Periodontal disease associated with interdental osteotomies after orthognathic surgery

LARRY

417

M. WOLFORD

References 1. &tad S, Zachrisson BU: Longitudinal study of periodontal condition associated with orthodontic treatment in adolescents. Am J Orthodont 761277, 1979 2. Bien SM: Difficulties and failures in tooth movement: Biophysical response of mechanotherapy. Trans Eur Orthodont Sot 55:31, 1967 B: Orthodontic forces and recurrence of 3. Ericsson I, Thilander periodontal disease. Am J Orthodont 74:41, 1978 4. Hamp SE, Lundstrijm F, Nyman S: Periodontal conditions in adolescents subjected to multiband orthodontic treatment with controlled oral hygiene. Eur J Orthodont 4:77, 1982 5. Harry MR, Sims MR: Root resorption in bicuspid intrusion: A scanning electron microscope study. Angle Orthodont 52:235, 1982 6. Hirschfelder U: Nachuntersuchung zur Reaktion des marginalen und apikalen Parodontiums unter kontinuierlicher Kraftapplikation. Fortschr Kieferorth 51:82, 1990 Untersuchungen fiber das destruk7. Jonas J: Histomorphologische tive und restitutive Verhalten des Ligamentum parodontale unter kieferorthopBdischen Zahnbewegungen. Fortschr Kieferorthop 39:398,1978 8. KIoehn JS, Pfeiffer JS: The effect of orthodontic treatment on the periodontium. Angle Orthodont 44:127, 1974 in upper and anterior 9. Linge BO, Linge L: Apical root resorption teeth. Eur J Orthodont 5:173, 1983 10. Rateitschak KH, Herzog-Specht FA: Reaktion und Regeneration des Parodonts auf orthodontische Behandlung mit festsitzenden Apparaten. Schweiz Mschr Zahnheilk 75:741,1965 bodily tooth movement and its histologi11 Reitan K: Continuous cal significance. Acta Odont stand 6: 115, 1947 12 Reitan K: Some factors determining the evaluation of forces in orthodontics. Am J Orthodont 43:32, 1957 WM: Faciolingual tooth movement: Influence on 13 Wainwright the root and cortical plate. Am J Orthodont 65:278, 1973

J Oral Maxillofac 56417-419,

14. Wehrbein H, Dietrich P: Parodontale Verxndenmgen nach orthopsdischer Zahnbewegung-eine retrospektive histologische Studie am Menschen. Forts& Kieferorthop 53:167, 1992 BU, Alnaes L: Periodontal condition in orthodonti15. Zachrisson tally treated and untreated individuals. I. Loss of attachment gingival pocket depth and clinical crown height. Angle Orthodont 43:43, 1973 16. Zachrisson BU, AInaes L: Periodontal condition in orthodontitally treated and untreated individuals. II. Alveolar bone loss: Radiographic findings. Angle Orthodont 44:48, 1974 R: Histologische Pulpenuntersuchungen an 17. Zisser G, Gattinger den maxillgren und mandibulsren AlveolarfortsBtzen. Dtsch Mund Kiefer Gesichtschir 1:36, 1977 E: SpPtergebnisse nach Korrekturen von Dysgnathie 18. Madritsch und Zahnstelhmgsanomalien durch Alveolarfortsatzbewegungen mit Kortikotomie. Med Diss, Ziirich, 1968 nach alveoltien Osteotomien. 19. Morgen U: Nachuntersuchungen Med Diss, Erlangen, 1981 20. Steinhiuser E, Rudzkiganson I: Kieferorthopidische Chirurgie; eine interdisziplinire Aufgabe. Berlin, Germany, Quintessenz Verlag GmbH, 1994 21. Kale H: Surgical operations on the alveolar ridge to correct occlusal abnormalities. Oral Surg Oral Med Oral Path01 12:277, 1959 22. Newman WG: Possible aetiologic factors in external root resorption. Am J Orthodont 67~522, 1975 principles and reactions, in Graber 23. Reitan K: Biomechanical TM, Swain BF (eds): Orthodontics, Current Principles and Techniques 13. St Louis, MO, Mosby, 1988 24. Micheelis W, Bauch J: Mundgesundheitszustand un+verhalten in der BundesrepubIik Deutschland. Deutscher Arzteverlag K6In, Institut der Deutschen Zahnarzte (IDZ), 1991, pp 216, 207, 220, a,b,c,d,e 25. Hohlfeld M, Bernimoulin JP: Teilergebnisse einer epidemiologischen Untersuchung des Parodontalzustandes bei 45-54 j&igen Berliner Probanden. Dtsch Zahniiatl 2 41:616,1986

Surg 1998

Discussion Periodontal Disease Associated With Interdental Osteotomies After Orthognathic Surgery Larry

M. Wolford,

Clinical University at Baylor

Professor of Oral and Maxillofacial Surgery, Texas A &M System-Baylor College of Dentistry; Private Practice University Medical Center, Dallas, Texas

DDS

These authors are to be commended on their article showing the significant periodontal problems that can occur in association with interdental osteotomies. In their study, Schultes et al studied 30 patients (only 10 patients had orthodontic treatment), assessing 74 interdental osteotomy sites and finding 51 sites with pathologic periodontal conditions.

