234

Effects

the Periodontium Following

Corticotomy-Facilitated Orthodontics.
Case Reports*

Bemard Gantes,

on

Eugene Rathbun,

and

Milford Anholm

This report describes the corticotomy surgical technique used in conjunction with
orthodontic therapy and its effect on the periodontal status of the involved teeth. The
surgical procedure included intracrevicular incisions and elevation of buccal and lingual
mucoperiosteal flaps. Buccal and lingual vertical grooves penetrating the cortical bone
were then made between the roots. These grooves were extended from just below the
interproximal alveolar bone margin to beyond the apex levels of the teeth. Buccal and
lingual horizontal grooves joined the apical extensions of the vertical grooves. The orthodontic appliance was activated immediately upon wound closure. Plaque scores, probing depths, and probing attachment levels were recorded before the surgical procedure
and after the completion of the orthodontic treatment in 5 patients. The results showed
that the corticotomy procedure caused minimal changes in the periodontal attachment
apparatus. J Periodontol 1990;61:234-238.

Key Words: Flap surgery; corticotomy; orthodontics/corrective; alveolar process/surgery

Reduction of orthodontic therapy treatment time is considered an important goal in the management of malocclusions
in the adult patient.
Corticotomy-facilitated orthodontic treatment may be
considered an intermediate therapy between Orthognathie
surgery and conventional orthodontics. It has been found
useful in reducing treatment time and allowing for conventional orthodontic measures treating adult patients with severe malocclusion. This treatment consists of a surgical
procedure followed by immediate application of orthodontic
forces heavier than usually used. A technique was first described by Kole1 and included partial removal of the cortical
layer of the alveolar bone. This technique has significantly
shortened the orthodontic treatment time and has eliminated
the risk of necrosis of the bone and the dental pulps. Recently, successful correction of severe adult malocculsion
was reported in several patients treated with the corticotomy

procedure.2

surgical procedure includes elevation of full-thickflaps and subsequent exposure of the crestal bone of
the teeth with healthy periodontium. It has been reported
that healthy sites with shallow gingival sulcus may lose
approximately 0.5 mm of clinical attachment subsequent to
surgical therapy.3"5 Therefore, the purpose of this report
The

ness

"Lorna Linda

University, School

of

Dentistry,

Loma Linda, Ca.

was to

follow the

this combined

periodontal status of teeth

surgical-orthodontic treatment.

involved in

MATERIALS AND METHODS

Subjects
Five adult patients, 21 to 32 years old, were included in
the study. The surgical procedure was described to the patients. They were informed of the risks related to any form
of major oral surgery and possible after effects including,
but not limited to, permanent deformities of the jaws and
supporting structures of the teeth. Other forms of orthodontic treatment were also explained and discussed, including no treatment. The patients consented to the
corticotomy-facilitated orthodontic treatment, which was an
orthodontic research project approved by the Institutional
Human Research Committee.
The patients exhibited different orthodontic problems,
including Angle Class II division 1 and 2 malocclusions
(Table 1). Prior to surgical and orthodontic treatment, the
patients were brought to periodontal health by means of
plaque control, and scaling and root planing as needed. In
addition, crown polishing was performed prior to the placement of orthodontic brackets and bands. The plaque'control
efforts were monitored monthly during the treatment period. An age-matched group of adult patients with similar
orthodontic problems was treated simultaneously without

Volume 61
Number 4

PERIODONTAL EFFECTS OF CORTICOTOMY

Table 1: Initial Diagnosis and Total Duration

Corticotomic Treatment, per Subject

Treatment Duration
With
Without

Treated

Subject
1

Diagnosis*
Brachyfacial;
Initial

Class II div 2
2

Brachyfacial;
Class I (crowding)

Brachyfacial;

Class II div 1

Brachyfacial;

brachyfacial
tendency;
Class II div I
Mean

S.D.
*

(full)

Class II div 1
Mesiofacial with

(Months) of the

(full)

Corticotomy
20

(17)

Corticotomy
24

235

Clinical Parameters
The following parameters were recorded: plaque scores (PS),
probing pocket depths (PPD), and probing attachment levels (PAL). Clinical photographs were taken during the treatment. The measurements were repeated throughout the
treatment (Table 2). All measurements were made by the
same examiner.

11

28

12

35

16

26

14.8
4.1

28.3
4.8

Angle classification.

t No matching control.
X Case presented partially in Figures 1 and 3.

surgery, using conventional fixed appliances and served as

a control group for the orthodontic study. This report does
not include the periodontal status of this control group.

