51 83.46 53.80 53.36 14.18 0.2740

III 36 16.22 83.18 58.20 64.69 18.99
Vertical MCA final II 35 16.16 80.17 58.80 65.00 16.87 0.9201
III 36 18.77 87.04 58.39 63.05 17.54
Vertical MCA change II 35 51.17 48.10 5.00 3.50 20.57 0.3179
III 36 61.72 47.17 0.19 0.80 19.69
There were no significant differences between Class II and Class III patterns relative to mean initial, final, and changes in the
vertical position of the MCA.

the vertical position was more variable with Class same vertical position as measured from FH pre-
II patients after surgery. The MCA in Class III and postoperatively were not evaluated as our
patients tended to basically remain in the same interest was in evaluating the changes in shape of
position despite a mandibular setback, which the MCA, regardless of the vertical position.
conceptually could cause dorsal repositioning of Further studies are needed to evaluate the
the tongue base, leading to obstruction.15 The airflow dynamics of these patients in order to
surgical movement of Class III patients was done determine if there is a clinical significance
with the airway in mind, which may account for associated with the vertical position of the MCA.
the relatively unchanged position of their MCA. The information provided here, as well as the
With regard to shape, one might expect recent emphasis on the evaluation of airways,
changes from ovoid lateral to more circular with should guide both the orthodontist and the
Class II mandibular advancements and vice versa surgeon when planning orthognathic cases.
for a Class III mandibular setback as the lateral One limitation of this study, as well as all other
soft tissues of the pharyngeal airway are advanced airway studies based on CBCT scans, is the
or allowed to relax. In fact, the opposite was potential for normal day-to-day variations in soft
found in this study where improvement was seen tissue. Also due to the wide spread in the gath-
in the lateral dimension of the airway in some ered data, a larger patient pool is necessary to
Class II patients, which is similar to finding by detect significant findings in vertical position.
Gonçales et al.5 who showed increases in the
lateral dimension of the airway in mandibular
Surgical planning considerations
and maxillary advancements (Fig. 3B and D).
This finding emphasizes that the collapsing and Research has shown that anterior movement with
dilating forces of the airway are complex dynamic orthognathic surgery produces an improvement
forces that are not yet fully understood. In this in the pharyngeal airway volume while posterior
study, we did visualize changes in the lateral and movement generally results in a negative effect
anterior posterior dimension, but the shapes did on the airway.5,9 Surgical design should incor-
not transition from ovoid lateral to round or vice porate an airway evaluation to mitigate or reduce
versa in most cases. These shape changes at the any negative impact on the pharyngeal airway in

Table 4. Univariate analysis for pooled sample on MCA changes (units: mm).
Dependent Parameter Estimate Standard error p Value

Vertical MCA change Vertical A Point change 0.42 1.25 0.7372

D Point change 0.53 0.83 0.5303
PNS change 1.28 0.88 0.1509
Sagittal A Point change 0.17 0.93 0.8513
D Point change 0.32 0.44 0.4614
Transverse Maxillary change 1.51 1.09 0.1695
For pooled data (Class II and Class III), there were no associations among any of the parameters. Negative value denotes superior
change while positive an inferior change.
 The airway implications in treatment planning two-jaw orthognathic surgery 23

Figure 4. (A) Preoperative airway. (B) Axial view highlighting the shape of the MCA (red arrow). (C) Post-
operative airway. (D) Axial view highlighting the shape change of the MCA (red arrow) compared to (B). (For
interpretation of the references to color in this figure legend, the reader is referred to the web version of this
article.)

mandibular setback and improve the volume and data showing that increased airway cross-
MCA in advancement cases. The airway evalua- sectional area has a significant improvement in
tion is vital in the planning phase as it can loosely apnea hypopnea index (AHI) correlating the
be described as a cylinder with collapsing and data with a decreased laminar and turbulent
dilating forces acting on it at all times.14 A smaller flow. Foltan et al.15 reported improvements in
diameter airway predisposes collapse more so obstructive apnea, respiratory disturbance index
than with a larger diameter airway. and oxygen desaturation index with mandibular
Many anatomic features impact the phar- advancement. Mandibular setback coupled with
yngeal airway such as angle orthodontic maxillary advancement had a negative effect in
classification, tongue size, mandibular plane these same areas. The authors concluded that
angle, elongation of the soft palate, and inferior dorsal positioning of the tongue base was the
hyoid position. They should be considered dur- likely cause of the negative impact on the
ing the preoperative airway evaluation.8,11,16 evaluated sleep study parameters. Van
Conditions relative to the existing skeletal clas- Holsbeke et al.12 studied patients with sleep
sification can also contribute to a patient’s airway apnea pre- and postmandibular advancement
dimensions as shown by Muto et al.,13 who via an anterior positioning appliance and
concluded that the tongue base and uvula as concluded the increases in MCA were the best
measured to posterior pharyngeal wall vary in the predictor of decreases in resistance of the airway.
different classification of patients depending on Furthermore, they stated that patients without
their posture. baseline obstruction of the airway responded
Several authors12,15,17 have evaluated the better to mandibular advancement than those
changes in skeletal position of the mandible and with baseline airway obstruction. Lastly, when the
maxilla and their impact on the airway utilizing MCA was near the tongue base, there was an
sleep studies. Sittitavornwong et al.17 provided increased chance of obstruction.
24 Maurer et al

Figure 5. (A) Preoperative lateral cephalogram of Class III patient. (B) Surgical treatment objective tracing
showing counterclockwise rotation with limited mandibular setback. (C) Postoperative lateral cephalogram of the
same patient with counterclockwise rotation.

Considerations in Class II patients Maxillary orthognathic movement also affects

the airway. Several studies 6,9,21 evaluated the
In treatment planning for Class II patients, one
vertical position of PNS or uvula and found that
can expect that there will be an increase in the
as nasopharynx volume increased, it did so at the
volumetric dimensions of the pharyngeal airway
expense of the total and oropharyngeal volume.
as well as the MCA. However, it is not possible to
Hart et al.9 found for every one millimeter
predict the change in vertical position. In order
of inferior movement of PNS, the total airway
to amplify the mandibular move, a counter-
decreased by 459.2 mm3 regardless of classifica-
clockwise rotation should be planned. This
tion and it produced a 10.6 mm2 decrease of
counterclockwise, maxillary movement will pro- the MCA. With this in mind, when planning
duce a far more accentuated mandibular the limits of maxillary movement, one needs
movement along with proper correction of the to evaluate the airway and determine if the
occlusal plane than with traditional, linear counterclockwise rotation will benefit the patient
orthognathic movement and thus have a greater as with Class II patients or have a deleterious
effect on the airway.9 The anterior mandibular effect on the airway as with some Class III
move could be further increased by increasing patients.
the overjet through removal of permanent teeth
in the mandible during presurgical orthodontic
treatment. For anterior maxillary impaction Considerations in Class III patients
cases, the rotation point may be placed around With regards to the pharyngeal airway, Class III
the anterior nasal spine (ANS), maxillary incisal patients also benefit from two-jaw orthognathic
edge, or between the posterior nasal spine (PNS) surgery with counterclockwise rotation. As Hart
and ANS. Stability of orthognathic movement has et al.9 demonstrated, one should expect a specific
greatly increased with the use of rigid fixation volumetric change with every one millimeter of
although some relapse can be expected.18 posterior movement of Point D. Their study also
Goncalves et al.19 showed that an increase showed that the MCA decreased by 15.45 units
in pharyngeal volume produced after counter- for every one millimeter of inferior vertical
clockwise rotation and maxillomandibular change at D. The current study showed that
advancement was stable long term in their the vertical position of the MCA from FH did not
study of 56 cases. Reyneke et al.20 demon- significantly change in Class III patients (Table 3)
strated that the stability of the mandible in because changes in vertical position were only
counterclockwise movement is similar to 0.2 mm in this group. This showed that the
stability in conventional linear movement long positions of the mandible and maxilla changed in
term (6–60 months) with the differences in such a way as to keep the tissues adjacent to the
relapse between the counterclockwise group MCA in essentially the same place. In planning
and the conventional movements being for Class III patients, the goal is to avoid
insignificant. decreases in the pharyngeal airway which may
 The airway implications in treatment planning two-jaw orthognathic surgery 25

lead to problems with collapse of the airway and References

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responsibility to achieve the best dental and chanics of the upper airway: changing concepts in the
skeletal results while preventing, or minimizing, pathogenesis of obstructive sleep apnea. Int J Oral
Maxillofac Surg. 2010;39:1149–1159.
any iatrogenic effects on the airway. This study 15. Hong JS, Park YH, Kim YJ, et al. Three-dimensional
provides some insight into the effects of surgical changes in pharyngeal airway in skeletal class III patients
movement on the MCA and the role the MCA undergoing orthognathic surgery. J Oral Maxillofac Surg.
plays on the patient’s ventilation. 2011;69:e401–e408.
26 Maurer et al

16. Schendel SA, Jacobson R, Khalessi S. Airway growth and 20. Reyneke JP, Bryant RS, Suuronen R, et al. Prostoperative
development: a computerized 3-dimensional analysis. skeletal stability following clockwise and counter-
J Oral Maxillofac Surg. 2012;70:2174–2183. clockwise rotation of the maxillomandibular complex
17. Sittitavornwong S, Waite PD, Shih AM, et al. Computa- compared to conventional orthognathic treatment. Br
tional fluid dynamic analysis of the posterior airway space Oral Max Surg. 2007;45:56–64.
after maxillomandibular advancement for obstructive 21. Lee Y, Chun Y, Kang N, et al. Volumetric changes in the
sleep apnea syndrome. J Oral Maxillofac Surg. 2013;71: upper airway after bimaxillary surgery for skeletal Class III
1397–1405. malocclusions: a case series study using 3-dimensional
18. Proffit WR, Turvey TA, Phillips C. The hierarchy of cone-beam computed tomography. J Oral Maxillofac Surg.
stability and predictability in orthognathic surgery with 2012;70:2867–2875.
rigid fixation: an update and extension. Head Face Med. 22. Mattos CT, Vilani GNL, Sant’Anna EF, et al. Effects of
2007;3:21. orthognathic surgery on oropharyngeal airway: a meta-
19. Goncalves JR, Buschang PH, Goncalves DG, et al. Post- analysis. Int J Oral Maxillofac Surg. 2011;40:1347–1356.
surgical stability of oropharyngeal airway changes follow- 23. Foltan R, Hoffmannova J, Pavlikova G, et al. The
ing counter-clockwise maxillo-mandibular advancement influence of orthognathic surgery on ventilation during
surgery. J Oral Maxillofac Surg. 2006;64:755–762. sleep. Int J Oral Maxillofac Surg. 2011;40:146–149.
Surgical exposure of impacted canines: Open or
closed surgery?
Adrian Becker, Ioannis Zogakis, Ionut Luchian, and Stella Chaushu

The methods for exposing impacted canines are outlined and the relative
merits of using a closed versus open surgical procedure are discussed in
relation to the projected long-term prognosis and appearance of the treated
outcome. These surgical modalities have a wide range of variations designed
for individual circumstances, each of which has advantages in specific cases.
Similarly, orthodontic biomechanic protocols vary depending on the 3-
dimensional location of the impacted tooth in the maxilla. Each of these
factors has an influence on the final outcome. Attempts to provide answers
showing a preference for one surgical technique over another using a
prospective randomized clinical trial would be difficult in the face of such a
wide spectrum of factors. (Semin Orthod 2016; 22:27–33.) & 2016 Elsevier Inc.
All rights reserved.

Introduction elements such as intermaxillary elastic forces,

extra-oral forces and temporary anchorage
hen an oral surgeon and orthodontist are
W willing to work together as a team,
impacted teeth may be successfully brought into
devices. At this point, the surgeon needs to be
brought into the scene to provide unobstructed
access to the impacted tooth.
ideal alignment and made completely indis-
Differences of opinion have arisen within the 2
tinguishable from other, normally erupted teeth
specialties regarding the best method of surgical
in the dentition.
exposure to produce an overall favorable con-
Standard procedure today dictates that treat-
dition and prognosis at the completion of
ment of such cases begins with the orthodontist,
treatment.1,2 Opinions are based on a prediction
and the initial goal is orthodontic alignment and
of the expected periodontal status of the out-
leveling of the teeth in the dentition, followed by
come, the esthetics of gingival form and post-
the creation of space in the dental arch to
treatment orthodontic relapse of the achieved
accommodate the impacted tooth. The ortho-
alignment.
dontist then consolidates and stabilizes the teeth
The aims of the surgical phase of the ortho-
in that jaw by placing a full thickness passive
dontic/surgical modality of treatment are:
archwire in all the brackets, with the intent to
create an anchorage unit including all the teeth.
(1) to eliminate hard or soft tissue pathologic/
It is against this unit that the forces designed to
obstructive entities,
reduce the impaction of the tooth will be pitted,
(2) to provide the orthodontist with access to the
and where necessary, the unit may be further
impacted tooth, including the creation of a
buttressed with the addition of other anchor
suitably isolated micro-environment for the
bonding of an attachment, and
Department of Orthodontics, Hadassah Faculty of Dental
(3) to perform these tasks with minimum tissue
Medicine, Hebrew University, Jerusalem, Israel; Department of
Periodontology, Faculty of Dental Medicine, Grigore T. Popa damage, while avoiding exposure and instru-
University of Medicine and Pharmacy, Iasi, Romania. mentation of the cemento-enamel junction
Address correspondence to Adrian Becker, BDS, LDS, DDO, (CEJ) and cervical portion of the root
Department of Orthodontics, Hebrew University-Hadassah Faculty of surface.
Dental Medicine, P.O.B. 12272, Jerusalem 91120, Israel. E-mail:
adrian.becker@mail.huji.ac.il
& 2016 Elsevier Inc. All rights reserved.
The most frequently impacted tooth consid-
1073-8746/12/1801-$30.00/0 ered for treatment with this conservative
http://dx.doi.org/10.1053/j.sodo.2015.10.005 modality is the maxillary permanent canine and

Seminars in Orthodontics, Vol 22, No 1, 2016: pp 27–33 27

28 Becker et al

the ensuing discussion will largely be described in mesially or distally.3,9 It involves raising a labial
this context. attached mucogingival flap from the crest of the
ridge and re-suturing it at the cervical level,
leaving the crown exposed.
Open-eruption techniques
The open-eruption technique is not limited to a
Closed-eruption technique
single option, but includes 3 principal alter-
natives, each incorporating minor variants: (1) There are also 3 main approaches to the closed
window technique, (2) full flap open procedure, exposure—all incorporating minor intra-
and (3) Apically repositioned flap technique. technique variations:

