- Email: [email protected]
Periodontal and pulpal condition of the central incisors after midline osteotomy of the maxilla
529
JEROLD S. GOLDBERG 23. Lindhe J: Textbook Clinical Periodonthology (ed 2). Copenhagen, Denmark, Munksgaard, 1989, p 317 24. Popp TW, Artun J, Linge L: Pulpal response to orthodontic tooth movements in adolescents: A radiographic study. Am J Orthod Dentofac Orthop 101:228, 1992 25. Ramsay DS, Artun J, Bloomquist D: Orthognathic surgery and pulpal blood flow. J Oral Maxillofac Surg 49:564, 1991
J Oral Maxiliofac
57529-530,
26. Shehab Al-Din OF, Coghlan KM, Magemris P: Sensory nerve disturbance following Le Fort I osteotomy. Int J Oral Maxillofac Surg 25:13, 1996 27. Kahnberg K-E, Engstrijm H: Recovery of maxillary sinus and tooth sensibility after Le Fort I osteotomy. Br J Oral Maxlllofac Surg 25:68, 1987
Surg
1999
Discussion Periodontal and Pulpal Condition of the Central Incisors After Midline Osteotomy of the Maxilla Jet-old S. Goldberg, DDS Dean, School of Dentistry, Professor of Oral & Maxillofacial Surgery, Case Western Reserve University( Cleveland, Ohio; e-mail: [email protected]
This article, which looks at periodontal and pulpal health after a segmental, midline osteotomy, is one of several publications on this or related subjects that are referenced by the authors. The various articles tend to use different parameters of pulpal or gingival health and often measures of those parameters are carried out in different ways or with different devices. It is unfortunate that none of the published research is an attempt to reproduce a previously done experiment at a different center. Be that as it may, this study successfully supports the notion that segmental osteotomies that are performed concomitantly with Le Fort I osteotomies rarely have clinically significant detrimental effects on either the pulpal or periodontal tissues. These positive results are true throughout the dental arch as well as specifically at the interdental osteotomy site. Concerning root resorption, it would have been helpful for this study to have a control group of orthodontically treated patients who did not have surgery with which to compare results. The article by Carroll et al, cited in this article, is an example of a similar report that falls short of presenting data that is reproducible.’ It investigated the parameters of plaque index, gingival index, tooth mobility, width of keratinized tissue, probing depth, and gingival recession. The experimental group had segmental orthognathic surgery and was compared with a control group of patients who had orthodontic treatment without surgery. This investigation looked at patients having osteotomies between the premolars and canines as well as between the central incisors. The only statistically significant findings were in the probing depths of the teeth adjacent to the osteotomies between the canines and the premolars and in the width of the keratinized tissue. However, no probing depths at the osteotomy sites exceeded 3 mm so that the statistically significant finding is of no clinical concern. The greater width of attached gingiva in the experimental group is probably related to the high incidence of vertical maxillary excess in the experimental population.
In addition to the main topic of this article, the authors support a technique using multiple palatal osteotomies to depress and widen the maxillary vault. In the original article, by Krekmanov and Kahnberg, describing this technique there is little to support its use over one or two parasagittal osteotomies.2 Krekmanov and Kahnberg reported horizontal relapse and soft tissue lacerations. It would be interesting to know what additional information there is to support this approach. The concept is interesting, but I do not know if the additional osteotomies really make a difference. The authors also describe using a chisel in the midline to complete the bone cut between the central incisors for a distance of 10 mm above the crest of the interdental ridge. In most cases, there is some indication of a suture line between the centrals. Placing a chisel in this line (or where you would imagine this line to be, if it does not exist) and carrying the osteotomy above the level of the teeth is both safe and easy. This should reduce the chance of direct injury to teeth about which the authors’ expressed concern. In reviewing the literature, it appears that earlier reports (in the 1970s) indicate a higher incidence of pulpal and periodontal complications than more recent investigations. Perhaps we have identified approaches that diminish the incidence of these complications. Using a flexible chisel for interdental osteotomies, requiring that there is adequate space between tooth roots before surgery, being careful not to damage the palatal soft tissue, designing splints that do not impinge on soft tissue, performing model surgery that depicts reasonable movement of segments, and planning procedures that do not exceed the physiologic or mechanical limits of the tissues are all things that may reduce the incidence of pulpal and periodontal complications. It is true that even with good planning and careful execution, vascular compromise may occur. However, it is infrequent that major vascular compromise leads to the loss of teeth or supporting bone. This and other articles show that it is also infrequent that more subtle complications, such as loss of alveolar crest, pulpal degeneration, or loss of the level of gingival attachment are a problem. One can express concern about the parameters that were chosen or the methods of measurement or about the existence or appropriateness of the controls but, at this point, it is reasonable to say that midline osteotomies performed con-
530 comitantly with Le Fort I procedures are safe procedures in relation to periodontal and pulpal health. It is also likely, but less well supported, that this is true for other segmental procedures, ie, between the premolars and canines. Despite the relative safety of these procedures, the article on aseptic necrosis by Lanigan et al3 should keep us mindful of the fact that significant complications can occur and that the decision to perform segmental surgery should be associated with a reasonable level of benefit.
