Three-Dimensional Evaluation of Periodontal

Remodeling During Orthodontic Treatment

Robert A. W. Fuhrmann

In 21 adult patients, two or three high-resolution computed tomography

(HR-CT) examinations were performed before, during and after orthodontic
treatment with fixed appliances. The time between the first, second, and
third CT scanning varied according to the individual treatment or retention
period from 12 to 36 months. Comparison of the CT examinations permits
three-dimensional evaluation of osteoclastic and osteoblastic periodontal
remodeling. The incidence of periodontal lesions, such as bone dehiscenses,
fenestrations and root resorptions were assessed in relation to the initial
periodontal situation and the applied orthodontic biomechanics. Anatomic
risks were a small alveolar process, thin buccal or lingual bone plates,
eccentric positioning of teeth, basally extended maxillary sinus, and pro-
gressive alveolar bone loss. Therapeutic risks were uncontrolled sagittal or
vertical movements of the incisors and cortical or intermaxillary anchorage
preparation. Orthodontically induced bone dehiscences were partly repaired
by osteoblastic periodontal remodeling in the retention period. (Semin
Orthod 2002;8:23-28.) Copyright 2002, Elsevier Science (USA). All rights
reserved.

Introduction the type and direction of tooth movement, scale

and duration of force application, volume and
he influences of orthodontic treatment on
T the gingiva, marginal periodontium, at-
integrity of the surrounding hard and soft tissue,
osteoblastic potential of the periosteum, bone
tachment levels and root integrity have been
elasticity, coupling belween bone resorption and
previously discussed. 13 In the orthodontic treat-
ment of adults, the focus is on involutive ageing apposition, and vascularity of the tissues.
processes of the periodontal ligament and a vary- The clinical o u t c o m e of extensive bone dehis-
ing degree of alveolar bone loss. This periodon- cences is a loss of anchorage and a predisposi-
tal involution increases the risk of bone dehis- tion to the development of gingival recession.
cences, fenestrations, and root resorption. Gingival recession may b e c o m e manifest dnring
Various animal experiments have shown that the orthodontic treatment or even many years later
loss of thin bone plates may be induced by orth- t h r o u g h an increasing crown length and ex-
odontic tooth movement.L.2 After reorientation posed cepdces. 2,:¢Buccal and lingual bone plates
to the initial position, attachment loss can be or bone dehiscences on the roots of the teeth
osteoblastically regenerated. The genesis of c a n n o t be imaged with dental radiologic projec-
bone dehiscences or fenestrations depends on tion techniques. 4 Graber noted critically that
with dental and panoramic radiographs and lat-
eral cephalograms we see little more than 50%
From the Department of Orthodontics Medical Facul(~,, R~VI'H-
Aachen, 52057 Aachen, Germany. of the real anatomic structures. ~ He calls for
Ad&~ss correspondence to Pro/'essorRobert A. W. Fuhrma~rz, integration of alternative imaging t e c h n i q u e s )
Dr. reed, Dr. meal. dent., MD, DDS, PhD, Klinik f~ir Kieferortho- Various in vitro and in vivo studies have
pddie, RgTH-Aaehen, 52057 Aachen, Germany.
shown the applicability of high-resolution com-
Copyright 2002, Elsevier Scie*~ce(USA). All rigtzts reserved.
10 Z3-8746/02/0801-0005535.00/0 p u t e d t o m o g r a p h y (HR-CT) in imaging the
doi: 10.1053/sodo. 2002.28168 t o o t h / b o n e relation true to scale without over-

