case report

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CASE REPORT Orthodontic Movement of Posterior Teeth into a Corticocancellous Bone-Block Allograft Area ANTÔNIO CARLOS DE OLIVEIRA RUELLAS, DDS, MS, PhD AMANDA CARNEIRO DA CUNHA, DDS, MS CAROLINA VIEIRA VALADARES, DDS, MS ANA PAULA TENÓRIO DE SÁ, DDS, MS CARLOS VENTURA DE OLIVEIRA RUELLAS, DDS

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rthodontic treatment of adult patients often involves such complicating factors as periodontal defects associated with a reduced level of attachment.1 Alveolar resorption is progressive and irreparable after tooth loss because the function responsible for maintaining homeostasis of the supporting structures is no longer present.1,2 These periodon-

Dr. Antônio Ruellas

tal defects may present clinically in either the vertical or horizontal direction or in bone volume, but the vertical defects are less predictable in terms of reparative procedures.3 In such a situation, orthodontic movement must be coordinated with corrective periodontal procedures, and orthodontic mechanics must be designed to min-

Dr. Cunha

Dr. Valadares

imize the risk of future bone loss.4,5 Studies have indicated that orthodontic movement into an intraosseous defect has no beneficial effect on tissue attachment.6,7 On the other hand, orthodontic movement into a site where tissue has been repaired makes it possible to gain attachment.8,9 Grafts and guided tissueregeneration techniques can be

Dr. Tenório de Sá

Dr. Carlos Ruellas

Dr. Antônio Ruellas is an Associate Professor and Drs. Cunha and Tenório de Sá are doctoral students, Department of Pedodontics and Orthodontics, Universidade Federal do Rio de Janeiro, Av. Professor Rodolpho Paulo Rocco, 325, llha do Fundão, Rio de Janeiro, RJ 21941-617, Brazil. Dr. Valadares is in the private practice of dentistry in Bairro Suissa, Aracaju, Brazil. Dr. Carlos Ruellas is in the private practice of implant ology and oral rehabilitation in Poços de Caldas, Brazil. E-mail Dr. Antônio Ruellas at [email protected].

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Orthodontic Movement of Posterior Teeth into an Allograft Area

Fig. 1 36-year-old male Class II patient with severe bone defect at upper right first-molar extraction site before treatment (continued on next page). (Panoramic and periapical x-rays show periradicular lesion before extraction of first molar.)

used to reestablish adequate bone volume.1,10,11 Autogenous grafts, which may be obtained from the patient’s own intra- or extraoral sites,12,13 are an option for partially or totally edentulous cases,14 and are considered the gold standard due to their osteogenic, osteoinductive, and osteoconductive properties.15 However, this mo-

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dality requires an additional surgical procedure, which entails a higher cost, greater time commitment, and increased risk to the patient.3 Allografts of tissues obtained from human donors are another viable alternative.16-19 This article describes the treatment of a patient with a severe bone defect using an al-

lograft, which was followed by orthodontic tooth movement into the graft site. Diagnosis and Treatment Planning A healthy 36-year-old male requested orthodontic treatment for cosmetic reasons. Clinical

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Ruellas, Cunha, Valadares, Tenório de Sá, and Ruellas

Fig. 1 (cont.) 36-year-old male Class II patient with severe bone defect at upper right first-molar extraction site before treatment. (Panoramic and periapical x-rays show periradicular lesion before extraction of first molar.)

examination showed a concave profile with a prominent pogonion (Fig. 1). The patient displayed a Class II molar and canine relationship, a deep curve of Spee, an overjet of 2mm, an overbite of 50%, no crowding in the maxillary arch, mild crowding in the mandibular arch, and a severe rotation of the lower left second premolar. Radiographic and cephalometric analyses indicated a Class I skeletal pattern (ANB = 3°) with a horizontal