Surgical Procedures
Orthodontic appliances were placed on the teeth prior to
surgery (Figs. l.A and l.B). The surgical procedures were
performed under local anesthesia and conscious intravenous
sedation. Buccal and lingual vertical incisions were then
extended from the gingival margin towards a level apical
to the apices of the teeth. These incisions were made distal
to the most posterior tooth included in the corticotomy procedure. The vertical incisions were connected by buccal and
lingual intracrevicular incisions. Mucoperiosteal flaps were
then reflected beyond the level of the apices of the teeth.
The remaining interdental tissue was preserved. Vertical
buccal and lingual grooves were then made through the
cortical layer of the exposed bone with a fissure bur (#556)
mounted in a high speed handpiece, starting 1.5 mm below
the interdental crest. A horizontal groove penetrating the
cortical bone connected all vertical grooves 2 mm to 3 mm
apical to the apices of the teeth (Figs. l.C and l.D). The
horizontal grooves were made by a round bur #4. The teeth
which had been planned for extraction were removed at this
time. The buccal and lingual cortical bone was removed
over the extraction sites (Fig. l.D). The surgical sites were
vigorously irrigated with saline prior to flap repositioning
and suturing using a vertical double mattress technique.
Dexamethasone was injected intravenously in order to reduce post-operative edema. Prophylatic antibiotics were
prescribed for 1 week (Penicillin V Potassium 500 mg.
every 6 hours). Orthodontic appliances were activated immediately after completion of the surgical procedures. The
nature and result of the orthodontic treatment will be described elsewhere.

Plaque Scores: 6 aspects of each tooth were examined:

mesiobuccal, midbuccal, distobuccal, mesiolingual, midlingual, and distolingual. Plaque was disclosed with an ery-

throsine dye.+ Areas adjacent to the gingival margin which

exhibited a deep stain that could be easily removed with
the side of a probe were scored. Plaque scores were expressed as the % of the total number of surfaces under
evaluation which revealed presence of plaque. Full-mouth
plaque scores were based upon the 6 aspects of all teeth

present.

Probing Pocket Depth

and Probing Attachment Levels:

Measurements of probing pocket depth and probing attachment levels were made using an electronic pressure sensitive probe.* A probe tip having 1 mm increments and 0.5
mm in diameter5 and a standardized force of 0.50
was
used. Recordings to the nearest 0.5 mm were made from
the mesiobuccal, midbuccal, distobuccal, mesiolingual,
midlingual, and distolingual sites of each experimental tooth.
A vacuum adapted soft acrylic onlay11 was used to provide
reference points for the probing measurements.6 Pocket depth
was measured from the gingival margin to the bottom of
the pocket. Probing attachment level was recorded from the
margin of the onlay to the bottom of the pocket. The onlays
were sectioned after completion of the orthodontic treatment procedures. The sectioned onlay was then fitted separtely on each tooth. Descriptive data analysis will compare
preoperative and posttreatment measurements. The data will
be analyzed by subject, by tooth type, by surface type, and
pooled sites.

RESULTS
Clinical healing

generally uneventful. However, one

patient (subject #2) experienced subcutaneous hematomas
of the face and the neck. All patients reported that discomfort levels during and after the surgery were much less than
expected. All teeth stayed vital after the surgical procedures.
Preoperative and post-treatment periapical radiographs are
presented in Figures 2.A and 2.B. The presence of apical
root rsorption was noticed after the orthodontic treatment.
Table 1 shows the initial diagnosis and the total duration
was

Lorvic Co., St. Louis, MO.

Electronic Periodontal Probe, Model 200, Vine
dlesex, NY.
LL20, Hu-Friedy, Chicago, IL.
Scheu-Dental, Iserlohn, West Germany.

Trace,

Valley Research, Mid-

236

GANTES, RATHBUN, ANHOLM

J Periodontol
April 1990

. Preoperative view, buccal aspect; B: Preoperative view, palatal aspect; C: After flap elevation the grooves are performed
the buccal cortical bone (see arrows); D: Same on palatal cortical bone, note the extraction site with the cortical plate removed;
E; One week post-surgically after removal of the sutures; F: One month later; G: Seven months later; H: Posttreatment, 16 months.

