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CE: A.B.; SCS-17-0545; Total nos of Pages: 5;
SCS-17-0545
BRIEF CLINICAL STUDIES
Corticotomy With a Palatal
Bone-Borne Retractor for
Correcting Severe
Bimaxillary Protrusion
Min-Ki Noh, PhD, Young-Jun Kim, PhD,y
Kyu-Rhim Chung, PhD, Seong-Hun Kim, PhD,
and Gerald Nelson, DDSz
Background: This article presents an alternate surgical treatment
method to correct a severe anterior protrusion in the adult patient
with an extremely thin alveolus.
Methods: In the maxilla, a wide linear corticotomy was performed
under local anesthesia. Cortical alveolar bone of the upper first
bicuspids area was widely removed. Orthopedic force for bony
block movement was applied by a palatal bone-borne type retractor
supported by skeletal anchorage. Residual extraction space closure
was performed by biocreative orthodontics strategy (BOS). In the
mandible, an anterior segmental osteotomy (ASO) and extraction of
1st premolars were performed under local anesthesia.
Results: In the maxilla, bony block movement followed by the wide
linear corticotomy with a palatal bone-borne type retractor was
implemented without complications. Remaining extraction space
after the bony block movement was closed effectively by BOS. In
the mandible, anterior segmental retraction was achieved effectively by ASO.
Conclusions: Wide linear corticotomy with a palatal bone-borne
type retractor and ASO under local anesthesia can be an effective
alternative to orthognathic surgery in adults with protrusion and an
extremely thin alveolus. The biocreative strategy also provides a
simple and effective method to retract the 6 anterior teeth.
movement is heavier than the optimal orthodontic force.6 In previous studies, skeletal anchorage devices such as the C-palatal plate
and C-tube performed the role of a reliable and rigid skeletal
anchorage for orthopedic force.7– 9 The treatment method is substantial just as much as anchorage requires. In the patient with either
thin alveolus or upright position of incisors in maxilla, it is restricted
with conventional treatment due to retraction forces directly to the
teeth. To overcome this limitation, contractor was established as a
reverse concept to distractor by applying backward forces in place
of forward forces (Fig. 1).
This protocol provides independent en-masse retraction of the
anterior teeth without requiring orthodontic appliances on the
posterior segments during the retraction.
The purpose of this report is to suggest that the bone-borne type
retractor after a wide linear corticotomy and a mandibular ASO are
an effective treatment option for the severe bimaxillary protrusion
with a thin alveolus.
METHODS
Under the local anesthesia, 1st premolar extraction on both arches
and particularly a wide linear corticotomy in the maxilla combine
with ASO in the mandible were performed.10 The cortical alveolar
bone around the upper first bicuspids was removed linearly as wide
as possible within the limit not to damage adjacent roots (Fig. 2A).
A palatal bone-borne type retractor was designed to move anterior
bony block segment in a posterior direction. This retractor consists
of 4 parts: palatal C-implants, expansion screws (Forestadent Co,
Pforzheim, Germany), an acrylic body (Forestacryl, Forestadent
Co), and a guiding plate. The acrylic resin body consists of an
anterior and a posterior part to hold an anterior and a posterior bony
segment, respectively. These separated bodies are connected with
expansion screws. A palatal bone-borne type retractor was stabilized when the expansion screws were fully opened in order to make
Key Words: Anterior segmental osteotomy, biocreative
orthodontics strategy, C-implant, palatal bone-borne type retractor,
thin alveolus, wide linear corticotomy
T
o overcome periodontal and skeletal limitations in adult bimaxillary protrusion patients, various surgical techniques such as
anterior segmental osteotomy (ASO)1,2 and corticotomy3 have been
developed. Chung et al introduced a new type of corticotomyassisted orthodontic treatment called speedy surgical orthodontics,
which allows movement of dental segments over a shorter time by
using a corticotomy and an orthopedic force for treating severe
anterior protrusion in adults.4,5 Orthopedic force for bony block
From the Department of Orthodontics, Graduate School, Kyung Hee
University, Seoul; yPrivate Practice, Bucheon, Korea; and zDivision of
Orthodontics, Department of Orofacial Science, University of California
San Francisco, San Francisco, CA.
Received March 25, 2017.
Accepted for publication August 2, 2017.
Address correspondence and reprint requests to Seong-Hun Kim, PhD,
Department of Orthodontics, Graduate School, Kyung Hee University,
1 Hoegi-dong, Dongdaemun-gu, Seoul 130-701, Korea;
E-mail: bravortho@gmail.com
The authors report no conflicts of interest.
Copyright # 2017 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0000000000004057
The Journal of Craniofacial Surgery
FIGURE 1. (A) Study model before setup. (B) Study model after setup. After 1st
premolars are extracted, anterior segment is retracted to the posterior part. (C, D)
Palatal bone-borne type retractor on set-up model. Red-dotted line means wide
linear corticotomy line. (E, F) Retractor on the palatal side with guiding plate.