Window technique Minimal exposure technique

This represents the simplest form of open In a closed procedure, a full and wide flap is
exposure. It entails the surgical removal of the reflected in the thick keratinized palatal mucosa
mucosa and bone immediately overlying the overlying the palpable bulge and retracted to
impacted tooth.3,4 It is the most direct way of reveal the bony surface beneath.10 A small area of
exposing an impacted canine that is located and the thin shell of bone covering the tooth is pared
usually palpable immediately under the surface. away to disclose the follicle. A window is cut into
With a very superficially located labial tooth, this the follicle to expose the surface of the tooth,
procedure can sometimes be accomplished by sufficient to provide a minimum attachment
using only topical anesthesia in the form of bonding area of tooth enamel, while
anesthetic spray. permitting the maintenance of hemostasis. The
In contrast, the usually palpable, palatally majority of the follicle is left intact; no attempt is
impacted canine is covered by thick mucosa, made to remove more bone than is necessary for
bone, and follicle. As such, it is at least 5–7 mm access to the tooth and the CEJ area is left
beneath the surface and considerably more when undisturbed. A small eyelet attachment, threaded
there is follicular enlargement or when the tooth with a ligature or chain, is bonded, followed by
is more grossly displaced. The surgical removal of the complete replacement of the surgical flap to
a circular area of tissue will provide exposure its former place, leaving only the ligature or
through a deep, raw and bleeding access chan- chain exiting through its sutured edge. Ideally,
nel, which will make attachment bonding highly orthodontic traction should start immediately.
risky. In such cases, the surgeon often prefers to
place a surgical pack to prevent healing over of Maximal exposure technique
the tissues. Sometimes the orthodontist may be
rewarded with renewed eruptive activity of the In an effort to standardize the procedure in a
canine and the possibility of autonomous multicenter controlled study to examine perio-
eruption.5,6 dontal outcome, the participating surgeons
adopted a significantly more radical exposure
than the one just mentioned, by the removal of
Full flap open procedure
bone and, presumably, complete enucleation of
An alternative is to reflect a full palatal flap to the follicle covering the tooth in its crypt, in
reveal the crypt of the canine, expose the tooth to order to achieve exposure of the tooth to its
its maximum circumference and then re-suture maximum circumference.7
the flap back to its former place, after having first
excised a circular portion of the mucosa imme- Tunnel approach
diately overlying the tooth.7,8
An interesting variant of the closed technique
was introduced by Crescini et al.11 The impacted
Apically repositioned flap
canine is drawn downwards through the
The main indication for this procedure is when a evacuated socket of the simultaneously
labially impacted tooth is situated above the level extracted deciduous canine. This modification
of the mucogingival junction, but not displaced is aimed at ensuring the preservation of the
 Surgical exposure of impacted canines 29

buccal plate of the alveolar bone and the then wait for the incisor to erupt or, at least
principal indication of this technique is for improve its position, before exposing it in a
impacted canines that are located high in the second surgical episode. Alternatively and
maxilla and in close proximity to the line of assuming that it is desirable to avoid 2 surgical
the arch. procedures, performing an open procedure on
this tooth runs the almost impossible task of
maintaining clinical access to the tooth, when the
The choice of surgical procedure in
highly mobile mucosa is desperately trying to
relation to 3D location of the impacted
heal the wound over. Furthermore, modifying
tooth
the technique by apically repositioning a partial
Teeth generally erupt through the attached thickness, keratinized, gingival flap, results in the
gingiva, but those which are more buccally dis- denudation of the entire labial mucosal cover of
placed have a tendency to erupt higher up above the ridge.
the attached gingival band and through the oral Attempting an open procedure risks leave a
mucosa. A closed surgical exposure or apically large defect in the soft tissues and bone. This
repositioned flap procedure in these cases is would not be appropriate in many instances,
indicated. The only justification for the simpler even if a surgical pack is used, because of the
window procedure exposure here is when there depth of the tooth within the maxilla, as reported
is a wide band of attached gingiva overlying the recently.15 Other contraindications to an open
impacted tooth.3 When the tissue is removed in procedure include exposure of adjacent tooth
this situation, there must be a millimeter or more roots to the oral environment, exposure of
of attached gingiva, apical to the cut edge. resorbing root apices, and loss of access due to
According to Ericson and Kurol12 and Walker healing of the mucosal tissues over the surgical
et al.,13 between 48% and 67% of impacted site. Furthermore, a closed procedure provides
canines are associated with resorption of the better access to a buried tooth by reflecting a
adjacent incisors. It has also been shown that wide mucosal covering of the area as a first step,
resorption ceases when the offending canine is making for better vision and better hemostasis,
distanced from the immediate vicinity.14 In order particularly in the palatal area.
to move the canine, it must first be exposed and No 2 oral and maxillofacial surgeons expose
an attachment placed on it. Since the crown of teeth in the same way. There is a wide range of
the canine is located at least partially within the preferred clinical protocols regarding the width
resorption crater, leaving the tooth open to the and depth of open exposure and to a varying
oral environment post-surgery endangers the extent the surgical flaps in closed procedures.
vitality of the incisor—clearly not an option. There is a broad spectrum of opinion and
Thus, the alternatives are either to extract 1 or practice among oral and maxillofacial surgeons
other of the 2 involved teeth or to leave the in regard to the elimination of the tissues around
canine to continue on its destructive eruption the impacted tooth, ranging from those who
path until it resorbs its way through the incisor expose just a small area of crown enamel, to those
root and out the other side. The third alternative who bare the tooth well down to the CEJ and
is to perform a closed procedure in which only a beyond.
small opening into the follicle is made at the most Many orthodontists prefer the services of a
distant part of the crown of the canine from the periodontist.1,3 The rationale for this is the belief
resorption front. A minimal amount of enamel is that the skills of a periodontist are more suited to
exposed, sufficient only to accept the attachment the finer nature of this particular procedure,
to be bonded to it. including greater care in the manipulation of the
What of the unerupted central incisor, soft tissues. This is indicative of different surgical
impacted by the presence of a supernumerary strategies or protocols within these 2 related
tooth or 2? The incisor is often very high up, specialties, with a corresponding variation in the
labially displaced and at the level of the reflection periodontal outcome.
of the oral mucosa in the summit of the labial It becomes evident that there are very many
sulcus. Some orthodontists prefer to have the objective factors to consider when selecting a
surgeon remove the supernumerary teeth and surgical method and planning for the surgical
30 Becker et al

exposure of an impacted tooth, many of which If we accept that it is preferable to place an

are dictated by the individual preference of the attachment at the time of surgery and that the
surgeon. The range of treatable impacted teeth attachment comes into intimate contact with the
that can be salvaged is wider if we are prepared to healing mucosa as the tooth is erupted into the
use a closed procedure than an open one. Thus, mouth, then a low profile and rounded eyelet
a technical bias creeps into the selection of cases must be the attachment of choice. Placing a bulky
that comprise the investigative sample. While the and sharply cornered standard bracket as a
indications and contraindications for the per- “back-pack” on the tooth will lead to impinge-
formance of one method versus another need to ment and consequent inflammation of the gin-
be evaluated on a patient-by-patient basis, there is gival tissues as it emerges. This will have a
a fairly wide range of situations in which either an negative effect on the periodontal outcome,
open or closed method would be equally suitable. particularly in the closed procedure cases. No
These are likely be the more straightforward and requirement was established regarding the type
simpler ones and differences in periodontal and of attachment to be bonded in the various
appearance-outcomes between the 2 are unlikely treatment centers, so the likelihood that a
to be great. However, these are precisely the cases standard orthodontic bracket was used is fairly
that would probably form their random inves- unlikely and the consequences could be quite
tigative sample, because those with more severely significant.
displaced teeth will be eliminated as unsuitable
for an open surgical approach.7,15 A further
Efficacy of treatment
methodologic flaw in that study relates to their
standardized, submucous, direct, orthodontic For optimum interdisciplinary cooperation,
traction of the canine to its location, emerging there is no substitute for the orthodontist being
intraorally only in its place in the arch. For many present at the surgical exposure to test for
impacted canines, the path to their destination is mobility of the tooth, to bond the attachment in
obstructed by the root of one or both incisors. No the most advantageous site, to draw the con-
allowance was made for this in the study, sug- nector in the calculated direction of traction, to
gesting the inclusion of only minor impaction connect up the traction mechanism and to
cases and correspondingly minor periodontal activate it at that time. Closed surgery provides a
outcome differences. wide surgical field, where the widely reflected
flap—the main source of bleeding—can be
retracted away from the bonding area. This also
provides for visibility of the entire field and
Attachment bonding
consequently, the surgeon can remove a mini-
With access to the tooth presented during sur- mum of bone around the tooth and expose a
gery, an attachment needs to be placed in the small area of enamel, just enough for placing a
most convenient location on the crown of the small eyelet. There is no need to expose the
tooth, with a connector leading from the tooth to whole crown of the impacted tooth,15 this will not
the exterior. Superficially, it would seem logical speed-up the eruption rate, but will increase the
to assume that, with an open exposure techni- risk for negative periodontal implications.16 The
que, bonding of an attachment may be per- biggest advantage is that immediate activation
formed either at the time of surgical exposure, or may be effected in the optimal direction, with the
at a later date. However, experience has shown appropriate force level and range of action—
that the cut and raw mucosal tissues rapidly close something only the orthodontist knows how to do
within the first few days and access to the tooth properly—and all this while the patient is still
may be lost, even when the exposure was very anesthetized!
wide.15 Placement of a surgical pack for the first
2–3 weeks of the healing period will delay the
Periodontal outcome
tissue closure, but bonding an attachment deep
into a surgically created cavern with an oozing Surgical repair after a closed procedure occurs by
periphery following pack removal, is far from primary intention, while open procedures heal
reliable. by secondary intention around the impacted
 Surgical exposure of impacted canines 31

tooth crown. Few studies clarify whether this

leads to different periodontal and esthetic out-
comes, while most have methodological limi-
tations. One study included a mixed group of
canines and incisors,17 another did not describe
the surgical procedure used,18 while others11,19
included both palatal and buccal canines. The
results must clearly be interpreted with caution,
since the periodontal outcome is not necessarily
the same with different teeth and with different
surgical methods.
Figure 1. Pre-treatment panoramic radiograph shows
Palatal canines a palatally impacted canine, with crown tip in the
midline. The lateral incisor roots lies in the direct path
A previously reported study on the periodontal between the canine and its final location.
outcome in groups of palatal canines treated with
the same surgical procedure showed that those for closed exposure in the Parkin series of studies
treated with closed procedures report very sat- carried an important rider, namely “……the
isfactory outcomes in terms of esthetics, a mini- canine exposed with the closed procedure was
mal increase in the depth of the periodontal moved beneath the mucosa.”7 This automatically
pockets and some loss of bone support.20 In excludes the many cases where the lateral incisor
contrast, Wisth et al.21 reported a significant loss root obstructs the direct path of the tooth to
of attachment associated with open procedures; the desired location. In this common situation,
however, since these groups of canines were a 2-stage resolution of the impaction is necessary
totally different and unmatched, a meaningful to overcome the strategic obstruction. The
comparison still cannot be made. Until recently, impacted tooth has to be initially erupted verti-
only one retrospective study aimed to compare cally into the mid-palate, from where it gains a
closed versus open procedures in a pure group of new and direct path to its place (Figs. 1–3).
palatal canines.22 It found deeper pockets in
teeth exposed by open exposures, but this study
had inherent methodological limitations due to Buccal canines
the lack of matching between the 2 surgery Studies reporting the periodontal condition of
groups. buccally impacted canines after closed-eruption
A Cochrane review23 concluded that there is exposure found excellent appearance but a
insufficient evidence to prefer one technique
over the other. In all, 2 subsequent prospective
studies7,8 reported contradictory results with
similar periodontal and esthetic results, irre-
spective of the type of surgery. These studies
randomly allocated the cases to the 2 surgery
groups, with no attempt to match them. Random
allocation does not guarantee perfect matching,
especially in terms of the severity of impaction. In
addition, the description of the surgical techni-
que included “surgical bone removal exposing
the largest diameter of the ectopic canine
crown.”15 For the closed procedure, this
represents a departure from good clinical
practice and a radical and unnecessary removal Figure 2. The same case, following a closed surgical
exposure, the initial movement vertically erupted the
of bony covering which would negatively tooth into the palatal area, in order to circumvent the
influence the final periodontal and esthetic lateral incisor root, before drawing it to the line of
outcome.16 The defined standardized criteria the arch.
32 Becker et al

mucosa is sutured over its labially exposed aspect.

A third procedure may later be prescribed for the
purpose of apicectomizing the labially prominent
root apex.30

Post-treatment quality of life

Our group reported on postoperative recovery
following surgical exposure of impacted teeth
treated with closed-eruption and an open-
eruption surgical-orthodontic technique.31–33
Figure 3. The same case at the completion of
treatment with the canine in its place.
Again, results must be interpreted in relation
to the initial location of the impacted tooth.
Buccal exposures, either closed or open, showed
decrease in the width of attached gingiva.24 No prolonged recovery in comparison to palatal
studies have directly compared open versus exposures. The buccal approach is probably
closed surgical outcomes in buccal canines more traumatic in either the open or closed
alone, although mixed groups of palatal and approaches than in the palatal approach because
buccal canines have been investigated.19,25,26 of the need to sever paranasal/oral musculature
and to locate the surgical flap in highly mobile
oral mucosa.33 In contrast, for palatal exposures,
Incisors
recovery was longer (5 days) after open eruption
Our group has reported on the periodontal and than after closed-eruption exposures (3 days),
esthetic outcome in a group of unilaterally especially with regard to pain, analgesic intake,
impacted incisors. The incisors treated by closed difficulty in eating and swallowing. The dis-
surgery resulted in a very satisfactory appearance comfort was greater if bone removal was needed.
in general but with a slight, occasional gingival In our studies, questionnaires were answered on
irregularity.27 Those treated by open exposures a daily basis from day 1 and the results indicated
showed an inferior periodontal result including a recovery in 3–5 days after surgery. Significantly, at
decrease in the width of attached gingiva, an the extreme ends of the spectrum, 6 patients who
increased crown length, a high frequency of still reported pain at 10 days were from the open
gingival irregularity and a significant reduction in surgery group and 3 of 4 patients who reported
the mesial bone support.28 The only article in the no pain, were from the closed surgery group.
literature which compared closed versus open In a similar study, the authors found no post-
was the study of a group of matched (in terms of surgical differences in discomfort following the
age, position and severity of impaction) impacted various procedures.15 However, in that study the
incisors found statistically significant differences patients completed the questionnaires on a
in 2 parameters: teeth in the open-eruption single occasion 10 days after the surgery, which
group had considerably longer crowns and would appear to be excessively taxing on the
decreased mesial bone support than those in the memory for an accurate and critical assessment
closed-eruption group.29 A special case has to be of post-surgery discomfort.
made in the surgical protocol for treatment of
severely dilacerate incisors, whose incisal tip is
Conclusion
high in the labial sulcus, adjacent to the anterior
nasal spine. These teeth require 2 separate and In conclusion, it must be recognized that there
contrasting surgical procedures. Initially, a closed are far too many variable factors involved in the
procedure is performed in the summit of the surgical and the orthodontic procedures in the
labial sulcus to place the attachment. As the tooth treatment of impacted canines and that any
moves down toward the crest of the ridge, its attempt to standardize the clinical approach to
incisal edge bulges the labial side and is danger of either of these 2 specialties in a randomized
erupting through the free oral mucosa. At this clinical trial can, at best, only provide answers to
point, an apically repositioned flap of gustatory the “sterile” conditions of those treated within
 Surgical exposure of impacted canines 33

that study. At worst, it ignores the individual in periodontal breakdown of treated palatally impacted
treatment needs and special operative require- canines. Am J Orthod. 1984;85:72–77.
17. Vermette ME, Kokich VG, Kennedy DB. Uncovering
ments that are determined by the clinical fea- labially impacted teeth: apically positioned flap and
tures and characteristics of many in the broad closed-eruption techniques. Angle Orthod. 1995;65:23–32
spectrum of patients whom we treat. [discussion 33].
18. Woloshyn H, Artun J, Kennedy DB, Joondeph DR. Pulpal
and periodontal reactions to orthodontic alignment of
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Surg. 2012;70:2026–2034. of recovery after exposure of impacted teeth: a compar-
16. Kohavi D, Becker A, Zilberman Y. Surgical exposure, ison of closed- versus open-eruption techniques. J Oral
orthodontic movement, and final tooth position as factors Maxillofac Surg. 2005;63:323–329.
Primary failure of eruption and other eruption
disorders—Considerations for management by
the orthodontist and oral surgeon
Sylvia A. Frazier-Bowers, Sonny Long, and Myron Tucker

Tooth eruption is a highly variable process, and the disorders that stem from a
defective eruption process are often difficult to diagnose. The eruption process
can range from normally timed and sequenced events to one characterized by
eruption delays or a primary failure of eruption (PFE, OMIM 125350)—with
partially or completely unerupted teeth in the absence of a mechanical
obstruction. Our understanding of the molecular basis of tooth eruption was
drastically strengthened when one gene, parathyroid hormone receptor 1
(PTH1R), was found to be causative for familial cases of PFE. Although PFE is a
relatively rare condition, knowledge of a biological mechanism underlying the
development of PFE illuminates: (1) the influence of genetics on orthodontic
tooth movement in general; (2) the differential diagnosis of clinical eruption
disorders; and (3) the correlation of a biologic basis with the clinical manage-
ment of eruption failure. In this article, we consider the best clinical manage-
ment of eruption disorders from the standpoint of what is known from a
biological perspective about normal tooth eruption and therefore eruption
disorders. Specifically, how the diagnosis influences the clinical management
of eruption disorders using biologic versus clinical factors is considered. These
advances in our understanding of normal and abnormal tooth eruption now
allow for a systematic clinical diagnostic regime that may include a surgical
approach or simply the elimination of treatment with a continuous archwire.
(Semin Orthod 2016; 22:34–44.) & 2016 Elsevier Inc. All rights reserved.