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growth pattern (GoGnSN = 19°), well-positioned upper incisors (U1-SN = 104.2°), and slightly retroclined lower incisors (L1NB = 22.8°). The main concern in this patient was an osseous defect in a recent extraction site of the upper right first molar, which was removed because a periradicular lesion had persisted even after endodontic treatment and restoration. The defect caused by the lesion could be observed after

extraction due to the loss of buccal and palatal bone. In view of the adequate relationship of the bony bases in the anteroposterior, vertical, and transverse dimensions, the aim of treatment was to correct the dental relationships and achieve adequate function and satisfactory esthetics. The main objectives were to establish a bilateral Class I canine relationship with proper intercuspation, overjet, and overbite; adjust the curve of

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Spee; correct the midline deviation; and recover the bone defect at the extraction site of the upper right first molar. Three treatment approaches were evaluated, each beginning with a bone graft in the region of the defect. Under the first option, this would be followed by mesialization of the upper right second and third molars and distalization of the premolars and canines to obtain Class I molar

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and canine relationships on that side. The upper left second premolar would also be extracted, the first premolar and canine distalized to achieve a Class I relationship, and the molars mesialized into a Class II relationship. In the second approach, grafting would be followed by extraction of the upper third molars to facilitate distalization of the teeth on both sides, thus obtaining Class I molar and canine rela-

tionships, and subsequent placement of an implant in the graft region to substitute for the lost upper right first molar. Under the third option, the upper posterior teeth would be distalized to achieve Class I canine and molar relationships on the right, and the upper right first molar would be replaced with a dental implant. On the left, the upper second premolar would be extracted, the molars would be mesialized into

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Fig. 2 Bone-grafting surgery performed one month after first-molar extraction. A. Tissue selected for allograft. B. After surgical exposure. C. After graft placement.

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Fig. 3 A. Coronal slices of cone-beam computed tomography showing increase in bone thickness and height after allograft. B. Bidimensional projection before removal of fixation screws.

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Fig. 4 A. After six months of leveling and alignment, space closure initiated on .018" × .025" archwires. B. Sliding jig used for distalization of upper premolars and mesialization of lower posterior teeth using bilateral Class II elastics.

Fig. 5 After 11 months of space closure and five months of incisor retraction.

a Class II relationship, and the first premolar and canine would be distalized to achieve a Class I relationship. Although the second and third options appeared to be simpler, with shorter treatment times, the patient was reluctant to have a dental prosthesis or an implant. Therefore, we decided to make use of the space left by the extraction of the upper right first molar. The spacing already present in the mandibular arch would be used to correct the dental midline, and the remaining spaces would be closed by mesial movement of the posterior teeth.

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Treatment Progress One month after extraction of the upper right first molar, autogenous bone grafting was performed to allow mesial movement of the upper right second molar (Fig. 2). Due to the dimensions and characteristics of the bone defect, a large quantity of spongy bone rather than cortical bone was required, making an allograft a good option. In addition, the patient did not want to undergo surgery at two sites (one for removal of the bone fragments and the other at the site of the defect). Therefore, we used an al-

lograft with two medullary cortical bone blocks (20mm × 10mm × 6mm for tooth movement) obtained from the Musculoskeletal Tissue Bank of Marilia Hospital, São Paulo, Brazil. After the grafting, an increase in bone thickness and height could be seen by means of cone-beam computed tomography (Fig. 3). The bone fragments were temporarily fixed with nickel titanium screws. Complete osseointegration of the graft took three months; at that time, the fixation screws were removed and orthodontic treatment started.

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A Fig. 6 A. Patient after 27 months of treatment (continued on next page).

The upper left second premolar was extracted, and a standard .022" edgewise appliance* was banded and bonded. Over six months of leveling and alignment, a sequence of .014", .016", and .018" nickel titanium and .020" stainless steel archwires was used in each arch. *Morelli Ortodontia, São Paulo, Brazil; www.morelli.com.br.

