The treatment alternatives for mandibular crowding

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1 CLINICIAN S CORNER Midsymphyseal distraction osteogenesis: A new alternative for the treatment of dental crowding Luiz Gonzaga Gandini, Jr, a Renato Parsekian Martins, b Cristina Azevedo de Oliveira, c Anamaria Abdala, d and Peter H. Buschang e Araraquara and Patos de Minas, Brazil, Quito, Equador, and Dallas, Tex In this article, we describe a midsymphyseal distraction osteogenesis treatment with a novel dentally supported appliance. This approach differs from that used in previous reports because the incisors were allowed to move during the distraction procedure. This report shows that midsymphyseal distraction osteogenesis can be used to expand both arches to produce a wider smile. Borderline cases can be treated with this technique without the compromising effects commonly observed with conventional therapy. (Am J Orthod Dentofacial Orthop 2009;135:530-5) The treatment alternatives for mandibular crowding are extraction of teeth and expansion of the arch. Extraction entails some potentially negative consequences, including relapse of the extraction space closure and lack of acceptance by the parents and the patient. 1 Although there is some evidence of stability in patients treated during the mixed dentition, there is no evidence concerning the stability of expansion in the permanent dentition. 2 An alternative treatment of transverse mandibular deficiencies and mandibular arch crowding is midsymphyseal distraction osteogenesis (MSDO). 3 Distraction osteogenesis is the biological process of bone formation between preexisting bone segments that are gradually drawn apart by controlled traction, which stimulates bone formation. 3-5 It was initially used in medical orthopedics for the treatment of length deficiencies in long bones 4 and later became an alternative for the treatment of craniofacial deformities, such as hemifacial microsomia and micrognathism. 6 The use of MSDO for the treatment of mandibular crowding associated with transverse deficiency was introduced by Guerrero et al. 7 Despite its great potential, a Professor, Araraquara Dental School, Universidade Estadual Paulista, Araraquara, Brazil. b Assistant professor, Araraquara Dental School, Universidade Estadual Paulista, Araraquara, Brazil. c Private practice, Quito, Equador. d Private practice, Patos de Minas, Brazil. e Professor, Baylor College of Dentistry, Dallas, Tex. The authors report no commercial, proprietary, or financial interest in the products or companies described in this article. Reprint requests to: Luiz Gonzaga Gandini, Jr, Araraquara Dental School, UNESP, Av Casemiro Perez, 560, , Araraquara, SP, Brazil; , Submitted, January 2006; revised and accepted, April /$36.00 Copyright Ó 2009 by the American Association of Orthodontists. doi: /j.ajodo only a few orthodontists use MSDO. More information is needed pertaining to MSDO, because it offers definite advantages over conventional treatment options. Based on over 40 treated patients, we discuss various clinical aspects of MSDO, including diagnostics, techniques, and its advantages and limitations in this article. The records of 1 patient are shown, illustrating the variability of those treated with this approach. This report is predicated on the fact that the MSDO procedure has not been fully explored and should be considered a viable alternative to nonextraction. 1 PRETREATMENT CHARACTERISTICS The patient s age was 13 years 11 months at the start of treatment. He had a convex profile, the right canines were in crossbite, and the lower midline deviated 3 mm to the left, with a Class I molar relationship, mandibuar crowding, and narrow arches (Fig 1). The lateral cephalogram indicated a vertical growth pattern and buccally positioned incisors (Table). His treatment options were limited. Interproximal reduction was ruled out because of the amount of enamel that would have to be removed to obtain the desired amount of space and the associated increased risk of sensitivity. Extractions might adversely affect the profile by making it retruded. The amount of arch expansion needed in the mandibular arch would probably have compromised long-term stability. 1 Therefore, MSDO treatment was planned. TREATMENT Initially, rapid expansion of the maxilla was performed with a hyrax device. The amount of rapid expansion was the same as the amount of distraction planned in the mandible, and the activation schedule was

2 American Journal of Orthodontics and Dentofacial Orthopedics Gandini et al 531 Volume 135, Number 4 Fig 1. Pretreatment photographs. Note Class I molar relationship, lower midline deviation, canine in crossbite, narrow maxillary arch, and mild mandibular crowding. Table. Cephalometric measurements Measurement Pretreatment Posttreatment SNA ( ) N-A/FH (mm) SNB ( ) N-Pg/FH (mm) ANB ( ) Wits appraisal (mm) S-N /Go-Me ( ) U1/N-A ( ) L1/N-B ( ) U1/L1 ( ) IMPA ( ) mm in the morning and 0.25 mm at night, until the desired amount of expansion had been accomplished. Even though there was no crossbite, the maxillary Fig 2. Mandibular incisor root divergence. arch had to be expanded to maintain the appropriate transverse relationships after the mandibular arch was distracted. Simultaneously with the rapid expansion, brackets were placed on the mandibular central incisors and

