Featured Case 01/21: SURGICALLY ACCELERATED ORTHODONTICS (Faster Braces, Better Tissue, Stable Result.)

Patient:

Becca, a 27-year-old female.

The problem:

• Becca has always wanted straight teeth and a more aesthetic smile.
• She was concerned about her crooked and crowded teeth.
• As a busy working adult, she did not want to be in braces for long.
• She longed for a better option.

Patient History:

• Becca is a healthy female patient.
• She sought a previous orthodontic consult a few years prior but never committed to treatment.
• The previous orthodontist proposed a treatment time of 18 months.
• There were concerns that she had thin gingival and bone tissue and the potential for gum recession.
• She noted that a couple of teeth were darker.

Pertinent Information:

• Traditional orthodontic therapy can range from 1 to 2 years depending on the case.
• Many patients have very thin tissue encompassing their teeth. This is referred to as the tissue phenotype.
• These thin phenotype patients frequently have paper-thin bone holding the teeth. In some cases, the roots are exposed or fenestrated through the bone. You can sometimes see the outline of the teeth roots through the soft tissue.
• This causes a concern for gum recession and general periodontal health in the short or long term.
• The relative health and quality of the tissue housing (gums and bone) around the teeth are a factor of relative stability long-term.
• Surgically facilitated orthodontics is an interdisciplinary process involving a minor procedure to induce a temporary acceleration in the inflammatory healing process known as the rapid acceleratory phenomenon (RAP).
• This RAP occurs between 2 weeks after the surgical procedure and lasts for 4 months.
• During these 4 months, the bone undergoes demineralization (transient localized osteopenia) that facilitates the rapid movement of teeth by orthodontics, reducing the total treatment time.
• Braces are placed first (typically without the archwire).

Procedures:

• Once braces are placed by the orthodontist, the patient is scheduled for this minor procedure under a relaxing IV sedation.
• The tissues are gently reflected off the teeth and a superficial groove (corticotomy) is notched around the roots of the teeth only through the dense outer layer.
• These corticotomies are usually performed on the teeth requiring significant movement.
• In this case, we chose to incorporate a soft tissue graft to thicken the gingival soft tissue complex.
• Acellular Human dermis (Alloderm) was utilized in this case
• This Alloderm was hydrated in the patient’s platelet-rich plasma concentrate (PRP) which was previously isolated by centrifuging her blood to isolate the PRP.
• This PRP takes the patient’s healing ability and concentrates it in the localized wound to maximize the healing potential of growth factors released by the platelets.
• A technique used in various reconstructive and cosmetic procedures.
• Then particulated banked bone grafting was veneered over the cortical bone layer to create a new hard tissue construct for the teeth and facilitate tooth movement.
• The bone graft was hydrated in the PRP to enhance the healing potential.
• Becca also had her 4 wisdom teeth removed at the same time.
• Sutures were placed to reposition the gingival soft tissue around the teeth.
• The images below show the healing after 4 days.

• She then returned to her orthodontist for treatment.
• Due to the accelerated process, Becca had to commit to being seen every 2 weeks by her orthodontist until treatment completion.

Commentary:

• Becca completed treatment in 3 months from start to finish.
• Surgically accelerated orthodontics, also referred to as periodontally accelerated osteogenic orthodontics, is a minor procedure with big advantages.
• It accelerates the treatment from ¼ to ½ the typical time, an advantage very attractive to busy working adults or those impatient with a long course of treatment.
• It creates a robust and healthy tissue quality that provides better long-term health and reduces the propensity toward gum recession.
• It creates a wider, more robust new bone construct that facilitates tooth movement over a potentially larger range (the envelope of movement) otherwise limited in the tin tissue type.
• Many cases that are planned for traditional jaw reconstructive surgery can be minimized and optimally treated with this technique.
• It is also postulated that thicker and healthier tissue provides a more stable tooth position over the long term, thereby reducing potential relapse.
• Becca was ecstatic over her smile makeover and final result.