Figure 1
on

Volume 61
Number 4

PERIODONTAL EFFECTS OF CORTICOTOMY

Table 2: Schedule of Treatment and Measurements

Time Frame

Table 4: Means and Standard Deviations of Probing Pocket

and Attachment Level Changes (Patient Means)

Treatment

Patient

selection, oral hygiene instruction (OHI), sealing, root planing, and crown polishing
Preopcrative measurements: PS, PPD, PAL, photos,
surgery, photos
Removal of sutures and postop treatment, photos

Prior
to treatment

0 week
1 week
2 weeks
1 month
3 months
6 months
X months

PS
PS
PS
PS
Orthodontic treatment completed

Subject
1
2

3
4
5

PS, PPD, PAL, photos

Mean
S.D.
*

in

Initial

PPD*
Final

237

Depth
PAL*

2.0

-0.3
-0.2
0
-0.4
-0.2

Difference
0
0
-0.3
+ 0.1
0

2.2
0.2

-0.2
0.2

-0.1
0.2

2.7
2.3
2.3
2.6
2.2

2.4
2.1
2.3
2.2

2.4

0.2

Difference

mm.

Table S: Means and Standard Deviations of Probing Pocket Depth

and Attachment Level Changes per Tooth Type (Tooth Means)

PAL*

PPD*

Initial

Type
Maxillary incisors

Tooth

Mandibular incisors

Maxillary cuspids
Mandibular cuspids
Maxillary bicuspids
Mandibular bicuspids
Mean
S.D.

Difference

Difference

-0.2
-0.4
+0.1
-0.1
0

2.7

Final
2.1
2.0
2.4
2.3
2.6
2.3

-0.4

-0.1
+0.2
-0.4
+0.1
-0.2
-0.1

2.4
0.1

2.3
0.2

-0.2
0.2

-0.1
0.2

2.3
2.4
2.3
2.4

2.6

Table 6: Means and Standard Deviations of Probing Pocket Depth

and Attachment Level Changes per Surfaces (Surface Means)

Figure 2 A: Preoperative radiographs;

Bv Post treatment

radiographs.
Surfaces

Table 3: Mean-Full Mouth

Standard Deviation

0
week
Mean %
S.D.

27
16

2
weeks
28
13

Plaque Scores (Patient Mean)

4
weeks
27
28

3
months
13
10

6
months

Post
orthodontic
treatment

1.5
1.9
2.5

-0.4
-0.1

+ 0.1

Proximal

1.9
2.0
2.7

-0.2

-0.1

Mean
S.D.

2.2
0.4

2.0
0.5

-0.2
0.2

+ 0.1

mean

plaque

scores

+ 0.2

0.1

reduced by 0.2 mm. Patient #3 experienced 0.3 mm

mean attachment loss.
Table 5 presents the mean and standard deviation of initial and final probing pocket depths and attachment level
changes per tooth type. The mean pocket depth changes
ranged from +0.1 to -0.4 mm. The maxillary cuspids
showed a mean attachment loss of 0.4 mm. The other teeth
showed mean attachment change of 0.2 mm or less.
Table 6 presents the mean and standard deviation of initial and final probing pocket depths and attachment level
changes per tooth surface. The mean pocket reduction was
0.4 mm for the buccal surfaces. The lingual and proximal
surfaces had fewer changes. The mean attachment level
changes were less or equal to 0.2 mm.
Figure 3 shows the frequency of sites with loss or gain
of probing attachment; 88% of the sites had an attachment
level which stayed within 1 mm of the original value.

was

Table 3 shows the

PAL*
Difference

14
14

of the orthodontic treatments for both experimental and

control groups. The mean treatment time was 14.8 months
for the experimental group and 28.3 months for the control
group. The treatment time of patient #2 was not used in
the mean calculation because his matching control was not
identified. Figures l.E through l.H show the postsurgical
orthodontic phases. Note that after 7 months most of the
orthodontic movement of the canine had been accomplished

(Fig. l.G).

Difference

Lingual

Buccal

and

Initial

PPD*
Final

throughout

the

experimental period. The mean full mouth plaque scores

were 27% prior to surgery, remained unchanged for 1 month,
then decreased throughout the observation period.
Table 4 presents the mean and standard deviation of initial and final probing pocket depths and attachment level
changes for the 5 subjects. The total mean pocket depth

of

238

J Periodontol

GANTES, RATHBUN, ANHOLM

April 1990
These short-term

importance.8

TOTAL NUMBER OF SITES

435
=

changes

seem

to be of

no

clinical

The observation of the post-operative periapical radiographs revealed that apical root rsorption took place during
the treatment. However, this type of phenomenon can be
observed after non-surgical orthodontic treatment also.
The treatment time was reduced by approximately 50%.
Furthermore, during the orthodontic treatment, due to the
increased appliance complexity and the frequency of patient

visits, the total chair time for these patients was estimated

-3

-2

Figure 3: Histogram offrequency of attachment level changes.

