elerated Osteogenic Orthodontics Technique

1. Accelerated Osteogenic Orthodontics
Technique: A 1-Stage Surgically Facilitated
Rapid Orthodontic Technique With Alveolar
Augmentation
M. Thomas Wilcko, William M. Wilcko, Jeffrey J. Pulver, Nabil
F. Bissada, and Jerry E. Bouquot
J Oral Maxillofac Surg 67:2149-2159, 2009

2. INTRODUCTION
• An increased tooth movement is generally observed after corticotomy surgery. It was
believed to be due to the movement of small outlined blocks of bone.
• Due to the circumscribing corticotomy cuts, the resistance to the tooth movement would
be provided only by the less dense medullary bone.
• Hence , It was thought that the slow periodontal ligament (PDL)- mediated process of
traditional orthodontics could be overcome because presumably the tooth–PDL complex
was being moved with the block of bone and not through the bone.

3. Concepts and indication
• In 2001, Wilcko et al suggested that the rapid tooth movement
associated with corticotomy-facilitated orthodontics is due to
demineralization/remineralization process consistent with the
initial phase of regional acceleratory phenomenon,

4. PAOO technique
 Wilcko et al and Ferguson et al reported a new in-office technique
BONE ACTIVATION
ALVEOLAR AUGMENTATION
ORTHODONTIC TREATMENT

5. BONE
ACTIVATION
SELECTIVE
ALVEOLAR
DECORTICATION
OSTECTOMY
BONE THINNING

6. ADVANTAGES OF PAOO
1. Enhanced scope of malocclusion treatment (ie, an increase in the limits of tooth movement
and a decreased need for extractions).
2. Decreased treatment times (increased rate of tooth movement).
3. Increased alveolar volume and a more structurally complete periodontium (correction of
preexisting bony dehiscences and fenestrations).
4. Alveolar reshaping for the subtle enhancement of a patient’s profile when indicated
5. Simultaneous rapid recovery of shallow unerupted teeth

7. AOO Surgical Technique
• Formulation of a treatment plan by the orthodontist/ surgeon team.
• Orchestrating the sequencing of the different aspects of the treatment.
• Typically, the orthodontic brackets are placed and a light wire engaged a week before
the surgery with the subsequent orthodontic adjustments being made at 2-week
intervals.

8. • In general, full-thickness flaps are reflected labially and lingually using a
sulcular releasing incision.
• The interdental papillae is reflected with the full-thickness flaps except between
the upper central incisors
• Vertical releasing incisions should be positioned at least 1 tooth beyond the
“bone activation,” especially if a large amount of bone grafting material is
used.
• The flap reflection is carefully extended beyond the apices of the teeth to avoid
damaging the neurovascular complexes

9. • After bone activation using circumscribing corticotomy cuts and intramarrow
penetrations, resorbable particulate bone grafting mixture placed over the
activated bone.

10. • This bone grafting material is typically first wet with a clindamycin
phosphate/bacteriostatic water solution of approximately 5 mg/mL or with
platelet-rich plasma
100 % DFDBA
A mixture of DFDBA and mineralized
freeze-dried bone allograft
A mixture of DFDBA and bovine
bone

11. • The amount of particulate bone grafting material that is used can vary from
0.25 to 1 cc or more per activated tooth
• It depends upon:
 amount of pre-existing bone,
 severity of the crowding that needs to be resolved
 severity of the anticipated dentoalveolar defect
 number and extent of the ostectomies required
 amount of intended subtle facial reshaping.

12. • Suturing is done with interrupted loop using non resorbable suture material
such as Gortex or Cytoplast
• Large bites of the gingival attachment are taken to lessen the likelihood of the
sutures pulling out.
• The patient is checked 4 to 5 days postoperatively to ensure that flaps have
not separated. The sutures are left in place for a minimum of 2 weeks. (3
weeks if more than 0.5 cc is used per tooth)
• Sufficient time must be allowed for the epithelial attachment to re-establish
itself

13. Case report – 1
NON EXTRACTION TREATMENT OF A SEVERELY
CONSTRICTED MAXILLAAND SEVERE UPPER
AND LOWER CROWDING

14. • 23-year old man
• Class I molar and canine relations
• Upper and lower arch crowding
• Severe upper arch constriction in the
anterior/bicuspid areas
• Anterior and posterior bilateral crossbites

15. PROCEDURE
• BONE ACTIVATION -labially and lingually around all the remaining upper and lower
teeth using circumferential corticotomy cuts and intramarrow penetrations
• The activated bone was then covered with a particulate bone grafting mixture consisting
of 50% DFDBA and 50% bovine bone
• 24cc of the bone grafting material was used (1 cc per tooth).

