4. This is based theoretically on the healing pattern of
bone known as regional acceleratory phenomenon
(RAP).
5. What is Wilckodontics
oIt is a clinical procedure that
combines selective alveolar
corticotomy, Particulate bone grafting
and the application of orthodontic
forces.
o Allows teeth to be moved 2-3 times further
in 1/3rd to 1/4th the time required for
traditional orthodontic treatment.
7. HISTORY
• 1800’s- used- surgically assisted
orthodontic tooth movement.
• First Described by- L.C. Bryan 1893-
corticotomy- facilated tooth movement.
• First introduced by- kole 1959- mean for
rapid tooth movement
8. o1991 - Suya replaced- the osteotomy cuts
with corticotomy - Selective Alveolar
Decortication (SAD)
o A more recent surgical orthodontic therapy
was Introduced by Wilcko which included
the innovative strategy of combining
corticotomy surgery with alveolar grafting
in a technique referred to as Accelerated
Osteogenic Orthodontics (AOO) (Wilcko et
al., 2000) and more recently called as
Periodontally Accelerated Osteogenic
Orthodontics (PAOO) (Wilcko et al., 2008).
9. WILCKODONTICS RESULTS:
o An increase in width of alveolar bone
o Shorter treatment time
o Greater post treatment stability
o Decreased apical root resorption
11. oCan be performed at any age.
oHealthy periodontal situation.
oCommon in adult patients-
- Increasing chance of hyalinization
- Conversion of collagen fibres is much slower in adults
- Periodontal complications
-Non-flexible alveolar bone.
12. INDICATIONS
o Class I with moderate to severe crowding.
o Class II with extraction Mild class III cases.
o To facilitate eruption of Impacted teeth.
o Molar intrusion and Openbite correction.
o Molar Uprighting.
o Molar Distalisation.
o Arch expansion.
13. CONTRAINDICATIONS
o Severe class III cases.
o Active periodontal disease or gingival recession
o It should not be considered as an alternative for surgically assisted palatal
expansion
o severe posterior cross-bite.
o It should not be used in Bimaxillary protrusion
oInadequately treated endodontic problems
16. New bone
(20-55 days)
Transient state
(soft and less resistance)
Movement of teeth is faster with help of orthodontic braces
Localized osteoporosis Injury accelerated healing process
Soft and hard tissue healing by 2-10 times
Regional acceleratory phenomenon (RAP)
RAPID TOOTH MOVEMENT
17. RAP
Decreased regional bone density Accelerated bone turnover increased
Tooth movement (long)
completed
Alveolar remineralization
18. ADVANTAGES
oReduced treatment time
oLess root resorption due to decreased resistance of cortical bone.
oMore bone support due to the addition of bone graft.
oImproved periodontal support.
oHistory of relapse very low.
oLess need for extra-oral appliances.
22. o Complete medical review
o Any systemic and local factors
o Phase 1 therapy - Scaling and root planning
- Oral hygiene
oClinical and Radiographic Evaluation
oFull mouth IOPA X - rays.
oOPG
o3D Imaging
oCan be used in both Maxillary and Mandibular arches.
23. PAOO CONSISTS OF 5 STEPS:
o Raising of flap.
o Decortication.
o Particulate grafting.
o Closure of flap.
o Orthodontic Force Application.
24. PRE - OPERATIVE PATIENT
PREPARATION
o Orthodontic archwire was removed in maxilla
o Mandible there is no need for removal of arch
wire due to proper accessibility
25. FLAP DESIGN
o Proper flap design
o Proper access
o Preservation of the gingival form
o Proper esthetic appearance.
26. o Crevicular incision is made buccally and lingually
extending at least two to three teeth beyond the
area to be treated.
oFlaps were reflected beyond the apices of the teeth
not to perforate the flaps
oPreservation of interdental papilla not to damage
any of the neurovascular bundles and muscle
attachments.
27. DECORTICATION
oRemoval of the cortical portion of the alveolar bone
o Initiate the RAP response
oNot to create movable bone segments
oDecortications is performed by using low-speed
round diamond burs
ostraight diamond bur under the Copious saline
irrigation
28. oPerformed at clinical sites without entering the
cancellous bone,
oPrevent damage to underlying structures
(maxillary sinus and mandibular canal).
oLabial and lingual aspects of the alveolar bone.
oVertical groove will be placed in the inter
radicular space midway between the root
prominences.
29. oGroove will start from 2 to 3 mm below the
crest of the bone
o2 mm beyond the apices of the roots
o1.5 - 2mm in depth.
o vertical corticotomies are connected with a
semicircular shaped in apical region.
30. oIf the alveolar bone of sufficient thickness,
solitary perforations may be placed in the
alveolar bone
oCortical perforation increase blood supply to
the graft material.
oPerforation thickness 1 to 2 mm
31.