Volume 00, Number 00, Month 2017
1
Copyright © 2017 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
CE: A.B.; SCS-17-0545; Total nos of Pages: 5;
SCS-17-0545
Brief Clinical Studies
The Journal of Craniofacial Surgery
Volume 00, Number 00, Month 2017
year. After anterior bone segment retraction and complementary
space closure anchored by C-implant, the finishing stage was
performed with full fixed appliances. This treatment mechanics
is called biocreative orthodontics strategy (BOS).11
CLINICAL REPORT
FIGURE 2. Wide linear corticotomy and palatal bone-borne type retractor
application. (A, B) Intraoral photographs of after wide linear corticotomy and
1st bicuspid extraction on maxilla. (C) Removal of guiding plate. (D) Intraoral
photograph of after removing both guiding plates. (E, F) Right before screw
activation. (G, H) Five days after screw activation: 5 mm closure.
it function reversely. A guiding plate was used to lead correct
positioning of the retractor during delivery (Fig. 1D-F).
An acrylic resin body and a guiding plate were fabricated on the
cast model along the surface of in order the palate and 1st, 2nd
premolars with 1st molar. After delivery of the retractor, guiding
plates that connected with acrylic resin by stainless steel wire were
removed (Fig. 2C-D).
The retractor is supported by 4 mini-implants bilaterally: 2 on
the anterior acrylic pad between the lateral incisors and canines, and
the other 2 on posterior pad between the first molars and the second
molars. Six partial osseointegration-based C-implants (sand-blasted, large-grit, acid-etched mini-implant; Dentium Co., Seoul,
Korea) with a 0.8-mm tube hole were placed palatally, 2 for anterior
segment, 1 for posterior segment per side. The next appointment of
insertion, they were bonded to the acrylic body with acrylic resin.
The retractor was activated by turning an expansion screw in the
reverse (closing) direction. Five days later, brackets were placed on
the anterior dentition for accomplishment of space closure. In this
study, C-implants were used as the only source of anchorage for enmasse retraction of the 6 maxillary anterior teeth.11 Four C-implants
were placed bilaterally between the 2nd premolars and the 1st
molars in both arches to achieve maximum anchorage for retraction.
No brackets or bands were placed on the posterior dentition for 1
2
A 25-year-old woman complained of anterior protrusion. Her protruded lip profile was affected by flat mentolabial sulcus and mentalis
hyperactivity. The intraoral examination showed Class III molar and
canine relationships on the left and Class I molar and canine relationships on the right, with an anterior openbite and dental midline
deviation (Fig. 3A-C). The initial lateral cephalometric analysis
showed a skeletal Class II relationship (A point, nasion, B point
angle, 5.58) with deficient mandibular length (Fig. 6A). Sagittal
images of cone beam computed tomography of incisors demonstrated
an extremely thin alveolus around the anteriors. Patients refused the
orthognathic surgery, which needs to be under general anesthesia.
Thereby surgical approaches under local anesthesia were applied
alternatively. ASO and 1st premolars extraction in the mandible, and
a wide linear corticotomy around 1st bicuspids area in the maxilla
were performed under local anesthesia. A palatal bone-borne type
retractor was applied for bony block movement. The patient was
instructed to activate both screws 4 quarter turns a day which
produces 0.25 mm of bony block movement (Fig. 2E-F). Five days
later, activation of expansion screws was suspended (Fig. 2 G-H).
Minimally remained extraction space was closed by BOS, which
allows independent en-masse retraction of the anterior teeth without
brackets or bands on the posterior teeth. C-implants were used as the
only source of anchorage (Fig. 4A-I), and terminally finishing stage
was performed with full-fixed appliances (Fig. 4J-L). Treatment
duration was 2 years. Proper overbite and overjet were obtained
(Fig. 5A-C). The result was stable without any periodontal complications. Better facial appearance was obtained. Remarkable retraction
of lip posture was achieved. Hyperactivity of mentalis muscle was so
relieved that a natural mentolabial fold appeared. The patient’s palatal
plane to upper incisor angle was changed from 1108 to 958 during
treatment and incisor mandibular plane angle was changed to 38
(pretreatment 1088, post-treatment 1058) (Fig. 6). Post-treatment
sagittal images of the cone beam computed tomography were
reviewed (Fig. 6D-G). There was no significant negative change
in the dentoalveolar status or root length of anterior teeth. Ten years
after the completion of treatment, the patient had a stable occlusion
and esthetic profile (Figs. 5G-L, 6H-K).