Introduction environmental, and of course idiopathic. Primary

D
failure of eruption (PFE, OMIM #125350),
iagnosis and clinical management of
originally described by Proffit and Vig,1 is
eruption disorders can be quite challeng-
characterized by eruption failure of permanent
ing. The critical features of diagnosis can be
teeth in the absence of mechanical obstruction
broken into several major categories, including
or syndrome. The hallmark features of this
syndromic versus isolated, genetic versus
condition are:
Department of Orthodontics, University of North Carolina, School
of Dentistry, Chapel Hill, NC; Department of Pediatric Dentistry,
1. Infraocclusion of affected teeth.
University of North Carolina, School of Dentistry, Chapel Hill, NC 2. Significant posterior openbite malocclusion
and Private Practice in Orthodontics and Pediatric dentistry, accompanying normal vertical facial growth.
Charlotte, NC; Department of Oral and Maxillofacial Surgery, 3. The inability to move affected teeth
Louisiana State University School of Dentistry, Oral and Max- orthodontically.
illofacial Surgery Educations Services Consultant, Isle of Palms, SC.
Address correspondence to Sylvia A. Frazier-Bowers, DDS, PhD,
Department of Orthodontics, University of North Carolina, School of Many historic studies have noted the heritable
Dentistry, Chapel Hill, NC 27599. E-mail: sylvia_frazier-bower- basis of infraoccluded teeth or eruption dis-
s@unc.edu
orders.2–7 Until the reports of mutations in the
We gratefully acknowledge the past support of the AAOF, SAO,
and NIH grants 1K23RR17442 and M01RR-00046. parathyroid hormone receptor 1 gene (PTH1R),
& 2016 Elsevier Inc. All rights reserved.
non-syndromic eruption disturbances (i.e., anky-
1073-8746/12/1801-$30.00/0 losis, secondary retention, primary retention, and
http://dx.doi.org/10.1053/j.sodo.2015.10.006 PFE) were difficult to distinguish from one

Seminars in Orthodontics, Vol 22, No 1, 2016: pp 34–44 34

 Clinical management of eruption disorders 35

another.8,9 Moreover, it became apparent that the obstruction of the eruption pathway, such as
orthodontic management of mechanical failure crowded dental arches.
of eruption (MFE)6 is different from that of In this report, we examine the relationship
PFE, therefore critically important to distinguish between the clinical eruption disorder, its eti-
between eruption failure due to local or ology and hence the best management using a
mechanical causes (e.g., cysts, interference of rubric created from a study of eruption dis-
adjacent tooth, lateral pressure from tongue, orders and genetic etiology.10 For the clinical
and secondary to syndrome such as cleidocranial orthodontist, the utilization of biologic inform-
dysplasia, OMIM #199600) versus a failure of the ation facilitates the accurate and timely diag-
eruption mechanism completely. nosis of an eruption disorder and therefore
Although PFE was previously thought to be an appropriate management of the orthodontic
isolated event, the identification of PTH1R problem.17,18
mutations associated with PFE provides con-
firmation of a genetic etiology for eruption
failure. It may also be reasonable to suspect a
The biology of tooth eruption
genetic etiology for other eruption disturbances The key to understanding abnormal tooth
(i.e., delayed eruption, impaction) that do not eruption should start with a complete under-
involve a mechanical barrier. This shifts the standing of normal eruption. Briefly, human
focus from a purely clinical description to one dental eruption is defined as the axial movement
that represents a combination of clinical and of a tooth from its non-functional, developmental
biologic factors.10 Accordingly, eruption distur- position in alveolar bone to a functional position
bances should be thought of in broad etiologic of occlusion.19 It is also known that normal tooth
categories rather than narrowly defined morph- eruption relies on a tightly coordinated process
ological characteristics.11,12 The major catego- including a series of signaling events between the
ries include biologic dysfunction (e.g., primary dental follicle and the osteoblast and osteoclast
failure of eruption) and physical obstruction (e. cells found in the alveolar bone.20 Several studies
g., mechanical failure, cysts, and lateral tongue confirm the role of the dental follicle as a central
pressure; Fig. 1A and B). Impacted teeth may fit mediator of tooth eruption21–23; the dental fol-
into either category, depending upon the licle provides the environment and chemo-
location of the impacted tooth (i.e., palatal or attractants for monocytes to differentiate into
buccal canine impaction). Palatally impacted osteoclasts, facilitating the bone resorption nec-
canines are hypothesized to be both multifact- essary for normal tooth eruption. Historical
orial and genetic in origin.13–16 Also, permanent experiments by Cahill and Marks21 demonstrated
teeth can become impacted secondary to an the critical role of the follicle in experiments

Figure 1. (A) Diagrammatic representation of the spectrum of tooth eruption, ranging from normal eruption to
mechanical or primary failure of eruption. Delayed eruption is at the far end of the normal eruption sequence.
Mechanical failure of eruption can be due, for instance, to local causes such as a cyst, supernumerary teeth, and
lateral pressure from the tongue. On the other hand, impactions (especially canine), and ankylosis represent
either a defect in the primary eruption mechanism or a mechanical obstruction. PFE is, by definition, “primary”
failure of eruption due to a defect in the molecular eruption mechanism. (B) Diagrammatic representation of a
rubric that initially distinguishes from a mechanical versus biologic etiology is a key step in treatment planning
decisions.
36 Frazier-Bowers et al

where a metal object was substituted for a tooth the tooth has transited, thus contributing to PFE.
in the dental follicle. Evidenced by the successful This relationship of PFE with PTH1R and PTHrP
eruption of the follicle containing a metal object, therefore provides clues to the possible mecha-
it was concluded that the follicle was necessary nism of tooth eruption and may be important
and sufficient for eruption. deducing an appropriate treatment modality.
Furthermore, the importance of key cytokines Because PTH1R and PTHrP act in the vitamin D
and diffusible growth factors in tooth eruption receptor—retinoid X receptor (VDR/RXR)
was nicely illustrated using rodent molars by Yao activation pathway—it is plausible that a critical
et al.24 Their studies suggested that specific target of the genetic defect in PFE is the alveolar
growth factors and cytokines and the following bone. The VDR/RXR pathway primarily affects
chain of events provides the mechanism that cell signaling, molecular transport, and vitamin
facilitates eruption into the oral cavity: and mineral metabolism.28,29 Yet VDR/RXR
signaling also plays a key role in balancing bone
1. Stellate reticulum cells found in the dental formation with bone resorption such as that seen
follicle are observed to secrete parathyroid in bone remodeling.30,31 In addition to influ-
hormone related peptide (PTHrP). encing calcium homeostasis in general, the focal
2. PTHrP induces expression of colony stimulat- genes, PTH1R and PTHrP, and the pathway in
ing factor-1 (CSF1) and receptor activator of which they belong, have been shown to affect the
NF-kappa B ligand (RANKL), which are pri- number, quality and function both of osteoclasts
mary factors involved in osteoclastogenesis.24 and osteoblasts32,33 as well as the volume, thick-
3. At the apical end of the dental follicle, ness and density of trabecular bone.34,35 Con-
concomitant expression of bone morpho- sideration of these biologic relationships helps to
genic protein (BMP) promotes osteogenesis form the basis for treatment options in the
in a temporally and spatially coordinated management of PFE versus other eruption dis-
fashion.25 orders discussed below.

These experiments in rats reveal that specific

Diagnosis and management of tooth
factors are necessary and sufficient to facilitate
eruption problems
eruption of the tooth into the oral cavity.26
Additionally, we know that genes involved in The identification of mutations in the PTH1R
mineralization, for example, amelogenin gene as the cause of PFE and the connection
(AMELX) and ameloblastin (AMBN) may act in between osteoclasts and osteoblast cells as dis-
concert with those involved in osteoclastogenesis, cussed above also provides the basis for potential
such as RANKL, CSF1 and C-Fos.27 These and clinical management approaches. We already
other findings enhance our understanding of the know that individuals affected with PFE do not
specific biologic mechanism underlying tooth respond to orthodontic forces and can be easily
eruption. The apparent connection between confused with ankylosis.1,6,9 However, clinical
PTH1R and PTHrP, which is secreted in the cases in question now can be evaluated for a link
stellate reticulum and responsible for the to a specific biologic cause (i.e., PTH1R muta-
induction of CSF1 and RANKL, was confirmed tion) and therefore rule out MFE or ankylosis.
in a simple network pathway analysis.12 The Although PFE is relatively rare (estimated inci-
established link between PTH1R and PTHrP dence of 0.6%), the occurrence of eruption
provides significant evidence of the problems in the dental/orthodontic setting is not
relationship between PFE, PTHrP signaling and uncommon.
the mediators of eruption necessary for normal A significant challenge in the accurate diag-
bone remodeling. noses of PFE is the high degree of clinical vari-
Consequently, one might hypothesize that ability observed in familial and isolated cases.6,11
some variants in one of these two focal genes For example, our phenotypic evaluation of
(e.g., PTH1R) could disrupt the balance between eruption failure in a large cohort revealed that
bone resorption, necessary to establish the pas- there are distinguishable types of PFE related to
sageway for an erupting tooth, and bone for- the extent of eruption potential in the ante-
mation, necessary to rebuild bone through which roposterior and vertical gradient. With respect to
 Clinical management of eruption disorders 37

the pattern viewed from an anteroposterior quite useful knowledge from viewing the dis-
gradient two types of PFE have been previously orders in a systematic fashion in a study that
described.6,11 Type I is marked by a progressive compares PFE with other eruption failure
openbite from the anterior to the posterior of the (Fig. 2).10 Evaluation and comparison of three
dental arches. Type II presents as a progressive cohorts (PFE with PTH1R mutation, ankylosis,
openbite from the anterior to the posterior; and PFE w/o mutation) with varying forms of
however, there also is a more varied expression of eruption disorders revealed that those who had a
eruption failure in more than one quadrant and mutation in the PTH1R gene (and a certain
greater although inadequate eruption of a sec- diagnosis of PFE) shared common phenotypic
ond molar. Type II is even more challenging to characteristics with one another. Specifically,
recognize than Type I because the second molar 100% of the 11 cases evaluated had at least
may appear erupted but upon careful examina- one affected first molar and 93% of all eruption
tion will lack the ideal interdigitation with the failure cases (N ¼ 64) had at least one affec-
opposing tooth. While the exact reason for ted first molar; all of the cases revealed a
this clinical variation is unknown, in light of clear eruption pathway radiographically. These
the recent PTH1R finding, we speculate that the findings were used to create a rubric that pro-
predominant affection of molar teeth may be vides a systematic diagnosis, but also that guides
the result of a coordinated series of molecular clinical management. Using the diagn-
events that act in a temporally and spatially ostic criteria defined in this study we may also
specific manner such that posterior rather than be able to elucidate the most efficient manage-
anterior alveolar bone is affected. ment sequence.
Despite the gap of knowledge that remains in Ankylosis, strictly defined as the fusion of
our understanding of how a significant problem, cementum to alveolar bone, represents an
such as eruption failure arises, we have gained eruption defect most easily confused with PFE.

Figure 2. A systematic study of eruption disorders to establish a diagnostic rubric determined the diagnostic
features of PFE based on those who carried a mutation in the PTH1R gene since this is a most objective criterion.
Three cohorts were evaluated for phenotypic and genetic characteristics: cohort (1) PFE—genetic (those that
harbor a mutation in PTH1R), cohort2) PFE—clinical (those that are phenotypically identical to PFE genetic
without the mutation in PTH1R, and cohort (3) ankylosis. The results of this study formed the basis for a diagnostic
rubric to distinguish eruption disorders, revealing the hallmark features of PFE based on those with PTH1R
mutations and at least one infraoccluded molar that had a clear eruption pathway.
38 Frazier-Bowers et al

The diagnosis of ankylosis relies largely on the were diagnosed with PFE, reveals a need to
clinical appearance of infraocclusion and radio- establish better diagnostic tools to distinguish
graphically by the absence of a periodontal lig- between ankylosis and PFE. The consequence of
ament space, however, the determination of an the misdiagnosis in this family led to unsuccessful
absent periodontal ligament space often can be attempts to correct the malocclusion orthodon-
misinterpreted on a radiograph. The absence of tically that instead worsened the severity of the
physiologic mobility and the sharp solid sound posterior openbite and intruded teeth anterior
on percussion of the tooth have also been sug- to affected teeth.9 A positive family history of PFE
gested as diagnostic approaches but show great and/or positive identification of a mutation in
variation based on the operator.36,37 In this case, the PTH1R gene should alert the clinician that
ankylosis can be difficult to distinguish from PFE. affected teeth would be unresponsive to ortho-
This scenario is exemplified in one family in dontic treatment. However, if a diagnosis of
which five members carried the same mutation in ankylosis is accurate then the affected tooth is the
PTH1R (Fig. 3A–L). Two affected individuals only tooth that will be unresponsive; the
were diagnosed previously with ankylosis as remaining teeth will be responsive to ortho-
determined by bone sounding (Fig. 3A–F). dontic treatment. Given the difficulty in diagn-
The fact that all family members carried the osing ankylosis accurately, if a physical or
same mutation causative for PFE, but only two mechanical cause cannot be documented and

Figure 3. (A–C and D–F) represents Type II PFE observed in pretreatment photographs of two siblings. This mild
presentation of a unilateral openbite initially was mistaken for isolated ankylosis. Both siblings have a unilateral
pattern of PFE with a Class I relationship on the unaffected side. Another affected sibling (G–I) and the mother of
all three children (J–L) show Type I PFE, with the distal most teeth affected more severely. Despite disparate
diagnoses, all of the family members carried the same mutation in the PTH1R gene.
 Clinical management of eruption disorders 39

a genetic etiology is discovered, then PFE more this diagnostic distinction informs the clinical
likely is the diagnosis. The diagnostic approach management. For instance, in one family, the
above will allow the clinician to follow two apparent biologic etiology was only determined
different treatment courses including: after the infraocclusion was misdiagnosed as
ankylosis and the occlusal relationships
1. If PFE can be confirmed, traditional ortho- worsened by treating the entire dentition with
dontic treatment with a continuous archwire a continuous archwire (Fig. 4A–F).9 In this
should be avoided. An accurate diagnosis of clinical scenario, the analysis of the PTH1R
PFE prevents a futile effort by doctor and gene was not available at the time of their
patient because the teeth will not respond. initial diagnosis but the apparent familial
2. If a first molar fails to erupt, early extraction of segregation was remarkable and forms the
the first molar will allow the second molar to basis of the systematic approach in diagnosis of
drift mesially if the second molar is normal eruption failures (Fig. 3A–L). In another family,
and does no harm if the second molar exhibits an eruption defect that aligns with PFE was found
abnormal eruption. in a mother and two daughters (Fig. 5A–I). The
only approach that would result in closure of the
posterior openbite and occlusal interdigitation is
Clinical approaches to manage eruption
single tooth osteotomies (corticotomies) with
failure
immediate elastic traction taking advantage of
A systematic clinical approach based on biologic Regional Acceleratory Phenomenon (RAP).
data was described previously in three cohorts Corticotomies followed by immediate elastic
of eruption failure and can be applied as traction is perhaps the most logical approach
follows: (1) first determine if the eruption defect to achieve a significant occlusal improvement but
has an apparent mechanical obstruction the key to such intervention is immediate
(e.g., cysts, tumors, or supernumerary teeth) or traction following the surgery (Fig. 6A–D) as
biologic etiology (i.e., family history, devel- shown in another individual affected with PFE.
opmental pathology; Fig. 1B).10 (2) Then the The surgical approach will likely be used for the
determination of whether a lower first molar is younger untreated daughter as well (Fig. 5G–I).
involved must be made. If the answer to these two The alternative treatment approach is always to
questions is yes, then the diagnosis may be PFE. avoid treatment with a continuous archwire and
Although a genetic analysis of the PTH1R employing a segmented approach from prem-
gene would be an ideal approach to confirm olar to premolar and leaving the infraocclusion in
a diagnosis of PFE, this is not yet routinely the molar region uncorrected.
available in most practices as it does not The management of PFE described above is
represent a standard genetic test.9 Nonetheless, quite distinct from other forms of eruption

Figure 4. (A–C) The same patient shown in Fig. 3(A–C) before treatment with a continuous archwire and (D–F)
after treatment. The outcome of orthodontic treatment with a continuous archwire in confirmed cases of PFE is
intrusion of the adjacent teeth.
40 Frazier-Bowers et al

Figure 5. An important aspect of the diagnostic rubric (Fig. 1A and B) is to determine if a biologic cause is present for
the eruption disorder. Application of this rubric can be illustrated in one family with an affected daughter who manifests
the posterior lateral openbite after orthodontic treatment (A–C). Re-evaluation of her mother, who was treated in the
distant past, and her younger sister revealed a milder (D–F) and more severe (G–I) case of PFE with at least one affected
molar (G–I). A genetic evaluation of PTH1R would be ideal to confirm the diagnosis, but can be concluded using the
information available. In this case treatment included corticotomies followed by elastic traction (J–L).

failure that should be managed quite differently with PFE (Fig. 7A). The absence of a family
(Fig. 7A–C). An 11-year-old male reported to an history and a systematic collection of historical
orthodontic clinic with an apparent first molar information revealed a complex odontoma in his
eruption failure that can be initially confused past that caused the initial impaction (Fig. 7B).
 Clinical management of eruption disorders 41

Figure 6. Example of adult male patient affected with PFE. Treatment included segmental osteotomy in the
maxillary arch (A and B) with immediate elastic traction (C and D).