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Space closure was then initiated on .018" × .025" archwires (Fig. 4A). Mesialization of the upper right second and third molars into the graft site was performed with elastic chain ligated to the upper right second premolar and canine. Simultaneously, the same mechanics were used for mesialization of the upper left first and second molars and distalization

of the left first premolar and canine into the upper left secondpremolar extraction site. A sliding jig was added on each side of the maxilla to promote distalization of the premolars and mesialization of the lower posterior teeth, using bilateral Class II elastics (Fig. 4B). After 11 months of space closure, an adequate Class I molar relationship on the right,

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B Fig. 6 (cont.) A. Patient after 27 months of treatment. B. Superimposition of pre- and post-treatment cephalometric tracings.

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Class II molar relationship on the left, and bilateral Class I canine relationship had been achieved. An .018" × .025" maxillary retraction arch with loops distal to the lateral incisors was used to resolve the overjet and close all remaining spaces (Fig. 5). Five more months were required for finishing; total treatment time was 27 months. Treatment Results At the completion of treatment, no changes were observed in the patient’s skeletal profile. There also was no significant change in the inclination of the upper (U1-SN = 104.6°) or lower (L1-NB = 19.2°) incisors. The overjet and overbite were corrected, all spaces were closed, and satisfactory molar and canine relationships were obtained (Fig. 6). Discussion Bone-replacement grafts have been used in medicine for more than a century.20 A variety of methods including autogenous grafts, exogenous grafts, allografts, and biocompatible synthetic materials have been thoroughly evaluated.21,22 Desirable properties of these materials include20,23,24: • Osteogenesis (formation of new bone by osteoblasts derived from the graft material). • Osteoinduction (induction of osteoblast formation from the tissue surrounding the graft site). • Osteoconduction (capacity of the material to support bone growth on a surface).

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• Osteointegration (chemical bonding of the graft to the surrounding bone). The only medium with all four of these properties is the autogenous graft.25-27 The removal of autogenous bone requires a second surgical site, however, increasing the complexity of the intervention as well as the risks, morbidity, and postoperative complications. Furthermore, when a graft is taken from an extraoral site, the patient must be hospitalized to allow removal of the necessary dimension, quality, and quantity of bone.20,27 Allografts offer several advantages over other types of grafts, including shorter surgical and postoperative recovery times, low morbidity, and the ability to manage the size and shape of the graft, as well as to adapt the graft to the defect.28 This material is available from bone banks in fresh, frozen, demineralized, or cryopreserved form.29,30 Protocols for donor selection and for processing and storage of the tissues prevent transmission of infection.31 In addition, procedures such as freezing the tissue at −20°C reduce the chance of antigenicity,32 minimizing the risk to patients.33 Studies have indicated that it is possible to reestablish bone height by means of tooth movement into a bone defect.34 Thilander concluded that teeth with inadequate bone support could be moved into areas of reduced bone height without harming the gingival and bone attachment levels if light forces were used and oral hygiene maintained.35 Additionally, the use of bone

grafting in extraction sites has significantly improved the shape and quality of the alveolar ridge, facilitating subsequent orthodontic movement. Moving the teeth through spongy bone is less damaging and helps avoid gingival recession.1 Tooth movement through areas filled with different types of grafting material has been described in the literature.4,33,36-42 Vitral and colleagues observed that a maxillary sinus lift with autogenous bone grafts made tooth movement more effective in an area with reduced alveolar height and pneumatization of the maxillary sinus.36 In animal studies, Araújo and colleagues40 and Oltramari and colleagues41 demonstrated the possibility of orthodontic movement into an area previously filled with xenografts derived from bovine bone. Although allografts have been extensively used to recover areas of bone loss for the placement of osseointegrated implants and rehabilitation with dental prostheses,43,44 few authors have documented clinical orthodontic cases involving tooth movement into allograft areas. Carvalho and colleagues described orthodontic movement into the region of a bone defect with an allograft by use of a guided tissue-regeneration technique (nonresorbable membrane), emphasizing that the type, magnitude, and clinical variability of the defect would determine the success of the procedure.4 The case shown here indicates that it is possible to move teeth into an allograft area without the need for guided tissue regeneration.

