A new modified bone grafting technique for periodontally accelerated osteogenic orthodontics

Abstract

The aim of this study was to introduce an improved surgical technique using a pouch design and tension-free wound closure for periodontally accelerated osteogenic orthodontics (PAOO) in the anterior alveolar region of the mandible.Patients with bone dehiscence and fenestrations on the buccal surfaces of the anterior mandible region underwent the modified PAOO technique (using a pouch design and tension-free closure). Postoperative symptoms were evaluated at 1 and 2 weeks intervals following the procedure. Probing depth (PD), gingival recession depth (GRD), and clinical attachment level (CAL) were assessed at the gingival recession sites at baseline, postoperative 6 and 12 months. Cone-beam computerized tomography (CBCT) was used for quantitative radiographic analyses at baseline, 1 week and 12 months after bone-augmentation procedure.The sample was composed of a total of 12 patients (2 males and 10 females; mean age, 21.9 years) with 72 teeth showing dehiscence/fenestrations and 17 sites presenting with gingival recessions. Clinical evaluations revealed a statistically significant reduction in swelling, pain, and clinical appearance from postoperative week 1 to week 2 (P < .05). Moreover, gingival recession sites exhibited a significant reduction in the GRD and an increase in CAL after surgery with mean root coverage of 69.8% at the end of observation period (P < .01). Both alveolar bone height and width increased after surgery (P < .01) and decreased during the 12-month follow-up (P < .01). However, compared with the baseline records, there was still a significant increase in alveolar bone volume (P < .01).This modified PAOO technique may have advantages in terms of soft and hard tissue augmentation, facilitating extensive bone augmentation and allowing the simultaneous correction of vertical and horizontal defects in the labial aspect of the mandibular anterior area.

Figure 1

The modified periodontally accelerated osteogenic orthodontics (PAOO) augmented corticotomy in the lower anterior alveolar region. (A) Full-thickness mucoperiosteal flap reflection. Black circles and arrows show root fenestrations and dehiscences, respectively; (B) performing circumferential corticotomy cuts and periosteal releasing incision at the bottom as a black line shown; (C) placing grafting materials along the cemento-enamel junction (CEJ) at the coronal aspect (wavy line); (D) suturing two barrier membranes together; (E) a well-defined pouch created by suture fixation (black circles)of membranes to the surrounding periosteum apically and laterally; (F) black box shows membrane exposure after flap repositioning. CEJ = the cemento-enamel junction, PAOO = periodontally accelerated osteogenic orthodontics.

Figure 2

Schematic diagram of modified PAOO. Suture fixation of membranes to the “apical” segment of the periosteal layer elevating from the mucoperiosteal flap by periosteum-releasing incision. PAOO = periodontally accelerated osteogenic orthodontics.

Figure 3

Schematic diagram of radiographic assessments. VBL, buccal vertical bone level, that is, distance between the labial aspect of the CEJ and the most coronal level of the alveolar bone at the labial cortical surface; CHBT, MHBT, and AHBT, buccal horizontal bone thickness at the middle level of the coronal, middle and apical thirds. AHBT = horizontal bone thickness at the middle level of the apical third, BL = baseline, CHBT = horizontal bone thickness at the middle level of the coronal third, MHBT = horizontal bone thickness at the middle level of the middle third, VBL = vertical alveolar bone level.

Figure 4

Buccal gingival recession in the lower alveolar region at baseline as black arrows shown (A) and effective root coverage during 6-month (B) and 12-month follow ups (C), respectively.

Figure 5

Cone-beam computed tomography images and image-based 3-dimensional reconstruction. Bone defect on the labial cortical bone at baseline (A, D) and increased alveolar volume during 6-month (B, E) and 12-month follow ups (C, F), respectively.

Figure 6

Longitudinal registration of the lower anterior alveolar region of a patient treated with modified PAOO. Closest point surface distances colour-coded maps showing obvious alveolar augmentation 1 week after surgery and marked resorption after 12-month follow-up. (A) 1 week postsurgery vs baseline; (B) 12 months vs 1 week after surgery; (C) 12 months postsurgery vs baseline. PAOO = periodontally accelerated osteogenic orthodontics.