Thirty-two

cent to the osteotomy

teeth

(22%)

were

lost

directly

adja-

sites, and 47.5% of the remaining

adjacent teeth had profound periodontosis. Only 6.7% of the osteotomy sites showed no periodontal pathologic condition. This extremely high rate of periodontal complications raises numerous questions in reference to case selection, surgical technique, and other salient factors known to contribute to unfavorable periodontal outcomes. In 1971, Kent and Hinds’ evaluated 30 maxillary osteotomies and associated complications, including the effects on the periodontium. They suggested that flap design and approximation of the segments were the most important factors affecting postoperative periodontal pocket formation and subsequently the development of periodontal disease. In their retrospective radiographic evaluation of 45 interdental osteotomies, 1 to 5 mm of bone loss was noted 1 year after surgery. Burke, et al,2 in 1977, reported interdental papillae destruction and periodontal pocket formation when labial stripping was followed by cortical osteotomies extending through the crestal ridge. They reported minimal

418

DISCUSSION

osseous and periodontal changes with careful surgical technique and terminating the surgical cuts 3 mm from the crestal ridge. Several published studies show relatively infrequent periodontal complications associated with interdental osteotomies. Using periodontal sounding measurements, Dorfman and Turveys found no significant interdental bone loss in 22 interdental osteotomy sites in 10 patients after maxillary segmental surgery, providing there was adequate spacing between the roots of the adjacent teeth. Two of the patients had significant bone loss, but the osteotomies were placed between closely approximated tooth roots. Shepard* reported a 5- to p-year follow-up study on 13 patients who underwent segmental alveolar surgery and found a very low incidence of periodontal pocketing, nonvital teeth, and tooth mobility. In 34 osteotomies sites in 17 patients, Kwon et al5 found clinically insignificant loss of bone and attached gingiva. They concluded that there were “minimal” longterm effects on the periodontal condition. We recently published a prospective study that clinically and radiographically evaluated the effects of 40 interdental osteotomies in the maxilla and mandible.G No statistically significant changes were noted in any of the clinical parameters, except that the attached gingival height was decreased slightly in the maxilla and increased in the mandible. These changes were not clinically significant and may have been affected by the direction of movement of the bony segments. Radiographic evaluation showed no statistically significant changes other than an increase in interdental width in both the maxillary and mandibular osteotomy sites. These measurements were made at the root level and, although the crowns were moved closer in most cases, the roots were actually flared apart because of anterior segment tipping to upright the incisors. Crestal bone height changed less than 5%. Carroll et al7 studied two age-matched populations of 40 patients each, with one group having orthodontic therapy only and the second group having orthodontic therapy and orthognathic surgery. No significant difference in periodontal status were noted 1 to 10 years posttreatment. With the refinement of surgical technique, a number of these studies”-’ showed clinically insignificant periodontal changes with interdental osteotomies. These studies, when compared with the Schultes et al report, raise a number of important issues as to the reason for the untoward periodontal outcomes experienced by these authors.

Patient

Selection

No information was available on the patients studied relative to preexisting periodontal conditions or oral hygiene. If active periodontal disease was present presurgery, then it could be expected to worsen, particularly with any compromise of the blood supply to the segments, or traumatic surgical technique. Also, no information was given in reference to the following factors that can affect periodontal outcomes: smoking, consumption of alcohol or caffeine, habitual patterns such as bruxism and clenching, preexisting connective tissue/autoimmune conditions, diabetes, malnutrition, or other diseases that could affect local tissue perfusion and healing. The fact that 22% of the patients had deep periodontal pockets away from the interdental osteotomy sites suggest that a significant portion of this group may have had advanced periodontal disease before surgery or significant vascular compromise to the segments that occurred as a result of surgery.

Presurgical

Orthodontics

Presurgical orthodontics were performed in only 10 of the 30 patients. Seven of those 10 patients showed root resorption that was attributed to the orthodontic movements because the resorption occurred in the anterior teeth away from the osteotomy sites. It appears that the orthodontic forces used in these patients was greater than the physiologic tolerance of the alveolar bone, periodontal ligaments, and teeth, resulting in root resorption. The orthodontic forces and movements generated could have exacerbated the periodontal condition. Two thirds of the patients in this study had no orthodontics, and, therefore, root alignment and the spatial changes between the segments may have played a significant role in the poor outcomes. Creating adequate space between the roots by orthodontic means before surgery can be very helpful in facilitating successful outcomes of interdental osteotomies.