Seminars in Orthodontics, Vol 8, No 1 (March), 2002: pp 23-28 93

24 Roberi A. W.. F u h ~ a n n

lying structures, and in identifying periodontal adapted when necessary. The contiguous axial
lesions.4,6, 7 CT scans of the .jaw ran from the cemento-
This review summarizes our experiences over enamel j u n c t i o n to the apices of the roots with a
the last 10 years integrating HR-CT scanning scan thickness and table feed of 1.0 ram. Accord-
during and after orthodontics. The aim was to ing to the curve of Spee and the root length, 15
investigate the incidence of bone dehiscences or to 30 scans per jaw were necessary. The CT data
fenestrations, root resorption, and osteoblastic were recorded in high-resolution m o d e with a
bone remodeling during and after orthodontic reconstruction matrix of 519 x 512 pixels, a tube
treatment in adult patients. voltage of 120kV at 125 to 165mA and a 2-second
exposure scanning time. For imaging, the axial
CT scans were exposed onto film with a window
Material and Methods
width of 4000 Hounsfield units (HU) and a cen-
Twenty-one adult patients with reduced peri- ter of 600 H U with a laser camera. To facilitate
odontal bone tissue (ie, narrow alveolar process, visualisation of the axial scan sequences and to
basally extended maxillary sinus, or advanced simplity qualitative assessment of the bone sur-
alveolar bone loss) were selected for this inves- face (dehiscence diagnosis), additional three-
tigation. In 15 of the patients, the first CT exam- dimensional reconstructions were c o m p u t e d
ination was p e r f o r m e d before the start of orth- from the primary axial scans for the maxilla and
odontic treatment. The remaining 6 patients mandible of selected patients with the recon-
were scanned after the first phase of orthodontic struction software of the CT console.
treatment.
All patients were treated with fixed straight
Case Report
wire appliances (0.022-in slot width) and contin-
uous arch wires. Additional segment arch wires In an 18-year-old patient with a primarily narrow
were integrated during the levelling and guid- mandibular alveolar process and crowding of
ance phases. The second CT examination was the lower incisors, the first premolars were ex-
p e r f o r m e d at an interval of 12 to 36 months after tracted after the pre-treatment CT-examination
the first CT examination according to the treat- (Fig 1). The axial CT scans revealed that the oval
m e n t time following removal of the fixed appli- section of the canine roots corresponded to the
ances. In 6 patients, a third CT examination was maximal width of the alveolar process. However,
p e r f o r m e d after a retention period of 6 to 36 no bone dehiscences and fenestrations over the
months after debonding. buccal surface of the lower canines and incisors
Comparability of the patients was limited by could be evaluated in the axial CT scans or
the varying labiolingual width of the alveolar three-dimensional reconstructions (Fig 1A and
process, attachment level, and orthodontic treat- B). During the orthodontic treatment, the lower
m e n t concepts. For that reason, a descriptive canines were derotated and distalized with Sen-
evaluation of the CT findings was made with talloy springs. The further levelling of the fron-
reference to the individual morphologic situa- tal mandibular crowding was accomplished with
tion and the biomechanic treatment concept to the insertion of resilient continuous arch wires.
highlight different anatomic or therapeutic risk This resulted in the further protrusion of the
factors in the genesis of periodontal lesions. lower incisors.
After two years of orthodontic treatment with
straight wire appliances, a second CT examina-
CT Scanning Parameters
tion showed extensive vestibular bone dehis-
The patients were placed horizontally oi1 the cences above the root surfaces of the lower ca-
table of the CT scanner (Somatom plus, Siemens nines and the incisors in the three-dimensional
Inc, Erlangen, Germany). Each patient's head reconstruction (Fig 1C). Because of the narrow
was fixed with foamed plastic to avoid m o v e m e n t alveolar process, this uncontrolled protrusion
artifacts. After an initial lateral topogram, the led to bone dehiscences over the vestibular root
axial CT scanning direction was orientated ac- surthces. The extent of primary bone covering
cording to the maxillary or mandibular occlusal and secondary subperiosteal apposition were not
plane. The gantry inclination was individually sufficient to prevent bone dehiscences. The cor-
 Periodontal Remodeling During Orthodontics 25

Figure 1. Rotated canines and crowding of the incisors are found in the pretherapeutic mandibular situation
(A). Corresponding pretreatment CT examination; 3D-reconstruction: Narrow frontal mandibular alveolar
process with thin facial bone plates (B). Corresponding posttreatment CT examination after two years of
orthodontic treatment; 3D-reconstruction: Extensive facial dehiscences above the roots of the incisors and
canines (C). Corresponding clinical situation and CT examination after three years of retention; 3D-reconstruc-
tion: Facial dehiscences above the roots of the lateral incisors and canines were completely remodelled. Tile
facial dehisences above the roots of the central incisors persisted; the periodontal relnodeling at the central
incisors were limited to the apical and lateral area of the dehiscences (D and E).