Figure 7. (A) Panoramic film illustrating an unerupted lower first molar that may initially appear to fit the
diagnostic rubric of PFE. (B) Assessment of an earlier panoramic film reveals the cause of eruption failure is a
complex odontoma. (C) This illustrates a good example of how identification of the etiology provides the
appropriate management and successful resolution of eruption failure.
42 Frazier-Bowers et al

Figure 8. Clinical photographs of 8-year-old male with an apparent lateral open bite (A) and an unerupted lower
left first molar (B). After extraction of tooth 19, which subsequently revealed a developmental pathology and not
PFE, the lower left second molar erupted normally (C–E). Eventual use of a vertical crib to discourage the tongue
from occupying the edentulous space resulted in a reasonable resolution of the open bite (E–J).

Removal of the adjacent second premolar and dentition was critical to point to MFE as the cause
surgical exposure of the impacted lower first of the eruption failure. The resultant occlusion
molar was selected to eliminate the mechanical was restored with surgical extraction of the
obstruction and allow resolution of the occlusion. premolar and orthodontics (Fig. 7C).
This case nicely illustrates the importance of After the determination of an affected first
determining mechanical obstruction versus molar is made, a critical step is to determine
family history. The management was clearly whether a biologic versus mechanical cause is
different than if the diagnosis was mistaken for known. This can be narrowed down by deter-
PFE, given the affected first molar. In this case, mining if a family history exists. Fig. 8A–D nicely
obtaining an appropriate natural history of the illustrates a different scenario of eruption failure
 Clinical management of eruption disorders 43

in the absence of a family history. This fact alone rare eruption disorder. Am J Orthod Dentofacial Orthop.
does not eliminate the diagnosis of PFE, but 2007;131(578):e1–e11.
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upon further inspection, radiographically, a Genetic analysis of familial non-syndromic primary failure
developmental pathology of the tooth can be of eruption. Orthod Craniofac Res. 2009;12:74–81.
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bony pathway. Surgical extraction was recom- loss-of-function mutations in familial, nonsyndromic
mended at the age of 8.7 years for the lower primary failure of tooth eruption. Am J Hum Genet.
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developmental pathology (Fig. 8E–G). Subseq- Ackerman JL. Primary eruption failure and PTH1R: the
uent eruption of the developing 7 (#18) was importance of a genetic diagnosis for orthodontic treat-
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(160):e1–e7.
eral openbite that was likely due to the tongue
10. Rhoads SG, Hendricks HM, Frazier-Bowers SA. Establish-
filling the edentulous area. A HAAS type appli- ing the diagnostic criteria for eruption disorders based on
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Update on treatment of patients with
cleft—Timing of orthodontics and surgery
Pradip R. Shetye

The management of patients with cleft lip and cleft palate requires prolonged
orthodontic and surgical treatment and an interdisciplinary approach in
providing them with optimal esthetics, function, and stability. This article
describes an update on the current concepts and principles in the treatment of
patients with cleft lip and palate. Sequencing and timing of orthodontic/
orthopedic and surgical treatment in infancy, early mixed dentition, early
permanent dentition, and after the completion of facial growth will be discussed.
(Semin Orthod 2016; 22:45–51.) & 2016 Elsevier Inc. All rights reserved.

Introduction cleft deformity itself, such as discontinuity of the

alveolar process, and missing or malformed
left lip and palate is the most frequently
C occurring congenital anomaly. Depending
on the extent of the cleft defect, patients may
teeth, whereas other aspects of the malocclusion
are secondary to the surgical intervention per-
formed to repair the lip, nose, alveolar, and
have complex problems dealing with facial
palatal defects. A malocclusion may exist in all
appearance, feeding, airway, hearing, and
the three planes of space; anterioposterior,
speech. Patients with cleft lip and palate are
transverse, and vertical. The malocclusion may
ideally treated in a multidisciplinary team setting
reflect the severity of the initial cleft deformity
involving specialties from the following dis-
and the growth response to the primary surgery.
ciplines: pediatrics, plastic and reconstructive
As malocclusion in patients with clefts is often a
surgery, maxillofacial surgery, otolaryngology,
growth-related problem, the effect of the cleft
orthodontics, genetics, social work, nursing,
deformity and primary surgery will be observed
speech therapy, pediatric dentistry, prosthetic
throughout the growth of the child until skeletal
dentistry, and psychology. The orthodontic and
maturity. The orthodontist must make critical
surgical treatment of patients with clefts is
decisions for orthodontic intervention at the
extensive, initiating at birth and continuing into
appropriate time and prioritize treatment goals
adulthood when craniofacial skeletal growth is
for each intervention. For the purpose of
finished. The role of the orthodontist in timing
organization, the orthodontic treatment of
and sequence of treatment is important in terms
patients with clefts will be presented in four
of overall team management. The goal for
distinct treatment phases: infancy, primary den-
complete rehabilitation of patients with clefts is
tition, mixed dentition, and permanent
to maximize treatment outcome with minimal
dentition.
interventions.
In a patient with cleft lip and palate, the
orthodontic malocclusion can be related to soft Treatment during infancy
tissue, skeletal, or dental defects. Some cleft
orthodontic problems are directly related to the Pre-surgical infant orthopedics has been used in
the treatment of cleft lip and palate patients for
centuries. In 1993, Grayson et al.1 described a
Wyss Department of Plastic Surgery, New York University, new technique, nasoalveolar molding (NAM), to
Langone Medical Center, New York, NY. presurgically mold the alveolus, lip, and nose in
Address correspondence to Pradip R. Shetye, DDS, BDS, MDS, infants born with cleft lip and palate.
Wyss Department of Plastic Surgery, New York University, Langone
The initial impression of the infant with cleft
Medical Center, 307 East 33rd St, New York, NY 10016. E-mail:
pradip.shetye@nyumc.org lip and palate is obtained within the first week
& 2016 Elsevier Inc. All rights reserved.
after birth using a heavy body silicon impression
1073-8746/12/1801-$30.00/0 material and the NAM appliance is inserted
http://dx.doi.org/10.1053/j.sodo.2015.10.007 within the first 2 weeks. The NAM appliance has

Seminars in Orthodontics, Vol 22, No 1, 2016: pp 45–51 45

46 Shetye

Figure 1. (A) Unilateral NAM plate with nasal stent showing lip taping. (B) The bilateral NAM plate in position
showing the tape adhered to the prolabium, stretched to the plate, and attached to the plate.

two components—the oral (molding plate) and bridge across the former cleft site improves the
the nasal (nasal stents). The oral component conditions for eruption of the permanent teeth
molds the clefted alveoli to allow them to and provides them with better periodontal sup-
approximate each other. The nasal components port. Studies have also demonstrated that 60% of
mold the distorted nasal cartilage on the clefted patients who underwent NAM and gingivoper-
nose, making it more symmetrical (Fig. 1). Nasal iosteoplasty did not require secondary bone
molding helps expand the tissue of the mucosal grafting9 (Fig. 2). The remaining 40% who did
lining of the nose. In unilateral cleft patients, the need bone grafts showed more bone remaining
nasal stent straightens the deviated columella in the graft site compared to patients who had
towards the non-cleft side. In patients with not had gingivoperiosteoplasty.10
bilateral cleft lip and palate, the nasal stent
elongates the deficient columella by gradually
stretching the columella tissue. With the help of Treatment during the primary dentition
tape, the lips are also molded to reduce the size
of the cleft. This process is done over a 3–4- The treatment goals during the primary denti-
month period and with active involvement by the tion stage of development focus on the acquis-
family in the nasoalveolar molding process. A ition of normal speech function, which is
recent study of caregivers demonstrated that
nasoalveolar molding was often associated with
positive factors for parents such as increased
empowerment, self-esteem, and bonding with
their infant.2 After completion of nasoalveolar
molding treatment, the infant is then referred to
the surgeon for primary closure of lip, nose, and
the alveolus.
There are several benefits with the nasoal-
veolar molding technique in the treatment of
cleft lip and palate deformity. Proper alignment
of the alveolus, lip, and nose helps the surgeon
achieve a better and more predictable surgical
result.3 Long-term studies of NAM therapy
indicate that the change in nasal shape is stable.4
The improved quality of primary surgical repair Figure 2. Sectional CBCT of a patient who underwent
reduces the number of surgical revisions, nasoalveolar molding and gingivoperiosplasty surgery
oronasal fistulas, and secondary nasal and to repair the alveolus at the time of primary lip closure.
Note good bone formation on the right former cleft
labial deformities.4–8 If the alveolar segments side. This patient did not need secondary alveolar
are in the correct position and a gingivoper- bone graft surgery. CBCT, cone beam-computed
iosteoplasty is performed, the resulting bone tomography.
 Update on treatment of patients with cleft 47

managed by a speech therapist or pathologist to stabilize pre-maxillary segments in patients

and the surgeon. During this phase, the patient is with bilateral clefts.
closely monitored by the speech and language Discrepancies in maxillary arch form or
therapists. Patients may or may not need speech transverse width should be improved before the
therapy depending on the diagnosis of speech secondary alveolar bone graft. It is of note that
issues. If the child has been diagnosed with the surgeon and orthodontist must work in
velopharyngeal insufficiency (VPI), then the tandem to determine the anatomical limits of
surgeon may perform a pharyngeal flap. This pre-surgical maxillary expansion. This is imper-
surgery is typically performed around the age ative, as overexpansion may create an oronasal
of 2 years. fistula or a defect that is beyond the limits of
Another important component of care for a surgical closure (Fig. 3).
patient during this time period includes routine To provide the most stable environment for
follow-up with a pediatric dentist. Regular visits to integration of the alveolar bone graft and the
the pediatric dentist every 6 months are strongly maintenance of palatal expansion, we routinely
recommended to prevent dental caries. place an occlusally-bonded acrylic or removable
trutain type splint at the time of surgery. The
splint serves to immobilize the alveolar segments,
as well as to prevent relapse of pre-surgical
Treatment during mixed dentition
maxillary expansion. The splint remains in
The treatment objectives for a child as he/she place for 6–8 weeks after surgery.
enters mixed dentition are directed toward The management of a bilateral cleft lip and
preparing the patient for secondary alveolar palate patient may pose a unique challenge with
bone graft (SABG) surgery. The alveolar bone respect to the position of the premaxilla before
graft surgery is typically performed at around 8–9 bilateral alveolar bone grafts. However, if the
years of age. A limited volume CBCT performed premaxilla is ectopically positioned, the patient
at this age is invaluable to identify the cleft defect may need pre-maxillary repositioning surgery.
and the position of the permanent teeth Pre-surgical expansion is preformed to improve
adjoining the cleft defect. The principal benefits the arch form before surgery. A bonded occlusal
of alveolar bone grafting are: (1) to provide splint is constructed after model surgery. In the
sufficient bone for the eruption of either the operating room, the surgeon uses the splint to
maxillary lateral incisor or canine, (2) to provide reposition the premaxilla and perform the sec-
adequate bone and soft tissue coverage around ondary alveolar bone graft surgery.
teeth adjacent to the cleft site, (3) to close the After 6 months of secondary alveolar bone
oronasal fistulae to prevent nasal air escape and graft surgery, a post-op CBCT must be obtained
fluid or food leakage, (4) to provide additional to confirm the outcome of SABG surgery (Fig. 4).
support and elevation to nasal structures, (5) to After successful repair of the cleft defect, the
restore the alveolar ridge in the area of the cleft, patient can then start Phase I fixed appliance
thereby allowing orthodontic tooth movement treatment to correct malpositioned anterior
and future placement of dental implants, and (6) teeth. If a patient shows a skeletal crossbite,

Figure 3. Sectional CBCT of pre- and post-alveolar bone graft sites. (A) Note the large alveolar defect on the
lateral wall of the maxillary left central incisor. (B) The post-alveolar bone graft sectional CBCT shows good bone
formation of the alveolar cleft site 6 months post iliac bone graft. CBCT, cone beam-computed tomography.
48 Shetye

Figure 4. Occlusal (A) and frontal (B) views of a patient with bilateral cleft lip and palate who underwent rapid
maxillary expansion with a bonded acrylic fan expander. Following transverse expansion, patient had bilateral
alveolar bone grafts and pre-maxillary repositioning.

manifested as negative overjet at this stage, contributing to posterior skeletal crossbite and
protraction headgear treatment can be reduced midface height. Dentally, there may be
initiated for about 9 months to correct the lingually inclined incisors and constricted max-
skeletal crossbite. illary posterior arch width, causing anterior or
posterior crossbite. The extent of abnormal
midface growth may vary from mild to severe.
Treatment during permanent dentition
The severity distribution of abnormal midfacial
Lateral cephalometric growth studies have shown growth is concentrated in the center of the bell
that the maxilla in treated patients with cleft lip curve, whereas patients with good growth and
and palate show variable degrees of maxillary severe growth disturbances are dispersed on
hypoplasia. The reasons for abnormal facial either side of the curve.11 Depending on the
morphology in treated cleft patients may involve severity of the malocclusion presented by the
intrinsic skeletal and soft tissue deficiencies, cleft patient, the management can be catego-
iatrogenic factors introduced by treatment, or a rized into three types. In the first category, the
combination of both. At birth, cleft lip and palate patients have no skeletal discrepancy and ortho-
deformities vary greatly in severity. In some dontic correction is limited to tooth movement
patients, there may be adequate tissue volume only. In the second category, there is a mild
but the cleft segments have failed to fuse together skeletal discrepancy and the patients will benefit
due to inadequate cell migration. In others there from camouflaging the malocclusion by
may be varying amounts of missing tissue (bone, orthodontic tooth movement alone. In the last
soft tissue, and teeth) associated with non-fusion category of patients, there is moderate to severe
of the cleft segments. Both groups of patients skeletal deformity and optimal results can only be
may respond differently to surgical treatment. obtained by combined surgical/orthodontic
Clinically, patients with clefts may present with intervention. It is important to establish as
a concave profile, midface deficiency, and a Class early as possible if the patient will be treated
III skeletal pattern. The maxilla may also be with orthodontics alone, or orthodontics in
deficient in transverse and vertical planes, conjunction with surgery. The direction of
 Update on treatment of patients with cleft 49

orthodontic tooth movement to camouflage a molars are moved mesially. The patient’s ortho-
very mild midface deficiency is opposite to that of dontic treatment is completed with a Class II
tooth movement required to prepare a patient occlusal relationship on the side of the missing
for midface advancement surgery. lateral incisor. With successful esthetic bonding,
excellent results can be achieved with this
option.
Patients with no skeletal deformity
If a cleft patient in permanent dentition presents Patients with mild skeletal discrepancy
with no skeletal deformity (AP transverse or
In patients presenting with mild skeletal dis-
vertical), then the management of the dental
crepancy and minimal esthetic concern, ortho-
malocclusion does not differ very much from that
dontic dental compensation may be recom-
of the non-cleft patient. Patients with isolated
mended. A thorough clinical exam, growth status
clefts of the lip and alveolus or clefts of the soft
and stature, hand wrist films, and serial cepha-
palate may fall into this group and will benefit
lometric assessments need to be performed
from fixed orthodontic treatment alone. The
before suggesting this option. However, the
dental malocclusion may be limited to mild
patient and the family should be cautioned that
dental anterior or posterior crossbites, rotated
the outcome can be compromised if the patient
and malposed teeth, and missing the lateral
outgrows the dental compensation and ulti-
incisor in the cleft area. Mild anterior cossbites
mately may need extended orthodontic treat-
can be corrected with an advancing arch wire and
ment to remove the compensations and prepare
posterior crossbite with arch wire expansion or
for orthognathic surgery. Proclination of the
with a removable quad helix.
maxillary incisors and lingual inclination of the
There are two options regarding management
lower incisor can adequately camouflage a mild
of a missing lateral incisor: either maintenance of
skeletal discrepancy.
the space for a dental implant, or movement of
the canine into the lateral incisor space, recon-
Patients with moderate to severe skeletal
touring it to resemble a lateral incisor. If the
discrepancy
decision is made to maintain space for a dental
implant, optimal space must be made available Patients presenting with moderate to severe
for the implant to replace the missing lateral skeletal discrepancy may achieve the best esthetic
incisor. During active orthodontic treatment, this and functional results through a combination of
space can be maintained with the use of a pontic orthodontic treatment that is carefully coordi-
tooth that contains a bracket and is ligated to the nated with orthognathic surgery. Depending on
orthodontic arch wire. At the conclusion of the severity of the skeletal discrepancy, the
treatment, a cosmetic removable prosthesis patient may require only maxillary advancement
should be fabricated to maintain the space. Once or a combination of maxillary advancement and
craniofacial skeletal growth is complete, a single mandibular setback. If the surgical/orthodontic
tooth implant can be placed. option is elected, timing of the orthodontic and
If canine substitution is planned for replace- surgical treatment becomes critical (Fig. 5).
ment of the missing lateral incisor, then several Under optimal conditions, it is recommended
canine crown modifications are needed to ach- to remove all dental compensations and to align
ieve optimal esthetics. The permanent canine the teeth in an optimal position relative to the
will need re-countering on incisal, labial, mesial, skeletal base and alveolar processes. The ortho-
distal, and lingual surfaces. Recontouring can be dontist will plan the coordination of maxillary
done progressively during active orthodontic and mandibular arch widths by hand articulating
treatment. When bonding this tooth, a lateral the progressing dental study models into the
incisor bracket will be placed more gingivally, to predicted postsurgical occlusion. Once the pre-
bring its gingival margin down to the level of the surgical orthodontic treatment goals are ach-
adjacent central incisor. The first bicuspid will ieved (coordinated maxillomandibular arch
then take the canine position and will also need width, compatibility of occlusal plans, and sat-
reshaping to resemble a permanent canine. isfactory intercuspation), the patient may be
The second premolar and first and second debonded and placed on removable retainers
50 Shetye