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Tooth movement into the upper right first-molar extraction site in this patient occurred at the same rate or even faster than movement into the upper left second-premolar extraction site. This may be attributed to the stimulation of bone metabolism by the graft, a mechanism similar to corticotomy procedures used to accelerate tooth movement. 45-47 With orthodontic movement facilitated in the graft area, the patient finished with an adequate canine relationship, complete space closure, and a satisfactory outcome. REFERENCES 1. Diedrich, P.R.: Guided tissue regeneration associated with orthodontic therapy, Semin. Orthod. 2:39-45, 1996. 2. Pietrokovski, J.: The bony residual ridge in man, J. Prosth. Dent. 34:456462, 1975. 3. Barone, A.; Varanini, P.; Orlando, B.; Tonelli, P.; and Covani, U.: Deepfrozen allogeneic onlay bone grafts for reconstruction of atrophic maxillary alveolar ridges: A preliminary study, J. Oral Maxillofac. Surg. 67:1300-1306, 2009. 4. Carvalho, R.S.; Nelson, D.; Kelderman, H.; and Wise, R.: Guided bone regeneration to repair an osseous defect, Am. J. Orthod. 123:455-467, 2003. 5. Melsen, B.: Tissue reaction following application of extrusive and intrusive forces to teeth in adult monkeys, Am. J. Orthod. 89:469-475, 1986. 6. Polson, A.; Caton, J.; Polson, A.P.; Nyman, S.; Novak, J.; and Reed, B.: Periodontal response after tooth movement into intrabony defects, J. Periodontol. 55:197-202, 1984. 7. Wennström, J.L.; Stokland, B.L.; Nyman, S.; and Thilander, B.: Perio dontal tissue response to orthodontic movement of teeth with infrabony pockets, Am. J. Orthod. 103:313-319, 1993. 8. Aguirre-Zorzano, L.A.; Bayona, J.M.; Remolina, A.; Castaños, J.; Diez, R.; and Estefanía, E.: Postorthodontic stability of the new attachment achieved by guided tissue regeneration follow-

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ing orthodontic movement: Report of 2 cases, Quintess. Int. 30:769-774, 1999. 9. Diedrich, P.: The eleventh hour or where are our orthodontic limits? Case report, J. Orofac. Orthop. 60:60-65, 1999. 10. Garg, A.K.; Morales, M.J.; Navarro, I.; and Duarte, F.: Autogenous mandibular bone grafts in the treatment of the resorbed maxillary anterior alveolar ridge: Rationale and approach, Implant Dent. 7:169-176, 1998. 11. Corinaldesi, G.; Pieri, F.; Marchetti, C.; Fini, M.; Aldini, N.N.; and Giardino, R.: Histologic and histomorphometric evaluation of alveolar ridge augmen tation using bone grafts and titanium micromesh in humans, J. Periodontol. 78:1477-1484, 2007. 12. Jäger, M.; Westhoff, B.; Wild, A.; and Krauspe, R.: Bone harvesting from the iliac crest [in German], Orthopäde 34:976-982, 984, 986-990, 992-974, 2005. 13. Misch, C.M.: Comparison of intraoral donor sites for onlay grafting prior to implant placement, Int. J. Oral Max illofac. Implants 12:767-776, 1997. 14. Barone, A. and Covani, U.: Maxillary alveolar ridge reconstruction with nonvascularized autogenous block bone: Clinical results, J. Oral Maxillofac. Surg. 65:2039-2046, 2007. 15. Khan, S.N.; Cammisa, F.P. Jr.; Sandhu, H.S.; Diwan, A.D.; Girardi, F.P.; and Lane, J.M.: The biology of bone grafting, J. Am. Acad. Orthop. Surg. 13:7786, 2005. 16. Rougraff, B.T.: Bone graft alternatives in the treatment of benign bone tumors, Instr. Course Lect. 54:505-512, 2005. 17. Shasha, N.; Krywulak, S.; Backstein, D.; Pressman, A.; and Gross, A.E.: Long-term follow-up of fresh tibial osteochondral allografts for failed tibial plateau fractures, J. Bone Joint Surg. Am. 85:33-39, 2003. 18. Simpson, D.; Kakarala, G.; Hampson, K.; Steele, N.; and Ashton, B.: Viable cells survive in fresh frozen human bone allografts, Acta Orthop. 78:26-30, 2007. 19. Gazdag, A.R.; Lane, J.M.; Glaser, D.; and Forster, R.A.: Alternatives to autogenous bone graft: Efficacy and indications, J. Am. Acad. Orthop. Surg. 3:18, 1995. 20. Kao, S.T. and Scott, D.D.: A review of bone substitutes, Oral Maxillofac. Surg. Clin. N. Am. 19:513-521, 2007. 21. Reynolds, M.A.; Aichelmann-Reidy, M.E.; Branch-Mays, G.L.; and Gun solley, J.C.: The efficacy of bone re-