r e s p o n d i n g clinical situation, however, showed T h e d e h i s c e n c e s over the r o o t surfaces of the

n o p e r i o d o n t a l recession. lower c a n i n e s a n d the lateral incisors were com-
After t h r e e years of r e t e n t i o n with r e m o v a b l e pletely filled with n e w alveolar b o n e . However,
appliances, a t h i r d C T e x a m i n a t i o n showed p a > the d e h i s c e n s e s over the r o o t surfaces o f the
tial p e r i o d o n t a l r e m o d e l i n g o f the vestibular c e n t r a l incisors persisted partly. O n l y the apical
b o n e a n d d e h i s c e n c e s over the r o o t surfaces. a n d lateral area of these b o n e defects was re-
26 Robert A. W. Fuhrmann

paired s (FiglE). T h e clinical examination not observed over the palatal surfaces of the
showed no differences between the lower inci- u p p e r incisors. T h e retrusion of the tipper inci-
sors (Fig 1D). sors, however, initiated root resorption.
Therapeutic risks can be observed with un-
controlled tipping tooth m o v e m e n t s with con-
Results
tinuous resilient arch wires and with a tooth
Comparison of the first, second, and third CT m o v e m e n t vertical to the alveolar process. Pro-
findings revealed substantial differences in the trusion, retraction, and intrusion of m a n d i b u l a r
positions and angulations of individual teeth as a or maxillary incisors were especially critical
result of orthodontic treatment, therefore, the tooth movements. Similarly, overloading of the
CT sectioning did not always correspond. T h e r e intraoral anchorage by using intermaxillary elas-
was no clinical evidence of marginal periodonti- tice or cortical root torque may result in substan-
tis or periodontal recession at the orthodonti- tial a t t a c h m e n t loss.
cally m o v e d teeth in any of the patients before, A complete osteoblastic periodontal remodel-
during, or after orthodontic treatment. ing of the orthodontically induced b o n e defects
T h e CT findings revealed substantial individ- was seen above the palatal root surfaces of the
ual variation, d e p e n d i n g on the extension of the tipper premolars and molars. T h e lowest level of
alveolar process and the therapeutic concept. In osteoblastic periodontal r e m o d e l i n g was seen in
cases of translatory tooth m o v e m e n t s in a can- the lower frontal area above the buccal and lin-
cellous alveolar process, generally there was no gual root surfaces of the incisors and canines. In
notable root resorption or b o n e dehiscences re- some teeth, the dehiscences or fenestrations
vealed. were totally repaired, in others not. A spontane-
Expansion of the maxillary arch with a quad- ous reorientation or relapse of single teeth in
helix and continuous e x p a n d e d arch wires initi- the direction of the initial tooth position initi-
ated a partial resorption of the covering b o n e ated a complete periodontal remodeling.
above the buccal root surfaces of the posterior
teeth. T h e CT scan revealed buccal b o n e dehis-
Discussion
cences, especially in the coronal root third of the
posterior teeth. It was conspicuous that the mo- As the labiolingual diameter of the alveolar pro-
lars and premolars at the center of m a x i m u m cess decreases and the eccentric positioning of
expansion had the highest degree of b o n e re- the tooth increases, the facial/lingual b o n e plate
sorption and of subperiosteal b o n e apposition. above the root surfaces is reduced. The thera-
Despite the reactive osteoblastic r e m o d e l i n g of peutic risk i n h e r e n t in the application of uncon-
the buccal b o n e plate and the primary b o n e trolled orthodontic force systems may lead to a
covering, dehiscences were seen in the second breakdown of the b o n e plate and the covering
CT examination. No c o r r e s p o n d i n g lateral root soft tissue in terms of periodontal recession. T h e
resorption, n o r clinically detectable gingival re- b o n e can be only slightly increased by periosteal
cession was found. apposition during orthodontic tooth movement.
CT examination of adult patients indicates On extending beyond the primary b o n e volume
various anatomic a n d / o r topographic and ther- of the alveolar process and the secondary, newly
apeutic risk factors in the initiation of periodon- f o r m e d b o n e apposition, the periodontal liga-
tal lesions. Some of these were anatomic a n d / o r m e n t fuses with the apposing periosteum, and a
m o r p h o l o g i c risks arising f r o m a disproportion b o n e dehiscence develops. Additional factors,
between tooth width and labiolingual extension such as traumatic lesions resulting f r o m forceful
of the alveolar process or fi-om an eccentric cleaning techniques or plaque-induced mar-
tooth position, a d e e p maxillary sinus, or ad- ginal gingivitis a n d periodontitis, may accelerate
vanced b o n e loss. Bone dehiscences or fenestra- the d e v e l o p m e n t of periodontal recessions.
tions were repeatedly f o u n d at m a n d i b u l a r CT scanning in orthodontically treated pa-
incisors. A small symphysis with r e d u c e d labio- tients allows single-tooth interpretation of re-
lingual b o n e width, frontal crowding, and thin modeling and hard-tissue lesions at the peri-
facial or lingual b o n e plates predispose to b o n e odontal tissue in the wake of various therapeutic
dehiscences. Fenestrations or dehiscences were techniques. 8 T h e periradicular osteodynamics
 Periodontal Remo&lingDuring O~hodontics 27