Figure 5. Bilateral cleft patient with two jaw surgery. (A) Pre- and post-lateral profile photographs show significant
improvement after maxillary advancement and BSSO. (B) Lateral cephalogram pre- and post-surgery. BSSO,
bilateral sagittal split osteotomy.

until craniofacial skeletal growth is complete. their family must be cautioned that the patient
This assessment is made by observation of the may outgrow the surgical orthodontic correction
closing sutures in the hand wrist radiographs, by and may need another corrective surgery upon
measurements of mandibular body length in the completion of skeletal growth. In these cases,
serial lateral cephalograms and measurements of distraction osteogenesis may be considered as an
change in stature or height. The patient is placed alternative. The advantages of distraction osteo-
on fixed orthodontic appliances for a short, pre- genesis in a growing patient with cleft lip and
surgical orthodontic treatment phase before palate include the generation of new bone at the
orthognathic surgery. The combined surgical site of the osteotomy, large advancement without
and orthodontic treatment goals are planned in the need for a bone graft, and gradual stretching
close coordination with the surgeon. After sur- of the scared soft tissue. Since distraction
gical correction is completed, a 12-month post- osteogenesis and midface advancement are perf-
surgical orthodontic phase of treatment begins. ormed at the rate of 1 mm per day, changes in
The objectives of postsurgical orthodontics are to velopharngeal competency can be monitored
balance the forces of skeletal relapse with during the advancement. For the skeletally
intermaxillary elastics, to observe the skeletal mature cleft patient who shows severe maxillary
stability of the surgical correction, and to detail deficiency, advancement of the midface with
the postsurgical occlusion. distraction osteogenesis is also a good treatment
Sometimes a maxillomandibular skeletal dis- option (Fig. 6).
crepancy is severe, and for psychosocial reasons, Distraction in the cleft patient can be achie-
early surgery during the mixed or permanent ved with external or internal distraction dev-
dentition is indicated. However, the patient and ices. Depending on the surgeon’s preference and

Figure 6. Series of patients treated for LeFort I midface advancement with internal distraction: (A) Before, during
and after internal midface distraction lateral profile photographs. (B) Before, during, and after internal midface
distraction lateral cephalograms.
 Update on treatment of patients with cleft 51

clinical presentation of deformity, either References

approach may be used to achieve the desired 1. Grayson BH, Cutting C, Wood R. Preoperative columella
results. Internal distraction devices are more lengthening in bilateral cleft lip and palate. Plast Reconstr
acceptable to the patient; however, they offer Surg. 1993;7:1422–1423.
some clinical limitations. The external devices 2. Sischo L, Broder HL, Phillips C. Coping with cleft: a
conceptual framework of caregiver responses to nasoal-
can be adjusted to change the vector of skeletal veolar molding. Cleft Palate Craniofac J 2014 [Epub
correction during the active phase of distraction, ahead of print].
while the internal device cannot be adjusted in 3. Rubin MS, Clouston S, Ahmed MM, Lowe K M, Shetye PR,
this way. After the LeFort I osteotomy and a Broder HL, Warren SM, Grayson BH. Assessment of
latency period of 5–6 days, the distraction device presurgical clefts and predicted surgical outcome in
patients treated with and without nasoalveolar molding.
is activated at the rate of 1 mm per day until the J Craniofac Surg. 2015;1:71–75.
desired advancement is achieved. Interarch 4. Maull DJ, Grayson BH, Cutting CB, Brecht LL, Bookstein
elastics may be used during the active phase of FL, Khorrambadi D, et al. Long-term effects of nasoal-
distraction osteogenesis to guide the maxilla to its veolar molding on three-dimensional nasal shape in
unilateral clefts. Cleft Palate Craniofac J. 1999;5:391–397.
optimal position and the teeth to optimal
5. Cutting C, Grayson B, Brecht L, Santiago P, Wood R,
occlusion. On completion of the advancement, Kwon S. Presurgical columellar elongation and primary
there is a 8-week period of bone consolidation retrograde nasal reconstruction in one-stage bilateral
during which time the distraction devices serve as cleft lip and nose repair. Plast Reconstr Surg. 1998;3:
skeletal fixation appliances. Following this period 630–639.
of bone healing, the distraction devices are 6. Pfeifer TM, Grayson BH, Cutting CB. Nasoalveolar
molding and gingivoperiosteoplasty versus alveolar bone
removed and post-distraction orthodontics graft: an outcome analysis of costs in the treatment of
begins. The objective of post-distraction ortho- unilateral cleft alveolus. Cleft Palate Craniofac J. 2002;1:
dontics is to retain the position of the advanced 26–29.
midfacial skeleton and to fine tune the occlusion. 7. Patel PA, Rubin MS, Clouston S, Lalezaradeh F, Brecht
LE, Cutting CB, Shetye PR, Warren SM, Grayson BH.
Comparative study of early secondary nasal revisions and
costs in patients with clefts treated with and without
nasoalveolar molding. J Craniofac Surg. 2015;4:1229–1233.
Conclusion 8. Lee CT, Grayson BH, Cutting CB, Brecht LE, Lin WY.
Prepubertal midface growth in unilateral cleft lip and
The successful management of a patient with palate following alveolar molding and gingivoperiosteo-
cleft lip and palate requires careful coordination plasty. Cleft Palate Craniofac J. 2004;44:375–380.
of all members of the Cleft Palate Team. Intro- 9. Santiago PE, Grayson BH, Cutting CB, Gianoutsos MP,
Brecht LE, Kwon SM. Reduced need for alveolar bone
duction of nasoalveolar molding has significantly
grafting by presurgical orthopedics and primary gingivo-
changed the outcome of cleft treatment. The periosteoplasty. Cleft Palate Craniofac J. 1998;1:77–80.
shape, form, and nasal esthetics of patients with 10. Sato Y, Grayson BH, Garfinkle JS, Barillas I, Maki K,
clefts are significantly better in those who have Cutting CB. Success rate of gingivoperiosteoplasty with
had the benefits of NAM. Clinical techniques and without secondary bone grafts compared with
constantly will be improved to enable the clini- secondary alveolar bone grafts alone. Plast Reconstr Surg.
2008;4:1356–1367.
cian to provide the best possible care while 11. Ross RB. Treatment variables affecting facial growth
striving to reach the goal of excellent facial in complete unilateral cleft lip and palate. Cleft Palate J.
esthetics in patients born with clefts. 1987;1:5–77.
3D guided comprehensive approach to
mucogingival problems in orthodontics
Marianna Evans, Nipul K. Tanna, and Chun-Hsi Chung

Advances in technology have enabled the clinician to use a 3-dimensional

(3D) guided approach to orthodontic diagnosis and treatment planning,
leading to a more predictable treatment sequence and outcome for
orthodontists and surgeons. Important factors must be taken into consid-
eration when planning orthodontic treatment such as the existing and
projected tooth position as well as the periodontal soft and hard tissue
phenotype. 3D anatomic analysis of the dentoalveolar complex may provide
more information than what can be derived from 2-dimensional radiographs
and the clinical examination. It can help identify patients at risk for the
development of mucogingival problems during or after orthodontic treat-
ment and can guide the clinician in determining the appropriate intervention
to minimize the risks of an unfavorable outcome. (Semin Orthod 2016; 22:52–
63.) & 2016 Elsevier Inc. All rights reserved.

Introduction gingival conditions include gingival recession,

absence or reduction of keratinized tissue and
stablishing periodontal health in con-
E junction with the existence of a biologically
and anatomically acceptable environment that
probing depth extending beyond the MGJ. For
the purpose of this article, attachment loss due to
periodontitis will not be discussed.
allows for the proper function and maintenance
Gingival recession is defined as an apical shift
of that health is critical for the longevity of the
of the marginal gingiva from its normal position
dentition. This requires teeth to be positioned in
on the crown of the tooth to levels on the root
the center of the alveolar housing with adequate
surface apical to the cementoenamel junction
buccolingual bone support, an adequate
(CEJ). Once developed, this condition is irre-
inflammation-free keratinized gingival seal and
versible without surgical intervention. It is critical
the presence of an occlusal scheme that allows
to note that gingival recession is simply a clinical
for even force dissipation in an axial direction,
manifestation of an underlying alveolar bone
free of interferences.
problem. It is always accompanied by alveolar
Patients with a malocclusion may present with
bone dehiscences of varying degrees. Löst,2 in a
pre-existing mucogingival problems or fragile
human study on correlation between gingival
periodontal support that is susceptible to
recession and alveolar bone dehiscences, found a
attachment loss during or after orthodontic
minimal distance of around 3 mm between the
treatment. The American Academy of Perio-
vestibular gingival margin and the alveolar bone
dontology (AAP) defines mucogingival con-
margin of teeth affected by gingival recession.
ditions as deviations from the normal anatomic
Alveolar bone dehiscence may be present
relationship between the gingival margin and the
without manifestation of gingival recession, but
mucogingival junction (MGJ).1 Common muco-
gingival recession cannot develop without simul-
taneously manifesting or pre-existing bone loss.2
Department of Orthodontics, School of Dental Medicine, Uni- According to Loe et al.,3 gingival recession
versity of Pennsylvania, Pennsylvania, PA. begins early in life and is found primarily on the
Address correspondence to Marianna Evans, DMD, Department
labial root surfaces. Prevalence varies from 3% to
of Orthodontics, School of Dental Medicine, University of Pennsylva-
nia, Philadelphia, PA. E-mail: mevans@infinityorthoperio.com
100% depending on the population and the
& 2016 Elsevier Inc. All rights reserved.
methods of analysis, and appears to be lower in
1073-8746/12/1801-$30.00/0 younger groups, where the incidence increases
http://dx.doi.org/10.1053/j.sodo.2015.10.008 with age.4 If left untreated, it may result in the

Seminars in Orthodontics, Vol 22, No 1, 2016: pp 52–63 52

 3D guided comprehensive approach to mucogingival problems in orthodontics 53

loss of the tooth, followed by further resorption To prevent or address gingival recession in sus-
of the underlying bone. ceptible patients, predictable soft tissue grafting
The etiology of recession is multi-factorial5 procedures such as the subepithelial connective
and may include bacterial plaque, tooth brush tissue graft (SCTG) and the free gingival graft
and toothpaste abrasion, occlusal trauma, oral (FGG) may be performed prior to or after tooth
piercing, iatrogenic factors related to restorative movement.14,15 Since gingival recession is also a
and periodontal therapy, tooth position/tooth bone problem, hard tissue grafting procedures to
size in relation to the surrounding bone volume, thicken the buccolingual alveolar bone dimen-
orthodontic malocclusion, gingival biotype and sion may be beneficial in selected cases.
high frenum attachment. Alveolar bone deficiency is a common finding
Gingival recession may develop or progress in the general population.16 Before cone-beam
before, during or after orthodontic treatment. computed tomography (CBCT) technology, the
The correlation between orthodontic tooth alternative to diagnosing buccolingual alveolar
movement and attachment loss remains con- bone dimension without flap reflection was to
troversial due to the lack of randomized con- use costly, medical CT scans that were associated
trolled studies.6,7 In spite of that, it has been with much higher radiation. Traditionally, 2-
reported that the buccolingual tooth position dimensional images such as lateral cephalograms
and movement will affect the thickness and width have been used to evaluate changes in the incisor
of keratinized gingiva.8,9 Teeth positioned more inclination. These images are limited to evalua-
lingually will often have a wider band of kerati- tion of the average buccolingual incisor position
nized gingiva than those positioned more labi- in relationship to large anatomic landmarks such
ally. This phenomenon may be explained by as mandibular plane or the A-Pog line and lack
spatial redistribution of the gingival tissue in a precise visibility of the anatomy of the symphysis
buccolingual dimension during tooth move- and position in the bone of each individual
ment. Multiple studies also confirm that thin tooth.17 Often, mandibular incisors that are
gingival biotype and the presence of alveolar positioned within the normal range of 851–951
bone dehiscences predispose patients to gingival to the mandibular plane present with significant
recession with or without orthodontic tooth variations with respect to their position within the
movement.10–12 Wennstrom et al.13 evaluated the symphysis and with different amounts of
periodontal reaction to orthodontic movement supporting bone. This variation can only be
in monkeys and reported that plaque-induced identified with 3D images (Fig. 1).
inflammation and the thickness (volume) of CBCT imaging allows for an additional per-
the marginal soft tissue, rather than the spective into understanding how mucogingival
apico-coronal width of the keratinized and problems relate to orthodontic tooth movement
attached gingiva, are determining factors for the by allowing us to differentiate whether the
development of gingival recession and attach- problem lies in the tooth position, the anatomy of
ment loss during orthodontic tooth movement. the surrounding bone, or both (Fig. 2). A weak

Figure 1. CBCT images of lower incisors (from different patients) positioned within 851–951 to the mandibular
plane but with a diverse positioning within the symphysis and with differing amounts of alveolar bone support.
54 Evans et al

Figure 2. CBCT images of mandibular incisors with recession (tooth 24) from 2 different patients. (A) The lower
incisor is centered in the symphysis but presents with an alveolar bone deficiency on the labial. (B) The mandibular
incisor is positioned labial in relationship to the symphysis.

correlation has been reported between gingival a scan based on these factors. According to Patcas
thickness and underlying bone thickness, et al.,21 even the 0.125-mm voxel protocol does
although a positive correlation has been identi- not depict the thin buccal alveolar bone covering
fied between crestal alveolar bone thickness and reliably, and there is a risk of overestimating
width of the gingiva.18 Cook et al.19 reported that fenestrations and dehiscences. In a recent study
thin gingival biotype was associated with thinner by Sun et al.22 similar findings were reported with
labial plate thickness. It should be noted that CBCT images having some diagnostic value for
patients with a thick, wide band of keratinized detecting bony dehiscences and fenestrations;
gingiva may present with deficient alveolar bone. however, this method might overestimate the
Mandelaris et al.20 suggested that when studying actual measurements.
alveolar bone with CBCT, one must differentiate
between the crestal and radicular zones of
Buccolingual alveolar bone dimension
alveolar bone. The dentoalveolar crestal zone is
defined as the region from the CEJ to a point In the ideal situation, the tooth is positioned in
4-mm apically and the dentoalveolar radicular the center of the alveolus, to receive axial loading
zone is dependent upon the individual root with bone covering the root circumferentially 1–
length and is that area extending below the 4-mm 2 mm below the CEJ with at least 1 mm of bone
line for the remaining root length. Both crestal thickness on the labial and lingual surfaces of the
and radicular bone can be identified as thick root. We suggest evaluating the buccolingual
(41 mm) or thin (o1 mm). Patients also may (BL) alveolar and basal bone dimension in
present with different combinations of alveolar relationship to individual buccolingual root
bone thickness in both zones.20 dimension. In the optimal environment, when
the tooth is centered in alveolar bone, the BL
bone dimension should be at minimum 2-mm
3D guided evaluation of the dentoalveolar
wider than the root dimension at any given root
complex
cross-section (Type A) to allow minimal root
Advances in CBCT imaging technology and coverage within alveolar bone of 1 mm in
developments in 3D simulation software allow us thickness on both labial and lingual surfaces of
to evaluate not only pretreatment dentoalveolar the root (Fig. 3A). Anything less should be
anatomy but also the projected tooth movement considered as compromised (Type B) and will
and its relationship relative to the alveolar bone. present a risk for the development of gingival
While the additional information gained provides recession (Fig. 3B). Type B alveolar bone may be
a new perspective, it also brings with it many subdivided into Type B-1 (thin alveolar plate less
unanswered questions which will require ongoing than 1 mm in thickness), Type B-2 (fenestration)
research with randomized controlled studies. and Type B-3 (dehiscence) and is found either
Many factors such as variations in equipment, on the labial, lingual or both root surfaces. Teeth
settings, field of view, voxel size etc., play a critical with dehiscences (Type B-3) and thin overlying
role in the accuracy of the images. Thin labial gingiva are the most susceptible to gingival
plates, for example, may or may not be evident on recession.
 3D guided comprehensive approach to mucogingival problems in orthodontics 55

Figure 3. (A). Type A: A—Optimal buccolingual alveolar bone dimension of the anterior teeth. B—Posterior
teeth. C—Example of Type A bone as shown on a CBCT coronal slice at the first molar. (B) Type B: A,B—
Compromised buccolingual alveolar bone dimension of the anterior and posterior teeth. C—Example of Type B
bone as shown on a CBCT coronal slice at the first molar.