3 532 Gandini et al American Journal of Orthodontics and Dentofacial Orthopedics April 2009 Fig 3. Midsymphyseal distractor: A, acrylic covers canines and posterior teeth; B, lingual surface extends as far as possible; C, hyrax screw positioned buccally to incisors, between alveolus and lower lips. Fig 4. MSDO surgery: A, bone separation; B, periosteum suture. Fig 5. Occlusal x-rays of symphysis area: A, after activation; B, after consolidation period. angulated, so that the roots would diverge after the placement of an archwire of beta-titanium alloy, size in (Fig 2). This was done to obtain at least 5 mm of space between the apices for the osteotomy. Root divergence required approximately 2 months of treatment. Once root divergence was achieved, working impressions were taken so that the distractor could be fabricated. The distractor was made on the mandibular and maxillary casts mounted in a semiadjustable articulator. The acrylic that covered the occlusal surfaces of the mandibular molars was straight and smooth, with contacts to all maxillary posterior teeth. The acrylic covered the canines and the posterior teeth only (Fig 3, A). The lingual surface of the device extended downward as far as possible on the mandible, based on the patient s

4 American Journal of Orthodontics and Dentofacial Orthopedics Gandini et al 533 Volume 135, Number 4 Fig 6. Posttreatment photographs. comfort level (Fig 3, B). The expansion screw, similar to that used in the hyrax device, was positioned buccally to the incisors, between the alveolus and the lower lips, below the occlusal plane (Fig 3, C). The brackets were removed, and the device was fastened into place with glass ionomer cement immediately before surgery. The surgical procedure took place in a dental office, with the patient sedated with infiltrative anesthesia. After a semilunar incision, the tissues and periosteum were moved aside, and the symphysis was exposed. A round carbide bur was used to drill small holes between the roots of the incisors, and the rest of the mandible was cut with a striker saw, allowing its sides to be separated (Fig 4, A). The surgeon should check the activation of the device to ensure that the 2 halves of the mandible have been separated. The tissues were reapproximated and sewn together (Fig 4, B), and postsurgical medication was prescribed at the surgeon s discretion. One week after the surgery, the patient was instructed to activate the screw 4 times a day (twice in the morning and twice at night), producing 1 mm of expansion per day until the desired amount of distraction was achieved (Fig 5, A). The activation was then stopped, and the device was kept in place for 3 months for consolidation (Fig 5, B) and then removed. Immediately after removal of the distractor, conventional straight-wire appliances were placed in both arches for leveling and alignment with flexible wires. Detailing of the occlusion was accomplished with more rigid wires. It is important to use a transpalatal