resulting from a therapeutically induced tooth bone apposition, there was no histologic evi-
m o v e m e n t can be evaluated three-dimensionally dence of cortical perforation.
by comparing two or three different CT exami- Marginal bone dehiscences were detected
nations during or after treatment. above the buccal root surfaces of teeth in the
Various anatomic, morphologic, and thera- expansion center of a maxillary arch. Clinically,
peutic risk factors are intensified reciprocally no localised periodontal recessions were f o u n d
because the side effects of orthodontic therapy in these patients. The empirical concept of cor-
increase with reduced attachment level. When tical anchorage preparation has the inherent
teeth with a critical ratio between the labiolin- risk of a massive attachment loss at the incisors
gual tooth diameter and the width of the alveo- and at the molars because the roots are being
lar process are derotated, marginal bone dehis- moved in the dense compact tissue. ~:~ The
cences are induced if the bone apposition is present CT findings revealed extensive b o n e de-
inadequate. In histologic posttreatment exami- hiscences after cortical anchorage preparation.
nations of a h u m a n specimen dehiscences and In particular, orthodontic uprighting of the in-
fenestrations of various sizes were found. 9,1° Ex- cisors to cephalometric norms may be question-
tensive fenestrations resulting from tooth move- able in cases of a narrow symphysis, thin bone
merit in an atrophied alveolar process or the plates, or advanced alveolar bone loss.
dentoalveolar maxillary sinus were detected his- Orthodontically induced bone dehiscences
tologically. Overall, the present CT findings con- were partly repaired by osteoblastic periodontal
remodeling or spontaneous reorientation of the
firm these histologic findings. Clearly, there is a
teeth in the retention period. Within the scope
predisposition to attachment loss at these sites.
of differential therapeutic assessment of tooth
The degree of bone apposition by the superim-
movements, a reasonable risk-benefit calculation
posed periosteum is not e n o u g h to avoid bone
is n e e d e d to assess the extent to which the initial
dehiscences in cases of a primarily narrow apical
periodontal situation, the adaptability of the cov-
base or a deep maxillary sinus and extensive
ering hard and soft tissue and the expected os-
tooth movements. With critical initial findings,
teoblastic remodeling permit extensive orth-
tooth movements should be confined to the an-
odontic tooth movement.
atomic limits of the alveolar process. Selecting
controlled biomechanics can most readily re-
duce this anatomic and topographic risk factor.
The initial application of continuous resilient References
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28 Robert A. W. Fuhrmann

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