Tooth position position has been addressed. However, in most

situations this improvement is not possible with
CBCT examination of the dentoalveolar complex
orthodontic tooth movement alone.
also includes evaluation of the pretreatment and
A more common clinical scenario is when the
projected spatial position of the tooth within tooth movement may result in a situation with
bone. In some situations, the tooth might be more compromised soft tissue and bone sup-
positioned off-axis and present radiographically port.24 With advances in 3D software, the
with fenestrations and dehiscences with sufficient majority of the tooth movement can be
quantity of surrounding bone to support it in simulated before treatment begins. Fig 5
proper position (Fig. 4A). In these situations, the illustrates possible projected tipping and bodily
determination needs to be made whether movements of the mandibular incisor from the
anticipated orthodontic treatment will improve original optimal position (A) in the center of the
tooth position in the bone or not. In some ridge and the effects on the alveolar bone. Image
situations, positioning the tooth in the center of B, for example, shows that significant labial
the alveolar bone may improve dehiscences and tipping will not compromise the alveolar
fenestrations and even possibly gingival housing, while lingual tipping (C), labial bodily
recession23 (Fig. 4B). If that improvement is movement (D), and combination of lingual
feasible, many mucogingival and alveolar bone tipping and labial root movement (E), will
deficiencies can be re-evaluated after the tooth compromise alveolar bone support.

Figure 4. (A) Retroclined lower incisor with severe labial dehiscence related to labial root position. (B) The same tooth
after orthodontic movement into the center of the symphysis presents with improved labial alveolar bone support.
56 Evans et al

Figure 5. Projected tooth movement with alveolar bone implications. (A) Optimal tooth position in the symphysis
with optimal labial and lingual alveolar bone support. (B) Labial tipping with no effects on the alveolar bone
support. (C) Lingual tipping with thinning of the labial alveolar bone. (D) Labial bodily movement with an
anticipated development of a labial dehiscence. (E) Lingual crown tipping and labial root torque outside the
symphysis with the anticipated development of a severe labial dehiscence.

By studying dentoalveolar anatomy in 3D at gingival bleeding index, thickness and width of

the individual tooth level, we may be able to the attached and keratinized gingiva and frenum
better identify patients at risk of developing anatomy. Conventional periapical radiographs
mucogingival problems and also to understand reveal the interproximal bone level, presence
the underlying anatomy of the existing muco- of a lamina dura and root length, but are
gingival deformities. limited in the evaluation of the buccolingual
dentoalveolar anatomy. 3D imaging provides
additional information to assess the buccolingual
Pre-orthodontic comprehensive 3D guided
anatomy, and when combined with the clinical
periodontal evaluation
exam, will serve as a guide to identify patients with
Patients with malocclusion often present for anatomic risk factors for attachment loss prior to
orthodontic treatment with periodontal mani- initiating tooth movement.
festations of varying degrees, thin gingival bio- When identifying mucogingival problems and
type and deficient alveolar bone support.25,26 potential risks of developing them in orthodontic
A comprehensive periodontal evaluation is patients, 3 scenarios may be identified:
essential for all adult patients and when indi-
cated, for selective adolescent patients with thin (1) Pre-existing mucogingival conditions: When
periodontium. patients present for orthodontic treatment
The presence of orthodontic appliances makes with gingival recession, with or without lack
oral care challenging and may present a risk for of attached gingiva and high frenum
the development of plaque-induced gingival attachment.
inflammation.27 Additionally, some types of (2) Pre-existing risks: When patients present
orthodontic tooth movement may position the with Type B buccolingual alveolar bone
teeth outside the envelope of periodontal support. dimension accompanied by thin or thick
The clinical periodontal evaluation includes gingiva without clinical manifestations of
measurements of sulcular probing depth, mucogingival problems.
 3D guided comprehensive approach to mucogingival problems in orthodontics 57

(3) Projected risks: When the anticipated tooth attachment loss, periodontal augmentation pro-
movement is predisposed to the develop- cedures should be considered.
ment of dehiscences, fenestrations and gin- Augmentation may include manipulation
gival recession. within the soft tissue, the hard tissue, or a com-
bination of both based on the clinical and
First and foremost, educating patients in radiographic findings and the treatment plan.
proper oral hygiene is fundamental to prevent Therapeutic grafting is indicated in patients with
attachment loss during and after orthodontic pre-existing mucogingival conditions, while
treatment. prophylactic grafting is performed in situations
With pre-existing mucogingival conditions, of pre-existing or projected risks.
grafting should be considered when there is a When performing periodontal augmentation
risk for the progression of attachment loss during surgery, oral hygiene is critical to optimal heal-
or after tooth movement. This is usually related ing. Gingival inflammation related to poor oral
to compromised oral hygiene, labial tooth care will compromise healing and presents
movement and lack of attached gingiva. When challenges to diagnose the true periodontal
the patient has a wide band of keratinized tissue, condition of the marginal gingival tissue. Place-
free of inflammation and the anticipated tooth ment of orthodontic appliances should be
movement will not exceed beyond the bone delayed until after soft tissue healing takes place
support, root coverage may be postponed until (4-6 weeks post-surgery) when the patient
after orthodontic treatment. resumes a regular oral hygiene regimen.
When evaluating patients at risk for develop-
ing attachment loss during or after orthodontic
treatment, initial identification of the tooth Soft tissue augmentation
position is critical. Teeth positioned outside of Pre-orthodontic soft tissue augmentation is
bone support and in traumatic occlusal rela- performed to address existing mucogingival
tionships may significantly contribute to exacer- deformities (i.e., gingival recession) (Fig. 7)
bation of mucogingival problems. Therefore, as well as to convert a patient from a thin
positioning them back into bone and relieving gingival biotype to a biotype less susceptible
occlusal trauma should precede surgical inter- to periodontal breakdown during tooth
vention. In some instances, a mucogingival movement (Fig. 8). Autogenous free gingival
problem will improve after occlusal trauma is and subepithelial connective tissue grafts as well
eliminated and surgical intervention may be as skin allografts have been successfully used for
avoided (Fig. 6). gingival augmentation.28,29 Autogenous soft tis-
sue grafting procedures require a thorough
understanding of the anatomic relationships to
Pre-orthodontic periodontal augmentation vital structures in recipient and donor sites. Free
Once it has been determined that orthodontic gingival grafts may be harvested from palatal
tooth movement will present a risk for and buccal areas, depending on the required

Figure 6. (A) A 7-year-old male patient presents with an anterior crossbite and crowding with lack of
attached gingiva on tooth 24. (B) 6 Months after addressing the anterior crossbite and improving the lower
incisor crowding, tooth 24 presents with a sufficient band of keratinized gingiva without the need for
surgical intervention.
58 Evans et al

Figure 7. (A) Gingival recession on tooth 22 with no attached keratinized gingiva. (B) A SCTG
was performed prior to tooth movement to address the recession and create keratinized attached gingiva.
(C) Complete root coverage was achieved with a 2 mm band of keratinized attached gingiva at 1 month post-
surgery.

graft size, thickness and quantity of available recipient and donor sites due to thinner grafts,
donor tissue. improves patient comfort, prevents reattach-
A recently held AAP Regeneration Workshop ment of the frenum and allows for better
(2015) concluded that in optimal plaque-control graft blending with the surrounding gingiva
conditions, in the absence of inflammation, (Fig. 9).
there is no need for a minimal width of kerati- Since gingival recession is an alveolar bone
nized gingiva to prevent attachment loss. How- problem, hard tissue grafting may also have to
ever, in situations when plaque control is be considered in addition to the soft tissue
suboptimal as during orthodontic treatment, a augmentation. In these situations, it might be
minimum width of 2 mm of keratinized tissue beneficial to combine a connective tissue graft
with 1 mm of attached gingiva is required.29 This with bone augmentation, which will be discussed
workshop recommended the FGG as a standard later in this article.
for the gain of keratinized gingiva, although the
free connective tissue graft (FCTG) may also
fulfill this purpose.28
Hard tissue augmentation
Considering all treatment modalities in It is worth noting that the concept of surgical
periodontal plastic surgery to create an ade- manipulation of the alveolar ridge facilitating
quate band of attached keratinized gingiva, the tooth movement dates back to Kole30 in
most optimal indication for the FGG procedure 1959. Suya31 specifically reported corticotomy
today in orthodontic patients is when it is facilitated orthodontics in 1991. Findings from
performed in conjunction with a frenectomy. this work lead Wilcko et al.32 to explore the
FGGs that are performed in conjunction with a concept further. While additional randomized
frenectomy are usually smaller in size and controlled trials are still needed to understand
almost always may be harvested from the buccal. this process and to substantiate certain
This allows for expedited healing of the claims, initial case reports have shown stable

Figure 8. (A) An 11-year-old Caucasian male patient presents for orthodontic treatment with severe lower
crowding, thin gingival tissue with no attached gingiva on tooth 25. (B) SCTG procedure was performed on the
lower incisors to thicken the gingiva in order to prevent attachment loss during tooth movement. (C) 6 Months
after grafting, lower incisors were aligned and presented with a thick band of coronaly positioned keratinized
gingiva.
 3D guided comprehensive approach to mucogingival problems in orthodontics 59

Figure 9. (A) A 15-year old AA female presents for orthodontic treatment with thin labial gingiva and a high
frenum attachment at the level of the mandibular central incisors. (B) Prior to orthodontic tooth movement, a
FGG was harvested from the buccal gingiva between the maxillary right premolar and canine. (C and D)
Transplantation to the frenectomy site with the purpose of widening the zone of keratinized gingiva and
preventing re-attachment of the frenum. Buccal donor tissue was used for the sake of patient comfort. (E) 1-year
post-treatment, mandibular incisors present with a healthy band of keratinized gingiva without signs of
attachment loss.

results with a significant decrease in the time of bone may prevent gingival recession, while
treatment.32 In addition to the benefit of augmentation in the radicular zone may
a decrease in treatment time, the use of prevent root movement outside the alveolar
bone grafting materials, acting as scaffolding bone dimension and increase stability of the
for additional bone formation, has been achieved tooth alignment.
explored further to increase the envelope of Although decrease in treatment time35 and
tooth movement and still provide a stable post-orthodontic stability36 have been reported
periodontal outcome. Previous studies5,33,34 in the literature as a result of this procedure, the
have reported cases in which orthodontic cor- effectiveness of bone augmentation has yet to be
rections were achieved with movement into sites investigated.
that would normally have been considered
periodontally unhealthy if they had been com-
pleted using conventional methods without
Combined hard and soft tissue augmentation
surgical intervention.
Bone augmentation is beneficial for ortho- When the clinical and radiographic exam
dontic patients with Type B alveolar anatomy, in reveals an underlying or projected soft and
particular when non-extraction therapy is elected hard tissue deficiency as shown in Fig 12,
for airway and esthetic considerations (Fig. 10). combined soft and hard tissue augmentation
Studying the pre-existing and projected den- may be the treatment of choice. Subepithelial
toalveolar anatomy will aid in the decision- connective tissue grafting may be done
making of whether bone grafting can be lim- simultaneously with bone grafting or in a
ited to the labial area or extended to the labial stepped approach. When soft tissue augmen-
and lingual root surfaces (Fig. 11). Anatomic tation involves multiple teeth, a soft tissue
limits also have to be considered with respect to allograft might be the material of choice as
graft containment. Augmentation of the crestal shown in Fig. 13.
60 Evans et al

Figure 10. (A and B) A 21-year-old Caucasian male presents for orthodontic re-treatment with upper and lower
crowding, thin gingival biotype and Type B alveolar bone on the mandibular anterior teeth. (C–G) Labial bone
augmentation of the lower anterior teeth was completed with corticotomy and grafted with particulate freeze-
dried bone allograft material. (H) CBCT sagittal slice of the post-treatment augmented labial alveolar bone with
3-mm increase in thickness at the level of lower incisor. (I) Final records taken 3 months after debond show
thickening of the labial gingiva after orthodontic alignment in conjunction with prophylactic labial bone
augmentation. (J) 3D image of the pretreatment airway with constriction in the retroglossal area of 83.2 mm2.
(K) 3D image of the post-treatment airway with increase of the airway volume in the retroglossal area to 188 mm2.
 3D guided comprehensive approach to mucogingival problems in orthodontics 61

Figure 11. (A and B) labial, (C and D) labial and lingual bone augmentation (blue dotted line) based on CBCT
findings of alveolar bone deficiency.

Figure 12. (A and B) A 28-year-old female patient presents for non-extraction orthodontic treatment with severe
crowding, thin gingival biotype and deficient Type B bone support on the labial of lower anterior teeth. (C–F) A
combination of labial soft and hard tissue augmentation was performed with subepithelial connective tissue graft in
conjunction with freeze dried bone allograft and xenograft mixture prior to tooth movement.
62 Evans et al

Figure 13. (A–C) Combined soft tissue and hard tissue augmentation with an acellular dermal matrix and freeze-
dried bone allografts performed on a 39-year-old female patient with thin gingiva and Type B alveolar bone.

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Implants for orthodontic patients with missing
anterior teeth: Placement in growing
patients—Immediate loading
Mohamed Bayome, Yoon-Ah Kook, Yoonji Kim, Cheol Won Lee, and
Jae Hyun Park

There is a marked increase in the importance of facial esthetics. This means

that interdisciplinary treatment plans are an important strategy for achieving
pleasing facial appearance with dental treatment. Over the decades, missing
anterior teeth have been a challenge for clinicians and replacing them with an
implant in children and adolescents was questionable. One concern was that
an implant might influence the growth of the alveolar ridge, which could
compromise facial esthetics in the long run since the positioning of the
implant within the alveolar ridge plays a key role in the esthetic outcome.
Another concern was the long-term effects of immediate loading of
orthodontic force on implants. The short-term effects have been evaluated
but not the long-term implications. This article summarizes a discussion
about the effects of implants to restore missing anterior teeth in growing
patients and the effect of the immediate application of orthodontic forces on
newly placed implants. (Semin Orthod 2016; 22:64–74.) & 2016 Elsevier Inc.
All rights reserved.