Surgical

Technique

This is probably the biggest area in which problems could have developed. The design of the soft tissue incisions is critical. In our experience and that of others,’ vertical incisions in the area of osteotomy will predictably create periodontal problems. Reflecting the mucoperiostium from the bone around the osteotomy site labially and lingually/ palatally will significantly compromise the blood supply to the interdental bone in the area and thus create significant loss of bone (and possibly teeth) and associated periodontal defects. Maximizing soft tissue attachment to the bone, particularly adjacent to the interdental osteotomy, maximizes the vascular&y to the area and minimizes untoward periodontal changes. The blood supply to the anterior segments in segmental maxillary surgery is primarily through the palatal mucoperiosteum when a circumvestibular incision is used. Therefore, trauma to the palatal mucoperiosteum can cause major vascular compromise to bone, teeth, and soft tissues, creating significant periodontal problems and possible loss of these structures. Tying off the descending palatine vessels can also create significant vascular compromise to the segments. The use of oscillating or reciprocating saw blades or rotary instruments, if not done properly, can cause severe damage by excessive heat generation, removal of excessive amounts of interdental bone, or soft tissue injury, creating a significant vascular compromise to the area. Copious irrigation and careful surgical technique are important to minimize bone overheating and tissue injury. If the roots are hit by a cutting instrument, this can do significant damage and could result not only in periodontal problems, but also the potential for ankylosis of the involved tooth. Cutting through the crestal bone with these instruments also may cause significant vertical loss of bone and periodontal problems. The interdental cuts should stop short of the crestal bone. If osteotomes are used between the teeth to complete the osteotomies, a thick blade may cause damage by compression of the adjacent alveolar bone and root structures. Thin spatula osteotomes work better, creating less pressure on the adjacent bone, but they must be used carefully so as not to damage the mucoperiosteum. If there is inadequate space between the roots to do the osteotomy, then significant periodontal problems will likely occur. The degree to which the segments are repositioned can also increase stress on the periodontiurn and the adjacent teeth, creating vascular compromise to the segments.

419

LARRY M. WOLFOm In Schultes et al’s study, although not described, it is assumed that arch bars or similar types of devices were used to stabilize the jaw segments in the 20 surgery-only patients. In such circumstances the circumdental wires around each tooth would be adjacent to the cervical margin, and the gingival papilla can be strangled and excessive pressure can be placed on the alveolar crestal bone that can cause resorption and periodontal problems. Patients with poor oral hygiene and the presence of arch bars can develop cervical decalcification or caries of the teeth. The longer the arch bars are left in place, the more potential damage to the periodontium and teeth. If space was opened between the repositioned segments, stress on the soft tissues or tearing could have caused the periodontal conditions. Bone gaps created between the alveolar segments without appropriate bone grafting could also lead to periodontal problems.

osteotomy sites, but this may simply be cervical caries related to the use of arch bars, poor dental hygiene, and preexisting periodontal disease.

Conclusion This is an extremely important article because it emphasizes the potential periodontal risks that can occur with interdental osteotomies. However, proper patient selection, establishment of a healthy periodontium pretreatment, appropriate presurgical and postsurgical orthodontics, as well as proper and careful performance of interdental osteotomies, should result in minimal periodontal effect as documented by a number of different authors3-’

References Postoperative

Management

Postoperative traumatic occlusion, teeth clenching and grinding, the use of maxillomandibular fixation or elastic traction, or inappropriate orthodontic mechanics can exacerbate a preexisting or iatrogenic periodontal condition. Excessive segment mobility, lack of interdental bony structure, or lack of bony approximation at the interdental areas could result in nonunion as well as worsening of the periodontal condition. The use of rigid fixation and bone grafting, when indicated, will help minimize these problems. Orthodontic tooth movement into a periodontally diseased area or where interdental bone has been removed will likely result in subsequent loss of teeth and bony structure. The only radiograph shown in this article (Fig 4) shows root “resorption” of the teeth adjacent to the

1. Kent JN, Hinds EC: IManagement of dentofacial deformities by anterior alveolar surgery. J Oral Surg 29:13, 1971 2. Burke JL, Provencher RF, McKean Tw: Small segmental and unitooth ostectomies to correct dentoalveolar deformities. J Oral surg 35:453,1977 3. Dorfman HS, Turvey TA: Alterations in osseous crestal height following interdental osteotomies. J Oral Surg 48:120, 1979 4. Shepard JP: Long-term effects of segmental alveolar osteotomy. Int J Oral Surg 8:327, 1979 5. Kwon H, Pihlstrom B, Waite DE: ECfectson the periodontium of vertical bone cutting for segmental osteotomy. J Oral Maxillofac Surg 43:953, 1985 6. Fox ME, Stephens WF, Wolford LM, et al: Effects of interdental osteotomies on the periodontal and osseous supporting tissues. Int J Adult Orthodont Orthognath 6:39,1991 7. Carroll WJ, Haug RH, Bissada NF, et al: The effects of the Le Fort osteotomy on me periodontium. J Oral Maxillofac Surg 50:128, 1992