DISCUSSION
The results obtained in this study should be interpreted with
care, as initial recordings were taken after the placement of
brackets and bands while the final recordings were taken
with no appliances on the teeth, after completion of the
orthodontic treatment. The plaque scores were initially high.
After the placement of the orthodontic appliance, the patients experienced some difficulties in reaching optimal plaque
scores. This had a definite influence on the bleeding scores
which were meaningless and, therefore, not presented. The
data on the pocket depth and attachment changes demonstrate that the surgical procedure was not excessively damaging to the periodontal tissues. Gingival recession was
minimal and the interdental papillae were preserved, insuring a good post-treatment esthetic result. The vertical mattress suturing technique as well as the attempt to preserve
the interproximal soft tissue during the surgery seem to be
successful in retaining the papilla architecture (Fig. l.E).
Longitudinal studies have shown that shallow sites lose
approximately 0.5 mm of probing attachment after periodontal surgery.3 In our study, we could not observe any
attachment loss of clinical significance. Possible explanations for this difference could be that initial pocket depth
and attachment measurements were recorded with the orthodontic appliances on the teeth and that the final recordings were taken without the orthodontic appliances in place.
Furthermore, we had to cut the onlays after the orthodontic
movements of the teeth in order to get the final recordings.
In addition, the orthodontic treatment had improved the
clinical attachment of some teeth which were out of aligment prior to the treatment. This has possibly influenced
the mean values.
The osteotomy restricted to the cortical bone layer minimized the injury of the vital structures. Kole1 showed the
importance of preserving an intact spongiosa using this
technique, while a total alveolar osteotomy may impair the
intraosseous and intrapulpal blood circulation.7
Rapid orthodontic treatment using heavy forces in combination with corticotomy does not affect tooth vitality but
induces histological changes in the periodontal ligament.

to be

approximately the same as for conventional orthodontic treatment.

Considering the surgical access of the bony structures,
this procedure was designed primarily for anterior teeth
movement. However, it may be possible to apply this technique to posterior segments as well when anatomical considerations permit.
This procedure should be avoided on patients having any
form of periodontal pathology or deformity including gingival recessions, teeth having buccal or lingual bony dehiscences, and teeth with reduced periodontium. Before such
treatment, we advise the surgeon to review carefully the
health history of the patient, request the routine laboratory
analysis, and examine a complete set of radiographs in order to pinpoint and, therefore, to foresee any anatomical
obstacle for the surgical procedure. Risks and possible after
effects should be explained and discussed with the patient.
In conclusion, in these 5 cases, the corticotomy procedure reduced the orthodontic treatment time. The descriptive statistics of these 5 cases indicate that no periodontal
adverse effects were clinically noticeable. The increasing
number of adults seeking correction of teeth and jaw malpositions may be a group of patients for this procedure.
Acknowledgment

The authors wish to thank Dr. Hajime

tions in the corticotomy technique.

Suya for his instruc-

REFERENCES
1. Kole H. Surgical operations on the alveolar ridge
abnormalities. Oral Surg 1959; 12:277.

to correct

occlusal

2. Anholm M. Corticotomy facilitated orthodontics. Calif Dent Assoc J

December 1986:7.
3. Kohler CA, Ramfjord SP. Healing of gingival mucoperiosteal flaps.
Oral Surg Oral Med Oral Path 1960; 13:89.
4. Persson P. The regeneration of the marginal periodontium after flap
operation. Acta Odont Scand 1962; 20:43.
5. Chamberlain AD, Garrett S, Renvert S, Egclberg J. Healing after treatment of periodontal intraosseous defects. IV. Effect of a non-rcsective
versus a partially resective approach. / Clin Periodontol 1985; 12:525.
6. Badersten A, Nilveus R, Egelbcrg J. Effect of nonsurgical therapy. II.
Severely advanced Periodontitis. J Clin Periodontol 1984; 11:63.
7. Bell W. Revascularization and bone healing after maxillary osteotomy.
/ Oral Surgery 27:249, 1969.
8. Duker J. Experimental animal research into segmental alveolar movement after corticotomy. J Maxillofac Surg 1975; 3:81.

Send reprint requests to: Dr. Bernard Gantes, Graduate Periodontics,

School of Dentistry, Loma Linda University, Loma Linda CA 92350.