32. PARTICULATE GRAFTING
o Commonly used for graft material are
oDeproteinized bovine bone,
o Autogenous bone Maxillary tuberosity
Mandibular symphysis
Angle of the mandible
Ramus of mandible
Exostosis
o Decalcified freeze-dried bone
oAllograft
oDecorticated bone acts to retain the graft material.
o Platelet rich plasma or calcium sulfate Increase the stability of the graft material.
33. • Resorbable grafting materials + antibiotic solution
applied directly over the activated bone.
• Frequently used augmentation grafting mixture :
2 parts demineralized freeze-dried bone (DFDBA)
and 1 part bovine bone wetted with clindamycin
phosphate solution (0.5 mg/ml) applied at a rate of
0.5 to 1 ml of grafting mixture per tooth to be
moved. Antibiotic produces soothening effect and
prevent the surgical site infection and act as a
medium for placement of graft material to the
surgical site
34. o Volume used is 0.25 to 0.5 ml of
graft material per tooth.
o If excess graft material result in
difficulty in full closure of flap.
35. FLAP CLOSURE TECHNIQUE
oNon - resorbable interrupted 3-0
sutures without creating excessive
tension.
oLeft in place for 1 to 2 weeks .
o After closer of flap Orthodontic arch
wire was secured
37. oParticularly important to adult patient
o Gingival recession
oDehiscence
oGraft is harvested by removing a 1 to
2mm thickness from elevated palatal
flap or acellular dermal matrix
allograft (alloderm).
39. oVercellotti & Podesta (2007) use of
Peizosurgery in conjunction with conventional
flap elevations to create an environment
conducive to rapid tooth movement.
oDibart et al(2010) introduced a procedure
known as Peizocision
o Minimally invasive procedure combining
microincisions, minimal peizoelectric osseous
cuts to buccal cortex only and bone and soft
tissue grafting concomitant with tunnel
approach
40. PROCEDURE
o All of the incisions are made only buccally.
o Ultrasonic instrumentation is used to perform
corticotomy cuts through the gingival
o Micro-incisions
o Depth of 3 mm.
o Gingival vertical incision- Interproximally
o 15 surgical blade
o Incision lies over attached gingiva.
o A tunnel is performed by means
of an elevator inserted between
the gingival incisions to form
sufficient space for receiving the
graft.
41. o Allograft is then placed
o Incision sutured (absorbable sutures 5-0).
42. ADVANTAGES OF PEIZOCISION
oShorter surgical time.
oMinimally invasive technique.
o No periodontal complications
oPost-operative morbidity is less.
43. DISADVANTAGES AND LIMITATIONS
o Lack of muco - periosteal flap elevation risk of root damage
oIncisions is keep at least 2 mm from the gingival margin to avoid the
formation of gingival cleft.
oPostoperative scar formation
45. • Germec et al (2006) introduced Modified
Corticotomy.
o “Conservative” technique to shorten the treatment
time during lower incisor retraction.
o Corticotomy done only on the buccal side without
lingual cuts.
o Mostly Orthodontic tooth has labial movement.
46. ADVANTAGES
Surgical time is less compared to classical technique.
Technique is less sensitive.
Patient acceptance is more and discomfort (Morbidity) is less.
47. potential for the non - operated lingual surface
“pull” of gingival and periodontal tissues postoperatively presents.
IT IS ELIMINATED BY
Simple circumferential fiberotomy
Supracrestal fiberotomy
Transmucosal Perforation with a irrigated Bur
If the acceleration of the
incisors retraction begins to
slow.
48. oAlternative approach introduced by Park et al (2006),
o Incisions directly through the gingiva and bone using a combination of surgical
blades and a surgical mallet.
o Decrease surgical time
o No flaps or sutures.
o only cortical incisions.
DISADVANTAGES
- No benefits of bone grafting
- Aggressive.
- Dizziness and vertigo
50. o Perform corticotomy procedure.
o Novel technique that creates micro -
osteopeforations.
o Micro-invasive procedure which accelerate
orthodontics.
o Chair side procedure
o Does not require any advanced training
51. o The instrument provides a surgical stainless-steel
lead edge uniquely designed and used to
atraumatically perforate the alveolus directly
through keratinized gingiva as well as movable
mucosa.
o No need of flaps surgery, bone grafting, or any
suturing
53. • THE IDEAL TREATMENT DEVICE FOR MICRO-OSTEOPERFORATION SHOULD BE –
provide control to the operator
Remain sharp through multiple perforations
Have a depth limiter to ensure penetration
Temporary anchorage devices
Miniplants
Burs
Disadvantage- Instrument is high cost ($149).
Not viable alternatives
to performing micro-
osteoperforation.