Introduction significantly higher impact on the oral health-

related quality of life than missing posteriors.1–4
ow a person looks can be an important
H factor in whether or not they are successful
in life and appearance affects self-esteem and
There has always been a question whether
missing teeth should be replaced with an implant
or fixed prosthesis, or whether the space should
social acceptance. Facial esthetics are a big part
be closed orthodontically. The decision depends
of appearance, and since teeth are a prominent
on several factors including age, profile, space
facial feature, dental appearance is a key part
availability, condition of adjacent teeth, gingival
of facial esthetics, especially if there are miss-
display on smiling, type of malocclusion, overjet,
ing anterior teeth. In addition, they have a
and overbite.5,6 Another study showed that it also
depends on the skill of the orthodontist and his/
her work environment.7 Andrade et al.8 reported
the lack of scientific evidence for any type of
Department of Dentistry, College of Medicine, The Catholic
University of Korea, Seoul, South Korea; Department of Postgraduate treatment for agenesis of the maxillary lateral
Studies, The Universidad Autonóma del Paraguay, Asunción, incisors.
Paraguay; Department of Orthodontics, College of Medicine, Seoul Dental implants have been one of the treat-
St. Mary’s Hospital, The Catholic University of Korea, Seoul, South ments of choice for missing anterior teeth. Their
Korea; Department of Prosthodontics, College of Medicine, Seoul St. success rate has been reported extensively and
Mary’s Hospital, The Catholic University of Korea, Seoul, South
Korea; Postgraduate Orthodontic Program, Arizona School of
depends on age, gender, which side, and which
Dentistry & Oral Health, A.T. Still University, Mesa, AZ; Graduate jaw, among other factors. On average, implants
School of Dentistry, Kyung Hee University, Seoul, South Korea. have a survival rate better than 97% and are
Address correspondence to Jae Hyun Park, DMD, MSD, MS, expected to last for decades.9 However, most of
PhD, Postgraduate Orthodontic Program, Arizona School of Dentistry
the literature focuses just on adult patients.
& Oral Health, A.T. Still University, Mesa, AZ. E-mail:
JPark@atsu.edu
Interestingly, children and adolescent suffer
& 2016 Elsevier Inc. All rights reserved.
from the same conditions requiring placement of
1073-8746/12/1801-$30.00/0 dental implants, even though the frequency is
http://dx.doi.org/10.1053/j.sodo.2015.10.009 lower than that of adults. The prevalence of

Seminars in Orthodontics, Vol 22, No 1, 2016: pp 64–74 64

 Implants for orthodontic patients with missing anterior teeth 65

traumatic dental injury to anterior teeth in prevent marginal bone loss and the presence of
children ranges from 9% to 35% depending on unesthetic papilla.20–22 Since the standard im-
the population.10–13 These injuries resulted in plant diameter ranges between 3.5 and 4.2 mm,
missing teeth in 10.9% of the cases.13 In addition, the narrowest edentulous space required is about
congenitally missing teeth occurs in 1.6–15.7% of 6.5 mm. However, when a narrow dental implant
various modern societies.14–18 However, clini- is used, the space required can be as small as
cians have been reluctant to install implants in 5 mm.
growing patients. Nevertheless, untreated dental The proximity and inclination of adjacent
problems have some negative impact on the teeth is important for the mesiodistal tooth
quality of life of children.19 position. The proximity of adjacent teeth is
This article aims to demonstrate some necessary to provide proximal support and vol-
orthodontic applications where implant place- ume of the interdental papilla. A mesially
ment can serve as an adjunctive treatment inclined tooth usually creates a more incisally
placement, especially in younger patient popu- located contact point and a much larger gingival
lations. embrasure, which requires more volume in order
to achieve the same vertical height. However, this
mesial inclination has an advantage in the case of
Adjunctive orthodontic treatment prior to
implantation due to the thicker interproximal
implantation
bone and lower risk of resorption. Hopeless teeth
When an edentulous area is left unrestored over with diastemas have similar advantages.23
an extended period of time, a more challenging
clinical situation arises when there is an extrusion Case 1
of the opposing teeth, tilting of neighboring
A 27-year-old female was referred by a general
teeth, and a vertically and horizontally resorbed
dentist for orthodontic tooth movement before
ridge. Often, such deteriorated conditions will
final restoration. The upper dental midline had
require orthodontic treatment prior to the start
been shifted to the left side and a missing
of any definitive restorative work.
maxillary lateral incisor caused spacing. Her peg-
In the anterior region, adjunctive orthodontic
shaped, right lateral incisor had been previously
therapy may be necessary to address misalign-
restored as revealed in a panoramic radiograph.
ment and tooth size discrepancy for better
A bracket was bonded to the acrylic pontic in the
function and esthetics. Proper alignment of
left lateral incisor area and an arch wire was
anterior teeth and creation of appropriate space
inserted to regain space to restore esthetic bal-
enhances purely esthetic restorations not only by
ance between the maxillary lateral incisors. The
preserving restoration space but also by main-
maxillary and mandibular dental midline coin-
taining the desired interproximal alveolar con-
cided and adequate space was regained for the
tour and gingival embrasure form. In order to
restoration. After debonding, an implant was
establish normal overjet and overbite, it might be
placed in the maxillary lateral incisor area. A
necessary to position the implant labiolingually a
crown lengthening procedure was performed on
bit beyond than the optimal position, which
the maxillary right lateral incisor to correct the
might in turn compromise the esthetic rela-
gingival height (Figs. 1–4).
tionship between the gingiva and the crown by
altering the ideal space required around the
Temporary anchorage devices as temporary
implant. The adjacent teeth may need to be
crown restoration
increased in width with adhesive restoration or
reduced by interproximal reduction. There are several treatment options for a missing
Generally, there should be enough bone maxillary anterior tooth in adolescent patients
around an implant to prevent bone loss. When including substitution, autotransplantation, and
placed between two natural teeth, at least 1.0 mm dental restoration. However, these methods
of interdental space is essential. For an implant each have limitations. An orthodontic miniscrew
restoration, there should be 1.5 mm of bone system (C-implant) may serve as an ex-
between the implant and adjacent roots, or cellent treatment option to maintain edentulous
3.0 mm of bone between adjacent implants to space upon completion of active orthodontic
66 Bayome et al

Figure 1. Case 1: pretreatment intraoral images and panoramic radiograph.

Figure 2. Case 1: treatment progress.

 Implants for orthodontic patients with missing anterior teeth 67

Figure 3. Case 1: debonding intraoral images.

treatment. Temporary crown restorations are miniscrews and documented with an 8-year fol-
required after orthodontic treatment for young low-up.25
patients when implant placement needs to be
delayed. An orthodontic C-implant system was
placed in a 3 mm-wide edentulous space to build
Case 2
up a temporary crown restoration after a short A C-implant was placed in the space resulting
period of orthodontic treatment to regain space from an avulsed permanent maxillary right lat-
for a missing permanent mandibular right eral incisor of a 14.6-year-old boy to prevent
lateral incisor (Fig. 5).24 Another report replaced aggressive alveolar bone resorption resulting
missing maxillary lateral incisors in growing from dental trauma (Fig. 6). Location and path
patients with temporary crowns fixed to of the implant were verified with a cone-beam

Figure 4. Case 1: implant placement.

68 Bayome et al

Figure 5. A C-implant placed in the edentulous space to support a temporary crown replacing mandibular right
lateral incisor.

computed tomography (CBCT) scan. Crowns option to maintain edentulous space upon
were fabricated with an indirect method of completion of active orthodontic treatment.24
telescopic abutment casting and porcelain build-
up (Fig. 7). The temporary crown restorations
were retained successfully until patients were
Anterior teeth movement with block bone graft
ready to proceed with a permanent restoration at Resorption of the alveolar bone usually occurs
a later time (Fig. 8). An orthodontic miniscrew after tooth extraction with a higher rate within
system may serve as an excellent treatment the 1st year. Extraction of maxillary anterior

Figure 6. Case 2: a C-implant placed in the space of a missing permanent maxillary right lateral incisor of a 14.6-
year-old boy.
 Implants for orthodontic patients with missing anterior teeth 69

Figure 7. Case 2: crown made by casting and porcelain build-up on a telescopic abutment.

teeth is associated with a progressive loss of bone, inflammation.27 Root replicates of polylactic acid
mainly from the labial side.26 Several factors are (PLA)28 or bioglass29 have been produced to
claimed to be responsible for this such as disuse preserve the alveolar crest width and height after
atrophy, decreased blood supply, and localized tooth loss, but their incomplete resorption may
impair later implantation. Also, to prevent
resorption, autogenous grafts have been used
to fill the tooth socket.30,31
As people age, more of their mandibular
incisors tend to be exposed, especially after their
40s. When insufficient papilla presents coupled
with severe alveolar bone loss, achieving an
esthetic treatment outcome becomes more
challenging. One way to approach such a prob-
lem is to begin from the periodontal aspect to
build up a healthier foundation for gingival
architecture. In the case presented below,
esthetic treatment results were enhanced by
encouragement of papilla formation through
movement of 2 lateral incisors into the missing
central incisor position. Alternatively, a bone
graft could also alleviate such conditions with
insufficient alveolar ridge.

Case 3
A 20-year-old female with 2 missing mandibular
central incisors that had been restored with a
fixed retainer carrying 2 pontics. She requested
implants rather than a fixed partial denture. Her
alveolar bone thickness was too narrow to place
implants (Fig. 9) based on a computed tomo-
graphy (CT) image. Also, placing 2 implants next
to each other in this area could produce
unesthetic results. Therefore, bone graft from
the mandibular symphysis was placed to augment
the medial area of the alveolar bone (Fig. 10).
Figure 8. Case 2: 4 years retention of the temporary Then, the 2 lateral incisors were moved to
crown restoration. close the space in the midline using indirect
70 Bayome et al

Figure 9. Case 3: CT images showing that the alveolar bone thickness was too narrow to place implants.

anchorage from a miniscrew (Orlus, 6 mm healing following implant placement. However,

length, 1.6 mm in diameter). This resulted in the reduced treatment time and increased patient
crown tipping, so the roots were controlled by acceptance rendered the immediate loading
repositioning the brackets in an over corrected approach more popular in implant prostho-
position and the 2 brackets were tied together. dontics.32 This approach was originally applied in
This insured sufficient inter-radicular space the anterior mandible and showed high success
between the 2 lateral incisors and the canines. rates.33,34 Then, it was applied in the maxillary
After 7 months of tooth movement, 2 implants dentition as a single implant restoration, again
were placed distal to the lateral incisors (Fig. 11). with a high success rate.35,36 A meta-analysis study
showed similar failure rates for immediately
loaded and conventionally-loaded implants.37
Immediate vs. delayed loading of dental implants To better understand the biologic evidence
The traditional protocol for implant rehabil- and the mechanisms of how peri-implant tissues
itation requires a healing period of 12 month respond to loading conditions, several studies
post-extraction and 3–6 months of undisturbed have been conducted including animal studies

Figure 10. Case 3: bone grafting from the mandibular symphysis to augment the medial area of the alveolar bone.
 Implants for orthodontic patients with missing anterior teeth 71

Figure 11. Case 3: after 7 months of the 2 lateral incisors mesial movement, an implant was placed on each side
between the lateral incisor and the canine.

and clinical trials. Bone–implant contact, bone under orthodontic and orthopedic forces.
area around implant apices, implant stability, and Majzoub et al.48 reported no adverse effect on
marginal bone loss were not significantly differ- the stability of the dental implant due to early
ent between implants loaded immediately and loading of implants by orthodontic distalization
those with delayed loading in dogs and mon- forces. Palagi et al.49 compared the effect of
keys.38–40 Clinically, there were no apparent delayed versus immediate orthodontic loading
differences between soft and hard tissue on dental implants for 6 months and concluded
responses to immediately and early loaded that a reduction of the healing period prior to
implants.41 force application had no adverse effect on the
Nevertheless, for immediately loaded single success of osseointegrated implants. A recent
anterior implants, few studies reported a success study showed that immediate loading had no
rate less than 95% and the risk factors were not inhibitory effect on osseointegration of implants
investigated.42,43 In general, the reduced success but may stimulate bone mineralization.50
rates were due to the bending loads of nonaxial While many studies report no adverse effects
forces on the implants. This increased the stress from early loading of implants, Cattaneo et al.51
at the bone–implant interface, elevating the demonstrated through histologic and finite
bone strain. Therefore, the probability of element analysis that the alveolar bone
micromotion and fatigue failure of supporting mechanical adaptation is complex and case-
bone was increased.44,45 specific around implants subjected to ortho-
Hurzeler et al.46 reported no significant effect dontic loading. In addition, a recent systematic
from orthodontic forces on changes in the peri- review concluded that there were no reports in
implant tissues in Monkeys. Turley et al.47 the literature of an adequate evaluation of the
showed that titanium implants remained stable negative effects caused by excessive orthodontic
72 Bayome et al

loading on implants.52 Therefore, further studies 2. Pallegedara C, Ekanayake L. Effect of tooth loss and
might be recommended to assess the effect of denture status on oral health-related quality of life of
older individuals from Sri Lanka. Community Dent Health.
immediate orthodontic loading on the osseo- 2008;25:196–200.
integration, stability, success, and survival rates of 3. Tsakos G, Marcenes W, Sheiham A. The relationship
the dental implants. between clinical dental status and oral impacts in
Case 2 in this report shows a C-implant sup- an elderly population. Oral Health Prev Dent. 2004;2:
porting a crown of a maxillary right lateral incisor 211–220.
4. Walter MH, Woronuk JI, Tan HK, et al. Oral health
as a temporary restoration in an adolescent related quality of life and its association with sociodemo-
patient. When orthodontic forces were applied, graphic and clinical findings in 3 northern outreach
no adverse effects on the stability of the pros- clinics. J Can Dent Assoc. 2007;73:153.
thesis were reported. The placement of the 5. Kokich VO Jr., Kinzer GA. Managing congenitally missing
lateral incisors. Part I: canine substitution. J Esthet Restor
implant may reduce the marginal bone loss,53,54
Dent. 2005;17:5–10.
and thus preserve the alveolar bone height. 6. Chaushu G, Chaushu S. The use of orthodontic treatment
However, with an increase in the height of the and immediate implant loading to restore the traumatic
alveolar bone in growing patients, the implant loss of a maxillary central incisor. Int J Adult Orthodon
can act as an ankylosed tooth and sustain an Orthognath Surg. 2001;16:47–53.
infraocclusion that results in a reduction of bone 7. Louw JD, Smith BJ, McDonald F, et al. The management
of developmentally absent maxillary lateral incisors—a
height.55,56 Therefore, it is recommended to survey of orthodontists in the UK. Br Dent J. 2007;203:E25
replace the implant or at least its crown after the [discussion 654-655].
completion of growth. In addition, if the tooth 8. Andrade DC, Loureiro CA, Araujo VE, et al. Treatment
next to the infraocclusion starts tilting, it would for agenesis of maxillary lateral incisors: a systematic
be advisable to remove the temporary implant.57 review. Orthod Craniofac Res. 2013;16:129–136.
9. Moraschini V, Velloso G, Luz D, et al. Implant survival
rates, marginal bone level changes, and complications in
full-mouth rehabilitation with flapless computer-guided
Conclusion surgery: a systematic review and meta-analysis. Int J Oral
Maxillofac Surg. 2015;44:892–901.
 Placement of implants in the anterior area in 10. Forsberg CM, Tedestam G. Traumatic injuries to teeth in
growing patients may become more frequent Swedish children living in an urban area. Swed Dent J.
due to the high esthetic demands of today’s 1990;14:115–122.
11. Garcia-Godoy F, Morban-Laucer F, Corominas LR, et al.
society. However, if the implant seems to be in
Traumatic dental injuries in preschoolchildren from
an infraocclusion position at the follow-up, it Santo Domingo. Community Dent Oral Epidemiol.
might be necessary to remove the implant and 1983;11:127–130.
replace it later on, but in reality, it would be 12. Soriano EP, Caldas Ade F Jr., Diniz De Carvalho MV, et al.
difficult to perform this procedure. The place- Prevalence and risk factors related to traumatic dental
injuries in Brazilian schoolchildren. Dent Traumatol.
ment of temporary miniscrews instead of a
2007;23:232–240.
dental implant to support a temporary crown 13. Oliveira LB, Marcenes W, Ardenghi TM, et al. Traumatic
offers a feasible treatment option for such dental injuries and associated factors among Brazilian
patients because removal of the miniscrews is preschool children. Dent Traumatol. 2007;23:76–81.
easier and results in a less bone damage. 14. Vahid-Dastjerdi E, Borzabadi-Farahani A, Mahdian M,
 The application of orthodontic forces to dental et al. Non-syndromic hypodontia in an Iranian ortho-
dontic population. J Oral Sci. 2010;52:455–461.
implants as an anchorage has no negative 15. Topkara A, Sari Z. Prevalence and distribution of
effect on the osseointegration of the implant. hypodontia in a Turkish orthodontic patient population:
However, the long-term effect on immediately results from a large academic cohort. Eur J Paediatr Dent.
loaded implants is still controversial. 2011;12:123–127.
16. Matalova E, Fleischmannova J, Sharpe PT, et al. Tooth
agenesis: from molecular genetics to molecular dentistry.
J Dent Res. 2008;87:617–623.
17. Diagne F, Diop-Ba K, Yam AA, et al. Prevalence of dental
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Surgical removal of asymptomatic impacted
third molars: Considerations for orthodontists
and oral surgeons
Sung-Jin Kim, Chung-Ju Hwang, Jung-Hyun Park, Hyung-Jun Kim, and
Hyung-Seog Yu

Surgical removal of impacted third molars is one of the most common surgeries
in the oral and maxillofacial region. While there is a general consensus that
symptomatic impacted third molars should be removed, management of
asymptomatic impacted third molars remains a controversial issue. Although
surgeons extract these teeth, orthodontists are often involved in the decision-
making process for their management, because not only do the majority of
orthodontic patients have asymptomatic impacted third molars but some of
them also need an extraction for orthodontic reasons. Here we review the
potential risks associated with the retention and extraction of asymptomatic
impacted third molars and discuss the orthodontic indications and consider-
ations for their extraction in terms of minimizing risks and maximizing patient
benefits. (Semin Orthod 2016; 22:75–83.) & 2016 Elsevier Inc. All rights reserved.