5 534 Gandini et al American Journal of Orthodontics and Dentofacial Orthopedics April 2009 bar and a lingual arch, both made with 0.9-mm round stainless steel wire, during this phase to maintain the transverse dimensions. Treatment with the fixed appliance took approximately 11 months. A fixed mandibular retainer was cemented from canine to canine, and a removable Hawley wraparound retainer was fabricated for the maxillary arch. The total treatment time was 22 months. TREATMENT RESULTS MSDO followed by fixed-appliance therapy produced good facial esthetics, good intercuspation, correction of crowding, and root parallelism for this patient (Figs 6 and 7). The treatment effects were all produced within a satisfactory period of time. DISCUSSION MSDO provides a good, predictable treatment option for borderline patients when extractions might compromise facial esthetics. Although the presurgical procedures are simple, the surgery must be performed carefully because excessive removal of osseous tissue or injury to the periodontal ligament could cause periodontal defects or ankylosis of the teeth involved. 8 The risk of injury to a mandibular incisor root during the surgery is relatively small if good root divergence is achieved during the initial treatment phase. If there is severe crowding, it might be necessary to diverge the roots of the lateral incisors before attempting to diverge the central incisors. The ideal distraction device to be used for MSDO is controversial. It has been argued that bone-supported distractors are more efficient than tooth-supported devices. 7 However, bone-supported distractors require a second surgical intervention to remove them, substantially increasing the cost of the treatment. 8 Although tooth-supported distraction devices produce greater dental than skeletal widening, transverse skeletal stability has been reported. 3 Activation of the distraction device should start a week after surgery; this allows enough time for the callous to be formed. This period is also important to prevent tooth loss and periodontal defects that can occur if distraction is started too soon. 7 The speed of activation is also important, because poor-quality bone results when the rate is too fast, and early consolidation of the segments occurs when the rate is too slow. A proper rate of activation maintains a gap between the mandibular segments and stretches the periosteum and the soft tissues. Initially, fibrous connective tissue along with Fig 7. Cephalometric tracings, superimposed on cranial base. collagenous fibers are formed in this gap; this is later replaced by bone. This process takes about 3 or 4 months; it is the stabilization period. 8 Importantly, our approach does not maintain the mandibular incisors during the distraction and consolidation periods. They align spontaneously, especially during the consolidation period, as previously reported, 8 and the soft tissue (clinically) and the bone (radiographically) showed as well. Whether orthodontic movement of teeth should be performed immediately after distraction or consolidation is controversial Based on our findings, a lingual arch and a transpalatal bar, both passive, should be used along with the fixed appliances to maintain the transverse dimensions after the consolidation period. So far, this patient has not complained about signs or symptoms of a temporomandibular disorder. According to Samchukov et al, 9 each condyle rotates approximately 3 for every 10 mm of expansion. Although rotation undoubtedly occurs, patients temporomandibular joints apparently adapt to the alterations. Retention was the same as used in conventional nonextraction treatment (maxillary Hawley appliance and mandibular fixed retainer). A mandibular Hawley has been recommended for that arch when there is reason to believe that the expansion might be lost. 7 Although there is evidence that this procedure has

6 American Journal of Orthodontics and Dentofacial Orthopedics Gandini et al 535 Volume 135, Number 4 potential for long-term stability, more studies are needed to establish MSDO as an efficient treatment. 3 CONCLUSIONS In combination with rapid palatal expansion, MSDO gives the orthodontist an approach to widen both arches. In growing patients, MSDO is an alternative therapy for borderline crowding when other nonextraction alternatives might be expected to compromise stability and extractions might compromise esthetics by flattening the profile. REFERENCES 1. Del Santo M, English JD, Wolford LM, Gandini LG Jr. Midsymphyseal distraction osteogenesis for correcting transverse mandibular discrepancies. Am J Orthod Dentofacial Orthop 2002;121: Ferris T, Alexander RG, Boley J, Buschang PH. Long-term stability of combined rapid palatal expansion lip bumper therapy followed by full fixed appliances. Am J Orthod Dentofacial Orthop 2005;128: Del Santo M Jr, Guerrero CA, Buschang PM, English JD, Samchukov ML, Bell WH. Long-term skeletal and dental effects of mandibular symphyseal distraction osteogenesis. Am J Orthod Dentofacial Orthop 2000;118: Samchukov ML, Cherkashin AM, Cope JB. Distraction osteogenesis: history and biologic basis of new bone formation. In: Lynch SE, Genco RJ, Marx RE, editors. Tissue engineering: applications in maxillofacial surgery and periodontics. editors. Carol Stream, Ill: Quintessence; Ilizarov GA. Clinical application of the tension-stress effect for limb lengthening. Clin Orthop Relat Res Jan: Toth BA, Kim JW, Chin M, Cedars M. Distraction osteogenesis and its application to the midface and bony orbit in craniosynostosis syndromes. J Craniofac Surg 1998;9: Guerrero CA, Bell WH, Contasti GI, Rodriguez AM. Mandibular widening by intraoral distraction osteogenesis. Br J Oral Maxillofac Surg 1997;35: Conley R, Legan H. Mandibular symphyseal distraction osteogenesis: diagnosis and treatment planning considerations. Angle Orthod 2003;73: Samchukov ML, Cope JB, Harper RP, Ross JD. Biomechanical considerations of mandibular lengthening and widening by gradual distraction using a computer model. J Oral Maxillofac Surg 1998;56: Liou EJ, Figueroa AA, Polley JW. Rapid orthodontic tooth movement into newly distracted bone after mandibular distraction osteogenesis in a canine model. Am J Orthod Dentofacial Orthop 2000;117: Nakamoto N, Nagasaka H, Daimaruya T, Takahashi I, Sugawara J, Mitani H. Experimental tooth movement through mature and immature bone regenerates after distraction osteogenesis in dogs. Am J Orthod Dentofacial Orthop 2002;121:

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