DISCUSSION
To overcome periodontal and alveolar housing limitations, and
extend the achievable range of tooth movement, surgical-assisted
tooth movement is needed.6,12 Anterior segmental osteotomy and
corticotomy are less invasive techniques than orthognathic surgery,
and can be performed under local anesthesia, which reduces the fear
of the patient and leads to fewer surgical complications or side
effects.3,13 Anterior segmental osteotomy can provide a significant
enhancement of the lateral soft tissue profile in bimaxillary protrusive patients who want immediate esthetic improvement.14 Corticotomy can reduce treatment time via the bony block movement
and regional accelerating phenomenon.15,16 Corticotomy facilitated
segmental movement of alveolar block is possible due to removal of
the cortical resistance.3,6 If more segment mobilization was attained
by corticotomy, more bony block movement effect could occur.17 In
this patient, the corticotomy line was wider than the typical
corticotomy line, so bony resistance was sufficiently reduced to
facilitate retraction of the bony block. Orthopedic force for bony
block movement needs to be heavier than the optimum orthodontic
force.6 In this patient, a palatal bone-borne type retractor was used
#
2017 Mutaz B. Habal, MD
Copyright © 2017 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
CE: A.B.; SCS-17-0545; Total nos of Pages: 5;
SCS-17-0545
The Journal of Craniofacial Surgery
Volume 00, Number 00, Month 2017
Brief Clinical Studies
FIGURE 3. (A-C) Pretreatment intraoral photographs (age, 25 years 11 months)
show anterior openbite, moderate crowding on maxilla and mandible. Set-up
models before retraction of anterior part on maxilla and ASO on mandible (D-F)
and after retraction of anterior part on maxilla and ASO on mandible (G-I). ASO,
anterior segmental osteotomy.
to generate the orthopedic force. The heavy force of the expansion
screws was transmitted to the perisegmental corticotomy site
through anterior and posterior parts of retractor. Because this is
not tooth-borne anchorage system, there is no possibility of unwanted tooth movement out of the alveolar bone housing. This type
of appliance also has an esthetic advantage during retraction, since
it is not visible to the patient’s public.
The palatal bone-borne type retractor was supported by 3 palatal
mini-implants bilaterally (Fig. 2). There was not sufficient room for
placing 1 more mini-implants in the posterior segment. But 1.8 mm-in
diameter 9.5 mm sand blasted large grit and acid etched surface-treated
C-implants successfully resisted the traction force. These implants
were enough to support the orthopedic force in this adult patient.
#
2017 Mutaz B. Habal, MD
FIGURE 4. Treatment progress intraoral photographs (biocreative orthodontics
strategy). (A-C) Beginning of En-masse retraction, 0.016 0.022-in stainless
steel utility archwire on both dentitions and 0.25-in, 3.5-oz elastics between
hooks and C-implant. (D-F) En-masse retraction, 0.25-in, 3.5-oz elastics, and
elastomeric chains between hooks and C-implant. (G-I) Completion of En-masse
retraction. (J-L) Finishing stage.
After the bony block movement by the retractor, BOS was
applied to complete the space closure. It has advantage of not
disturbing the posterior teeth.9,18 Retraction time is shortened, since
no preliminary alignment of posterior teeth is necessary. The Cimplant holes substitute for multiple posterior fixed appliances.
This concept was developed because partially osseointegrated miniimplants (C-implant) can endure multidirectional heavy forces and
support orthodontic archwires.11,19,20
3
Copyright © 2017 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
CE: A.B.; SCS-17-0545; Total nos of Pages: 5;
SCS-17-0545
The Journal of Craniofacial Surgery
Brief Clinical Studies
Volume 00, Number 00, Month 2017
FIGURE 6. Lateral cephalograms. (A) Pretreatment. (B) Right after anterior
segmental osteotomy on mandible. (C) Post-treatment. (D-G) Sagittal
images of cone beam computed tomography of incisors before treatment show
extremely thin alveolus. (H-K) Sagittal images of cone beam computed
tomography of incisors 10 years after treatment. There were no significant
differences in dentoalveolar changes and root length of anterior teeth.
ACKNOWLEDGMENTS
The authors thank to Won Lee, Professor and Chair of Department
of Dentistry, the Catholic University of Korea Uijungbu St Mary’s
Hospital for surgical assistance and Dr Nur Serife Iskenderoglu,
Department of Orthodontics, Graduate School, Kyung Hee University for manuscript editing.
REFERENCES
FIGURE 5. Post-treatment intraoral photographs and panoramic radiograph
(age, 28 years, A-F). (G-L) Ten years after treatment.
CONCLUSION
A wide linear corticotomy with a palatal bone-borne type retractor
in the maxilla, and a mandibular ASO under local anesthesia can be
an effective alternative to orthognathic surgery in adults with
protrusion and an extremely thin alveolus. Biocreative orthodontics’ strategy provides an efficient and effective method of retracting the 6 anterior teeth.
4
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#
2017 Mutaz B. Habal, MD
Copyright © 2017 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
CE: A.B.; SCS-17-0545; Total nos of Pages: 5;
SCS-17-0545
The Journal of Craniofacial Surgery
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5
Copyright © 2017 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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