Introduction asymptomatic impacted third molars remains

controversial. Some dentists favor an early
hird molars generally erupt between 17 and
T 24 years of age, the last teeth to erupt in the
oral cavity.1–3 The eruption age varies depending
prophylactic removal of asymptomatic third
molars to avoid future problems, which may be
more difficult to manage in older patients,7 but
on the racial and ethnic group.1 Frequently,
some risks such as nerve damage, alveolar oste-
these teeth fail to erupt and remain impacted,
itis, infection, pain, and swelling are inevitably
primarily because of the lack of space distal to the
associated with all surgical procedures.7 A recent
second molars.4 Among all human teeth, the
systematic review found no evidence to supp-
third molars show the highest prevalence of
ort or contradict the prophylactic removal of
impaction, with nearly two-thirds of all adults
asymptomatic third molars in adults, concluding
carrying at least one impacted third molar.2,5
that decisions regarding these teeth should
Impacted third molars can be either sympto-
depend on clinical judgment and patient values.8
matic or asymptomatic. Surgical removal is the
Asymptomatic impacted third molars often
treatment of choice when impacted third molars
require extraction for orthodontic reasons. Sev-
are associated with pain or pathological changes
eral orthodontic indications have been pro-
such as pericoronitis and/or resorption of adja-
posed, such as the prevention of late mandibular
cent tooth roots6; however, the management of
incisor crowding,9 molar distalization,10 and
preparation for orthognathic surgery.11 To
Department of Orthodontics, School of Dentistry, Yonsei make the appropriate decisions with regard
University, Seoul, South Korea; Department of Orthodontics, Institute
of Craniofacial Deformity, School of Dentistry, Yonsei University,
to the extraction of asymptomatic impacted
Seoul, South Korea; Department of Oral and Maxillofacial Surgery, third molars, both oral surgeons and ortho-
School of Dentistry, Yonsei University, Seoul, South Korea. dontists must know the associated risks and
Address correspondence to Hyung-Seog Yu, DDS, MS, PhD, benefits and carefully evaluate all indications.
Department of Orthodontics, Institute of Craniofacial Deformity,
Here we review the potential risks associated with
School of Dentistry, Yonsei University, 134 Shinchon-dong, Seodae-
mun-gu, Seoul 120-752, South Korea. E-mail: yumichael@yuhs.ac
the retention and extraction of asymptomatic
& 2016 Elsevier Inc. All rights reserved.
impacted third molars and discuss the ortho-
1073-8746/12/1801-$30.00/0 dontic indications and considerations for their
http://dx.doi.org/10.1053/j.sodo.2015.10.010 extraction.

Seminars in Orthodontics, Vol 22, No 1, 2016: pp 75–83 75

76 Kim et al

Potential risks of retained impacted third Resorption of adjacent second molar roots
molars
Impacted third molars may cause external root
Pericoronitis resorption in adjacent second molars, although
the underlying etiology is not completely
Pericoronitis refers to localized gingivitis or
understood. The incidence of this pathology
periodontitis around the crowns of unerupted
reportedly varies from 0.3% to 7.5%,14,16,28 pri-
or partially erupted third molars and is fre-
marily because of limited visibility on two-
quently associated with pain and swelling. It is
dimensional radiographs. However, a recent
the most common pathology related to third
study reported that the proportion of patients
molars, followed by dental caries.12,13 It has
diagnosed with external root resorption was
been reported that approximately 20–30% of
considerably higher when they were examined
partially erupted and 10% of completely
with cone-beam computed tomography (CBCT;
unerupted third molars were associated with
23%) rather than with panoramic radiographs
pericoronitis,12,13 with risk factors including
(5%), although CBCT cannot precisely dis-
partial coverage of soft tissue and vertical or
tinguish root caries from root resorption.15 In
distal inclination of the tooth.12,21,22 Prophy-
contrast to pericoronitis, resorption of adjacent
lactic extraction is recommended in such cases
second molar roots occurs more frequently in ass-
(Table).7,12–20
ociation with mesially or horizontally impacted
mandibular third molars.15
Development of cysts and tumors
Mandibular angle fracture
There is a potential for cysts or tumors to develop
in the dental follicular tissue surrounding Impacted mandibular third molars reportedly
impacted third molars.23 The incidence of such increase the incidence of mandibular angle
cysts and tumors as detected by radiographic fracture.29–32 Reitzik et al.33 showed that the
evaluation was reported to be 1.2–2.3%13,14,16,24 force required for mandibular angle fracture
and 0.5–0.8%,14,24 respectively. Surprisingly, by impacted third molars in monkeys is approxi-
histological examination in some studies mately 60% of that required for angle fracture by
revealed that approximately 30–50% of peri- erupted third molars.33 However, there is a
coronal tissue around radiographically normal evidence that the incidence of condylar fract-
impacted third molars showed cystic changes.25–27 ure was higher in the absence of impacted third
The most frequent pathology was dentigerous molars, probably because of the transmission of
cyst, followed by odontogenic keratocyst, altho- greater forces to the condylar region,34,35 and
ugh malignant tumors were also found.25 Beca- that these fractures are generally more difficult
use these pathologies severely impair the to manage than angle fractures.36 Therefore, the
patient’s quality of life, they are considered a prophylactic removal of third molars cannot be
major reason for the prophylactic removal of justified in terms of decreasing the risk of mandi-
impacted third molars. bular angle fracture.

Table. Risks Associated With Retention and Removal of Impacted Third Molars7,12–20
Retention Removal

Pericoronitis (10–30%) Postoperative discomforts (50%): pain, swelling, trismus, and generalized
malaise
Dental caries on themselves (11.5–13.6%) or Periodontal defect at the distal aspect of second molar (48% of healthy
adjacent second molars (2.0–7.9%) periodontium)
External root resoprtion of adjacent second Minor postoperative complications: alveolar osteitis (2.7–26%), infection
molars (0.3–23%) (0.72–4.2%), and secondary hemorrhage (0.09–5.8%)
Development of cysts (1.2–2.3%) and tumors Temporary or permanent nerve injury: inferior alveolar nerve (1.3–8.4%)
(0.5–0.8%) and, lingual nerve (0.5–5.7%)
Increased risk of bad split in BSSO and Injury to adjacent tooth (0.18%)
mandibular angle fracture
Maxillary tuberosity or mandibular fracture (0.09–0.6%)
BSSO, bialteral sagittal split osteotomy.
 Surgical removal of asymptomatic impacted third molars 77

Potential risks with impacted third molar Alveolar osteitis (dry socket)
extraction
Alveolar osteitis is defined as postoperative pain
Periodontal defects distal to second molars in and around the extraction site, which
increases in severity at any time between 1 and 3
A periodontal defect that develops distal to the
days after extraction and is accompanied by a
second molars following the removal of impacted
partially or totally disintegrated blood clot within
third molars is a challenging risk for clinicians
the alveolar socket, with or without halitosis.44
(Table). Although a systematic review reported
The incidence is reportedly 25–30% after
that the changes in attachment levels and
impacted mandibular third molar extraction,
probing depths on the distal aspect of second
being 10 times higher than that at other
molars were clinically insignificant, it also
locations.44
revealed that 48% patients with a healthy
The etiology of and risk factors for alveolar
periodontium before surgery showed worse
osteitis are poorly understood. The risks sug-
periodontal measurements after surgery.37
gested in the literature include surgical trauma45
These periodontal defects are attributed to
and bacterial infection,46 whereas the risk factors
several factors including bone remodeling after
are higher for females,47 patients who use oral
tooth extraction, bone removal and
contraceptives,48 smokers,49 and the elderly.50
instrumentation required during surgery, and
Alveolar osteitis causes extreme pain; therefore,
difficulty in oral hygiene maintenance at the
its management should focus on pain control
distal aspect of second molars.38 Other studies
until the commencement of normal healing.51
reported that age above 25 years, pre-existing
periodontal pockets, and mesial or horizontal
impaction of third molars are risk factors for Orthodontic indications for impacted
postoperative periodontal defects.39–41 Ortho- third molar extraction
dontic extraction of third molars may be indi-
Molar distalization
cated in patients with these risk factors; this will
be discussed in a later section. Molar distalization is employed to correct a Class
II or Class III molar relationship and to gain
space for the relief of crowding without func-
Nerve injury
tional premolar extraction.52,53 The clinical sig-
The inferior alveolar and lingual nerves may be nificance of molar distalization has increased
injured during the surgical removal of man- since the introduction of temporary anchorage
dibular third molars, a condition that results in devices (TADs) that allow predictable molar
sensory impairment in the ipsilateral lower lip, distalization with minimal patient com-
chin, and tongue. Patients may experience dis- pliance.54,55 However, molar distalization is not
comfort when talking, drinking, or eating in the always an efficient treatment modality; therefore,
presence of mild injury, whereas severe injury the decision to deploy this procedure should be
frequently leads to extreme discomfort and pain. carefully made. With regard to relief of anterior
The incidence of sensory impairment after third crowding, the amount of space gained after first
molar surgery was reported to be 1.3–8.4% for or second premolar extraction is approximately
the inferior alveolar nerve and 0.5–5.7% for the 5.5 and 3.5 mm, respectively, because the loss of
lingual nerve.18,19 This sensory impairment is posterior anchorage without TADs is reported to
mostly transient and disappears within the first be approximately 20%56 and 50%57 of the
6 months, while the incidence of permanent extraction space, respectively. Considering that
damage is reportedly less than 1%.42 In patients the conventional amount of molar distalization is
with persistent sensory impairment, however, approximately 3 mm,54,55,58 premolar extraction
nonsurgical treatments, including acupuncture may be the treatment of choice when more than
and low-level laser therapy, or surgical inter- 3 mm of molar distalization is necessary.
ventions including external neurolysis, direct Molar distalization requires not only adequate
suturing, autogenous vein grafting, and applica- anchorage but also available space distal to sec-
tion of a Gore-tex tube as a conduit may improve ond molars. Therefore, impacted third molars
sensation, although complete recovery is rare.43 are routinely removed before molar distalization
78 Kim et al

Figure 1. In patient A, extraction of the mandibular left third molar will provide space for second molar
distalization. However, in patient B, it is limited by root contact with the lingual cortex of the mandibular body.

in adults.10 In the mandible, however, even maxillary down-fracture without the risk of
impacted third molar extraction cannot guara- complications.
ntee enough space for molar distalization,
because the available space distal to second
Prevention of late mandibular incisor crowding
molars is determined by the lingual cortex of
the mandibular body and is not affected by third Late mandibular incisor crowding is a common
molar extraction.59 In addition, 35.3% second phenomenon that generally occurs in the early
molar roots were reported to be in contact with 20s. Various etiological factors have been pro-
the lingual cortex in patients with skeletal Class I posed including late mandibular growth,67
malocclusion and no history of orthodontic mesial drift of posterior teeth,68 an anterior
treatment.59 Therefore, regardless of the pres- occlusal force component,69 and pressure from
ence of mandibular third molars, examination of third molars.9 Among these factors, much
the available space distal to second molars using attention has been paid to pressure from third
computed tomography is recommended before molars, probably because direct intervention is
planning molar distalization (Fig. 1). possible. However, there have been conflicting
results, where some authors found third molar
removal beneficial in terms of the prevention of
Preparation for orthognathic surgery
late mandibular incisor crowding,9,70 whereas
The effect of impacted mandibular third molars others found no direct benefits.71,72
on unfavorable fracture or bad split during sag- Considering the lack of knowledge about
ittal split osteotomy (SSO) has been a con- precise etiological factors, the best approach to
troversial issue. Some authors reported a slightly match the extraction and retention groups and
increased risk of a bad split in the presence of eliminate potential sources of bias is random-
impacted third molars,11,60–62 whereas others ization. To date, only one randomized controlled
found no significant correlations.63–65 Because trial by Harradine et al.73 evaluated the influence
no data from randomized clinical trials are cur- of third molars on late mandibular incisor
rently available, the timing for third molar crowding. After an average 66 months of
extraction depends on the surgeon’s preference follow-up, there were no significant differences
and orthodontic necessity. If third molar in Little’s index of irregularity and intercanine
extraction is planned before SSO, it should be width between the two groups, although a small
performed at least 6 months before SSO to allow but statistically significant difference (approxi-
for complete bone maturation.66 mately 1 mm) was found in arch length. These
In contrast to SSO, the timing of extraction findings imply that the presence of third molars
is not critical in patients requiring vertical has little influence on late mandibular incisor
ramus osteotomy because the osteotomy line is crowding, although impacted third molars
distant from the dentition. Maxillary impac- appear to contribute to the mesial migration of
ted third molars may also disturb osteot- posterior teeth. Therefore, considering the cost
omy, although they can be easily removed after and morbidity, the surgical removal of impacted
 Surgical removal of asymptomatic impacted third molars 79

Figure 2. (A) Surgical exposure of an impacted mandibular right third molar. (B) Indirect application of a mini-
screw to reinforce the posterior anchorage for orthodontic extrusion of the impacted mandibular right third
molar. Radiographs obtained before (C) and after (D) orthodontic extrusion that moved the roots away from the
inferior alveolar nerve (Courtesy of Dr. Wonse Park).

third molars to prevent late mandibular incisor summarized relevant studies and concluded that
crowding cannot be justified. age 25 is a critical time after which complications
such as a higher infection rate, more periodontal
complications at the distal aspect of second
Special considerations for orthodontists molars, and delayed or incomplete recovery from
nerve injury increase rapidly.77 The higher
Timing of extraction
complication rate is partially attributed to
In general, increased age has been associated increased difficulty of third molar removal in
with increased morbidity after the surgical older patients because of continuing root
removal of third molars.74–76 A recent review development, a thinner periodontal ligament,
80 Kim et al

and an increased incidence of ankylosis and intrusion and distal tipping of the mandibular
hypercementosis. On the other hand, early posterior anchorage or extrusion of maxillary
removal of third molars by germectomy at 9–16 posterior teeth when intermaxillary elastics are
years of age does not decrease the complication used. Direct or indirect application of TADs can
rate compared to that at 17–24 years of age.78 provide stable anchorage to prevent these side
Therefore, the prophylactic removal of third effects (Fig. 2). Second, over-extrusion of third
molars can be postponed until 17–24 years of age molars is recommended to save more bone at the
when the patient’s compliance increases. distal aspect of the second molars. When max-
In orthodontic patients, however, there are illary third molars prohibit over-eruption of
special considerations for the timing of extrac- mandibular third molars, they should be
tion. First, when molar distalization is planned, extracted first.83 Third, a retention period of a
third molars should be removed immediately few months is required to allow for new bone
before molar distalization in an attempt to formation after extrusion.
decrease the treatment duration.55 Decreased
treatment time can be expected because of the
regional acceleratory phenomenon79 and a Conclusions
decrease in the amount of alveolar bone
Most of the orthodontic patients have asymp-
requiring removal.80 Second, in patients
tomatic impacted third molars; however, their
scheduled for SSO, third molars may be
surgical removal remains controversial in terms
removed 6–9 months before surgery to avoid
of risks vs. benefits. Even though a surgeon is
unfavorable fractures.66 Maxillary impacted third
the one extracting these teeth, orthodontists
molars can be easily removed after LeFort I
are in an ideal position to monitor them and
downfracture.
should participate in the decision-making
process for their management. Interaction bet-
Orthodontic extraction of impacted third molars ween orthodontists and surgeons with regard to
extraction timing and minimization of post-
Orthodontic extraction was introduced to mini-
operative complications by orthodontic inter-
mize the risk of nerve damage and facilitate the
vention may decrease risks and maximize
extraction of impacted mandibular third molars
patient benefits.
in close anatomical proximity to the mandibular
canal.81 It involves the orthodontic extrusion of
impacted third molars to pull their roots away
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 Seminars in Orthodontics
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