placement grafts in the treatment of periodontal osseous defects: A systematic review, Ann. Periodontol. 8:227265, 2003. 22. Garrett, S.: Consensus report. Periodon tal regeneration around natural teeth, Ann. Periodontol. 1:667-670, 1996. 23. Cypher, T.J. and Grossman, J.P.: Bio logical principles of bone graft healing, J. Foot Ankle Surg. 35:413-417, 1996. 24. Precheur, H.V.: Bone graft materials, Dent. Clin. N. Am. 51:729-746, 2007. 25. Boyne, P.J. and Sands, N.R.: Secondary bone grafting of residual alveolar and palatal clefts, J. Oral Surg. 30:87-92, 1972. 26. McAllister, B.S. and Haghighat, K.: Bone augmentation techniques, J. Periodontol. 78:377-396, 2007. 27. Bavetta, G. and Licata, M.E.: The use of human allogenic graft (HBA) for maxillary bone regeneration: Review of literature and case reports, Curr. Pharm. Des. 18:5559-5568, 2012. 28. Contar, C.M.; Sarot, J.R.; Bordini, J. Jr.; Galvao, G.H.; Nicolau, G.V.; and Machado, M.A.: Maxillary ridge augmentation with fresh-frozen bone allografts, J. Oral Maxillofac. Surg. 67:1280-1285, 2009. 29. Perrott, D.H.; Smith, R.A.; and Kaban, L.B.: The use of fresh frozen allogeneic bone for maxillary and mandibular reconstruction, Int. J. Oral Maxillofac. Surg. 21:260-265, 1992. 30. Dallari, D.; Fini, M.; Stagni, C.; Torricelli, P.; Nicoli Aldini, N.; Giavaresi, G.; Cenni, E.; Baldini, N.; Cenacchi, A.; Bassi, A.; Giardino, R.; Fornasari, P.M.; and Giunti, A.: In vivo study on the healing of bone defects treated with bone marrow stromal cells, platelet-rich plasma, and freeze-dried bone allografts, alone and in combination, J. Orthop. Res. 24:877-888, 2006. 31. Tomford, W.W.; Doppelt, S.H.; Mankin, H.J.; and Friedlaender, G.E.: 1983 bone bank procedures, Clin. Orthop. Relat. Res. 15-21, 1983. 32. Dodd, C.A.; Fergusson, C.M.; Freed man, L.; Houghton, G.R.; and Thomas, D.: Allograft versus autograft bone in scoliosis surgery, J. Bone Joint Surg. Br. 70:431-434, 1988. 33. Albert, A.; Leemrijse, T.; Druez, V.; Delloye, C.; and Cornu, O.: Are bone autografts still necessary in 2006? A three-year retrospective study of bone grafting, Acta Orthop. Belg. 72:734740, 2006. 34. Hom, B.M. and Turley, P.K.: The effects of space closure of the mandibular