16. RESULTS
• His case was completed in 6 months and 2
weeks from bracketing to de-bracketing.
• The total amount of cross-arch expansion
in the upper canine areas was 8 mm.

17.  A pretreatment and post-treatment crosssectional analysis of the computed
tomographic scan through the lower left central incisor shows an increase in
the alveolar bone width of 2.4 mm at B-point and 3.5 mm lingually .
 This increased thickness of cortex will help provide for increased stability
after treatment.

18. This case was re-entered at 8 months after de-bracketing (14.5 months )
Bone biopsy from the facial of the upper left first bicuspid
Thickness of 3 to 4 mm of new healthy bone
Particle of bovine bone that has not yet completely resorbed, surrounded by healthy lamellar bone.

19. 4 weeks 8 weeks
16 weeks
11 weeks

20. Case report- 2
TREATMENT FOR UNILATERAL SPACE
CLOSING IN AN ADULT

21. • 47-year-old healthy woman
• Moderate anterior crowding
• 4-mm overjet (underbite)
• Class I molar relation on the right side
• Class II molar relation on the left side
• Missing upper left second bicuspid

22. PROCEDURE
• Treatment plan - space closing at the upper left second bicuspid site and expansion to
correct the anterior crowding.
• Full thickness flaps were reflected facially and lingually from second molar to second molar
• Bone activation-
a) Lower arch- Canine to Canine
b) Upper arch- Right canine to the left first bicuspid +ostectomy at the left second
bicuspid site

23.  The activated bone was then covered with the bone grafting material
 An orthopedic retractor was inserted in the upper arch at 1 month after surgery
 The space was closed over the following 3 weeks, at which time the retractor
was removed

24. RESULTS
• The total treatment time from bracketing to de-
bracketing was 7 months.
• The lower left area was re-entered after 17
months of surgery. The bony fenestrations that
were present initially were completely filled in
with new bone.

25. • Bone biopsies taken from the facials of the lower left canine and lower left lateral
incisor were each 2 to 3 mm in thickness
 At 8 years after surgery, the lower right area was re-entered.
 The histologic findings were consistent with healthy lamellar bone

26. BONE MATRIX TRANSPORTATION
• In corticotomy-facilitated orthodontics, the optimal tooth movement
occurs when only a thin layer of bone overlies the root prominences in the
direction of the intended tooth movement in close approximation to the
osseous insult

27.  This rapid tooth movement after corticotomy-facilitated orthodontics is described as
“bone matrix transportation” and not “bony block movement”
1. Bone demineralization
2. Soft tissue matrix and islands of osteoid transported with the root surfaces
3. Remineralization at the completion of the orthodontic therapy.

28. SPECIAL CONSIDERATIONS AND
LIMITATIONS
• CONTRAINDICATED IN :
• Any medications that slow down bone turn over rate
• Long-term corticosteroid therapy
• Bisphosphonate ( even after cessation)
• NSAIDS

29. CROSS REFERENCE:
COMPARISON OF TOOTH MOVEMENT
AND BIOLOGICAL RESPONSE IN
CORTICOTOMYAND MICRO-
OSTEOPERFORATION IN RABBITS
Junghan Kim ,Yoon-Ah Kook , Mohamed Bayome , Jae Hyun Park , Won Lee ,
Hojae Choi ,Noha H. Abbas
Korean J Orthod 2019; 49(4): 205-213

30. OBJECTIVE OF THE STUDY
• To evaluate the amount of tooth movement and histologic changes
with different corticotomy designs and micro-osteoperforation in
rabbits.

31. METHOD
• SAMPLE - 24 rabbits
• triangular corticotomy [TC]
• indentation corticotomy [IC] with flap,
• flapless micro-osteoperforations [MP]) and a control.
• A traction force of 100 cN was applied by connecting the first premolars to the incisors.
The amount of tooth movement was measured.

32. RESULTS
• The amount of tooth movement increased by 46.5% and 32.0% in the IC
and MP groups, respectively, while the bone fraction analysis showed
69.7% and 8.5% less mineralization compared to the control.

33. CONCLUSION
• The AOO treatment provides for an optimal response to applied forces
because it is mediated by the PDL and spongiosa.
• Compared with traditional orthodontic treatment, this treatment has the
obvious advantages of dramatically shorter treatment times,the ability to
move teeth farther and yet provide a greater alveolar volume for increased
post-treatment stability with decreased side effect