54. STEPS FOR MICRO-OSTEOPERFORATION
55
1. Evaluate Treatment area
o Locate roots, the mandibular nerve and maxillary sinuses.
o Micro-Osteoperforation depths are determined by bone
and soft tissue thickness.
o Micro-Osteoperforations should penetrate through the
cortical plate into cancellous bone.
2. Chlorhexidine rinse
Two times for one minute each
3. Anesthetize & PROPEL
Treatment area can be anesthetized
using either a Topical or Local
Infiltrative anesthetic.
55. How to use PROPEL
56
1. Remove from the sterile package and turn the Adjustable
Depth Dial to the preferred setting 3mm, 5mm, or 7mm by
holding the driver body and rotating the dial clockwise
2. Hold the PROPEL Device against the gingiva.
3. Apply gentle pressure to engage the leading edge while
turning the device handle clockwise. Check engagement by
releasing pressure
4. Continue to turn until the desired depth is reached for
penetration of the cortical plate into cancellous bone
5. The LED Depth Stop indicator will illuminate when desired
depth is reached
6. Rotate the device counter-clockwise to remove
56. How Deep to PROPEL
57
PROPEL has three depth settings: 3 mm, 5 mm and 7 mm. The correct depth should
be selected based on the thickness of the gingiva and alveolar bone in the
treatment area. The anterior is usually 3 mm or less and the posterior is generally 5
mm or 7 mm.
Recommended
perforation depth
Ref: Baumgartner et al.
57. HOW MANY MICRO-OSTEOPERFORATIONS
58
Where possible perform 1-3 micro-osteoperforations depending on proximity of
anatomical structures. Perforations can be made buccal or lingual in linear or
triangular patterns.
58. WHERE TO PERFORATE:
BUCCAL OR LINGUAL
o Buccally or lingually.
o Buccal access is simplest approach,
o Depending on desired movement and patient’s oral anatomy.
59. LASERS COMMONLY USED TO
ACCELERATE TOOTH MOVEMENT
o Lasers potentially useful for accelerating tooth
movement are low-level lasers or “low intensity
level laser” (LILL).
o The therapy performed with these lasers is
called low-level lasers therapy (LLLT).
o LLLT operates in the range of power output
milliwatts (mW).
60. • Hibst et al (1988) were the first to report the use of the Erbium: Yttrium
Aluminium Garnet(Er: YAG) laser for ablation of dental hard tissues.
• Advantage:
o It had Dual ability to ablate soft and hard tissues with minimal damage
o No damage of surrounding tissue.
o Faster bone repair(healing) than conventional bur drilling.
o Suitable alternative for defect and root surface debridement in conjunction with
periodontal surgery.
61. oThe er,cr;ysg laser device was used to deliver an
energy range about 300 mj at pulse rates of 20 hz.
oBone cutting was performed under water-spray
cooling for absorption of laser radiation.
o Duration of laser for penetration was between 0.25
- 0.5 second
oIt was in a noncontact manner with a 2 mm
distance.
oThe proportion of air and water was 40% and 20%
respectively.
62. o It Creates a clear, dry field with no bleeding,
o Decreasing the possibility of infection.
o Less trauma in the surgical field.
o Post-operative swelling , scars and pain is minimal.
•
ADVANTAGES OF LASER CORTICOTOMY
63. DISADVATANGE
oHigh cost compared to conventional method.
oLoss of Attached gingiva.
oPeriodontal defects
oshort interdental distance .
oSubcutaneous hematomas of the face and the neck
opost-operative swelling and pain.
64. CONCLUSION
o Mops significantly increased the expression of cytokines and chemokines known
to recruit osteoclast precursors and stimulate osteoclast differentiation.
o Mops increased the rate of canine retraction.
o Patients reported only mild discomfort locally at the spot of the mops. At days 14
and 28, little to no pain was experienced.
o It is effective, comfortable, and safe procedure
o Reduce orthodontic treatment time by 62%.
Kole’s procedure involves the reflection of Full thickness flaps to expose buccal and lingual alveolar bone, followed by interdental cuts through the cortical bone and barely penetrating the Medullary bone (Corticotomy style). The Subapical horizontal cuts connecting the interdental cuts were osteotomy style, penetrating the full thickness of the alveolus. Because of the invasive nature of Kole’s technique, it was never widely accepted.
A condition in which normal tissue deteriorates into a homogeneous translucent material
Exostosis-a benign outgrowth of cartilaginous tissue on a bone, DFFB- cortical bone is deflected, CUT INTO PIECES,WASHED IN ABSOLUTE ALCOHOLE,DEEP FROZEN,VACUM SEALED, he transplant of an organ or tissue from one individual to another of the same species with a different genotype ALLOGRAFT
AlloDerm is derived from donated (cadaveric) human skin. It is FDA approved and is used in many different types of reconstructive surgery including breast reconstruction.
Increased cytokine activity has been well documented to increase bone remodeling.