DISCUSSION
References 1. Carroll WJ, Haug RH, Bissada NF, et al: The effects of the Le Fort I osteotomy on the periodontium. J Oral Maxillofac Surg 50:128,
1992 2. Krekmanov L, Kahnberg K-E: the maxilla. J Craniomaxillofac 3. Lanigan DT, Hey JH, West maxillary osteotomies: Report 48:142, 1990
Transverse surgical correction of Surg 18:332, 1990 RA: Aseptic necrosis following of 36 cases. J Oral Maxillofac Surg
JEROLD S. GOLDBERG 23. Lindhe J: Textbook Clinical Periodonthology (ed 2). Copenhagen, Denmark, Munksgaard, 1989, p 317 24. Popp TW, Artun J, Linge L: Pulpal response to orthodontic tooth movements in adolescents: A radiographic study. Am J Orthod Dentofac Orthop 101:228, 1992 25. Ramsay DS, Artun J, Bloomquist D: Orthognathic surgery and pulpal blood flow. J Oral Maxillofac Surg 49:564, 1991
J Oral Maxiliofac
57529-530,
26. Shehab Al-Din OF, Coghlan KM, Magemris P: Sensory nerve disturbance following Le Fort I osteotomy. Int J Oral Maxillofac Surg 25:13, 1996 27. Kahnberg K-E, Engstrijm H: Recovery of maxillary sinus and tooth sensibility after Le Fort I osteotomy. Br J Oral Maxlllofac Surg 25:68, 1987
Surg
1999
Discussion Periodontal and Pulpal Condition of the Central Incisors After Midline Osteotomy of the Maxilla Jet-old S. Goldberg, DDS Dean, School of Dentistry, Professor of Oral & Maxillofacial Surgery, Case Western Reserve University( Cleveland, Ohio; e-mail: [email protected]
This article, which looks at periodontal and pulpal health after a segmental, midline osteotomy, is one of several publications on this or related subjects that are referenced by the authors. The various articles tend to use different parameters of pulpal or gingival health and often measures of those parameters are carried out in different ways or with different devices. It is unfortunate that none of the published research is an attempt to reproduce a previously done experiment at a different center. Be that as it may, this study successfully supports the notion that segmental osteotomies that are performed concomitantly with Le Fort I osteotomies rarely have clinically significant detrimental effects on either the pulpal or periodontal tissues. These positive results are true throughout the dental arch as well as specifically at the interdental osteotomy site. Concerning root resorption, it would have been helpful for this study to have a control group of orthodontically treated patients who did not have surgery with which to compare results. The article by Carroll et al, cited in this article, is an example of a similar report that falls short of presenting data that is reproducible.’ It investigated the parameters of plaque index, gingival index, tooth mobility, width of keratinized tissue, probing depth, and gingival recession. The experimental group had segmental orthognathic surgery and was compared with a control group of patients who had orthodontic treatment without surgery. This investigation looked at patients having osteotomies between the premolars and canines as well as between the central incisors. The only statistically significant findings were in the probing depths of the teeth adjacent to the osteotomies between the canines and the premolars and in the width of the keratinized tissue. However, no probing depths at the osteotomy sites exceeded 3 mm so that the statistically significant finding is of no clinical concern. The greater width of attached gingiva in the experimental group is probably related to the high incidence of vertical maxillary excess in the experimental population.
In addition to the main topic of this article, the authors support a technique using multiple palatal osteotomies to depress and widen the maxillary vault. In the original article, by Krekmanov and Kahnberg, describing this technique there is little to support its use over one or two parasagittal osteotomies.2 Krekmanov and Kahnberg reported horizontal relapse and soft tissue lacerations. It would be interesting to know what additional information there is to support this approach. The concept is interesting, but I do not know if the additional osteotomies really make a difference. The authors also describe using a chisel in the midline to complete the bone cut between the central incisors for a distance of 10 mm above the crest of the interdental ridge. In most cases, there is some indication of a suture line between the centrals. Placing a chisel in this line (or where you would imagine this line to be, if it does not exist) and carrying the osteotomy above the level of the teeth is both safe and easy. This should reduce the chance of direct injury to teeth about which the authors’ expressed concern. In reviewing the literature, it appears that earlier reports (in the 1970s) indicate a higher incidence of pulpal and periodontal complications than more recent investigations. Perhaps we have identified approaches that diminish the incidence of these complications. Using a flexible chisel for interdental osteotomies, requiring that there is adequate space between tooth roots before surgery, being careful not to damage the palatal soft tissue, designing splints that do not impinge on soft tissue, performing model surgery that depicts reasonable movement of segments, and planning procedures that do not exceed the physiologic or mechanical limits of the tissues are all things that may reduce the incidence of pulpal and periodontal complications. It is true that even with good planning and careful execution, vascular compromise may occur. However, it is infrequent that major vascular compromise leads to the loss of teeth or supporting bone. This and other articles show that it is also infrequent that more subtle complications, such as loss of alveolar crest, pulpal degeneration, or loss of the level of gingival attachment are a problem. One can express concern about the parameters that were chosen or the methods of measurement or about the existence or appropriateness of the controls but, at this point, it is reasonable to say that midline osteotomies performed con-
530 comitantly with Le Fort I procedures are safe procedures in relation to periodontal and pulpal health. It is also likely, but less well supported, that this is true for other segmental procedures, ie, between the premolars and canines. Despite the relative safety of these procedures, the article on aseptic necrosis by Lanigan et al3 should keep us mindful of the fact that significant complications can occur and that the decision to perform segmental surgery should be associated with a reasonable level of benefit.
DISCUSSION
References 1. Carroll WJ, Haug RH, Bissada NF, et al: The effects of the Le Fort I osteotomy on the periodontium. J Oral Maxillofac Surg 50:128,
1992 2. Krekmanov L, Kahnberg K-E: the maxilla. J Craniomaxillofac 3. Lanigan DT, Hey JH, West maxillary osteotomies: Report 48:142, 1990
Transverse surgical correction of Surg 18:332, 1990 RA: Aseptic necrosis following of 36 cases. J Oral Maxillofac Surg