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first molar area in adults, Am. J. Orthod. 85:457-469, 1984. 35. Thilander, B.: Infrabony pockets and reduced alveolar bone height in relation to orthodontic therapy, Semin. Orthod. 2:55-61, 1996. 36. Vitral, R.W.; da Silva Campos, M.J.; de Andrade Vitral, J.C.; Santiago, R.C.; and Fraga, M.R.: Orthodontic distalization with rigid plate fixation for anchorage after bone grafting and maxillary sinus lifting, Am. J. Orthod. 136:109114, 2009. 37. Seifi, M. and Ghoraishian, S.A.: Deter mination of orthodontic tooth movement and tissue reaction following demineralized freeze-dried bone allograft grafting intervention, Dent. Res. J. (Isfahan) 9:203-208, 2012. 38. Zhang, D.; Chu, F.; Yang, Y.; Xia, L.; Zeng, D.; Uludağ, H.; Zhang, X.; Qian, Y.; and Jiang, X.: Orthodontic tooth movement in alveolar cleft repaired with a tissue engineering bone: An experimental study in dogs, Tissue Eng. (A) 17:1313-1325, 2011. 39. Yilmaz, S.; Kiliç, A.R.; Keles, A.; and

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Efeoğlu, E.: Reconstruction of an alveolar cleft for orthodontic tooth movement, Am. J. Orthod. 117:156-163, 2000. 40. Araújo, M.G.; Carmagnola, D.; Berg lundh, T.; Thilander, B.; and Lindhe, J.: Orthodontic movement in bone defects augmented with Bio-Oss: An experimental study in dogs, J. Clin. Periodontol. 28:73-80, 2001. 41. Oltramari, P.V.; de Lima Navarro, R.; Henriques, J.F.; Taga, R.; Cestari, T.M.; Ceolin, D.S.; Janson, G.; and Granjeiro, J.M.: Orthodontic movement in bone defects filled with xenogenic graft: An experimental study in minipigs, Am. J. Orthod. 131:302e10-302e17, 2007. 42. Re, S.; Corrente, G.; Abundo, R.; and Cardaropoli, D.: Orthodontic movement into bone defects augmented with bovine bone mineral and fibrin sealer: A reentry case report, Int. J. Period. Restor. Dent. 22:138-145, 2002. 43. Soltan, M.; Smiler, D.; Prasad, H.S.; and Rohrer, M.D.: Bone block allograft impregnated with bone marrow aspirate, Implant Dent. 16:329-339, 2007.

44. Chaushu, G.; Mardinger, O.; Calderon, S.; Moses, O.; and Nissan, J.: The use of cancellous block allograft for sinus floor augmentation with simultaneous implant placement in the posterior atrophic maxilla, J. Periodontol. 80:422428, 2009. 45. Keser, E.I. and Dibart, S.: Sequential piezocision: A novel approach to accelerated orthodontic treatment, Am. J. Orthod. 144:879-889, 2013. 46. Wang, B.; Shen, G.; Fang, B.; Yu, H.; Wu, Y.; and Sun, L.: Augmented corticotomy-assisted surgical orthodontics decompensates lower incisors in Class III malocclusion patients, J. Oral Maxillofac. Surg. 72:596-602, 2014. 47. Coscia, G.; Coscia, V.; Peluso, V.; and Addabbo, F.: Augmented corticotomy combined with accelerated orthodontic forces in Class III orthognathic patients: Morphologic aspects of the mandibular anterior ridge with cone-beam computed tomography, J. Oral Max illofac. Surg. 71:1760e1-1760e9, 2013.

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