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 I Journal of the International
AP
Academy of Periodontology
The official journal of the International Academy of Periodontology

Volume 14 Number 4 October 2012

Published by
The International Academy of Periodontology
 I
AP
Journal
of the
Volume 14
Number 4
International Academy of
October 2012

ISSN 1466-2094
Periodontology
Letter to the Editor
EDITORIAL BOARD Periodontal Disease Classification: Controversies, Limitations
Mark R Patters and the Road Ahead- A Proposed New Classification
Editor Flemingson J. Lazarus, Karthikeyan B. Varadhan,
Memphis, TN, USA Joann Pauline George and Kishore C. Hadal 84
Andrea B Patters
Associate Editor Efficacy of Chlorhexidine, Metronidazole and Combination Gel
in the Treatment of Gingivitis - A Randomized Clinical Trial
Sultan Al Mubarak A R Pradeep, Minal Kumari, Priyanka N and Savitha B. Naik 91
Riyadh, Saudi Arabia
P Mark Bartold Corticotomy-facilitated Orthodontics in Adults Using a Further
Adelaide, SA, Australia Modified Technique
Michael Bral Eatemad A. Shoreibah, Ahmed E. Salama, Mai S. Attia, and
New York, NY, USA Shahira M. A-moutaseum Abu-Seida 97
Nadine Brodala
Chicago, IL, USA Clinical and Radiographic Evaluation of Bone Grafting in
Cai-Fang Cao Corticotomy-facilitated Orthodontics in Adults
Beijing, People's Republic of China Eatemad A. Shoreibah, Samir A. Ibrahim, Mai S. Attia and
Daniel Etienne May M. Nabi Diab 105
Paris, France
Ahmed Gamal
Cairo, Egypt
Vincent J Iacono
Stony Brook, NY, USA
Isao Ishikawa
Tokyo, Japan
Georges Krygier
Paris, France
Francis Mora
Paris, France
Hamdy Nassar
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Journal of the International Academy of Periodontology 2012 14/4:84-90

Letter to the Editor

Periodontal Disease Classification:
Controversies, Limitations
and the Road Ahead-
A Proposed New Classification
Flemingson J. Lazarus1, Karthikeyan B. Varadhan2, Joann Pauline
2 2
George and Kishore C. Hadal
1
Department of Periodontics, Best Dental Science College,
2
Madurai; Department of Periodontics, Krishnadevaraya College
of Dental Sciences, Hunsumaranahalli, Bangalore, India

Abstract
History teaches us that a great deal of effort is put forward in giving birth to a classification
system, only to have it be quickly contradicted or condemned. Though we have made
great strides towards the understanding of periodontitis in general, the bitter truth is that
we have not hit the bull's eye on the true nature of etiopathogenesis. Until then any
classification based on infectious etiology would be a misfit. A classification that is easy to
understand and based on treatment needs would be more apt at this juncture. This article
is aimed at discussing the present American Academy of Periodontology 1999
classification and to suggest a new and simplified classification.

Key words: Classification, periodontal disease, periodontitis, gingivitis, peri-

implant mucositis

Introduction practical value (Attström and van der Velden, 1994;

Burchard and Inglis, 1904; McCall and Box, 1925;
The classification of periodontal diseases has come a
Thomas and Goldman, 1937; Miller and Pelzer, 1939;
long way over the past hundred years. Periodontitis is a
Hine and Hine, 1944; Lyons, 1946; Lyons et al., 1950;
complex disease of the tooth-supporting structures
Bernier, 1957; Ranney, 1977; Page and Schroeder, 1982;
that has no geographic, ethnic or age barriers.
American Academy of Periodontology, 1989). The
Classifying periodontal diseases is essential to provide a
irony of evolution of newer classifications is that they
framework to scientifically study the etiology,
are relevant even today, but incomplete (Armitage,
pathogenesis, and treatment of disease in an orderly
1999). This has led to increased confusion among the
fashion (Armitage, 1999).
periodontal` fraternity (Van der Velden, 2000).
Periodontal diseases have been classified based on
Today, there is no universal agreement among
knowledge during different time frames and various
researchers about the existing classification (Van der
paradigms such as classical pathology, clinical
Velden, 2000; Mombelli et al. 2002; Baelum and Lopez,
manifestations of disease and infectious etiology
2003; Meyer et al., 2004; van der Velden, 2005; Armitage
(Armitage, 2002). All classifications proposed so far
and Cullinan, 2010). Keeping this in view, we believe
have their share of controversies and limitations. The
that an analysis of the classification of periodontal
majority of these classification systems are merely
diseases is timely. The objective of this paper is to
offshoots of earlier classifications that exist only in the
discuss the American Academy of Periodontology
academic domain and have little or no clinical or
(AAP) 1999 classification system and propose a new
Correspondence to: Joann Pauline George, MDS system based on therapeutics. The new classification
6 Stephens Road, Frazer Town, Bangalore 560005, India. has been formatted with a critical and analytical point
Tel: +91 94 4854 1637 Fax: +91 80 2846 7083 of view and this paper intends to highlight its relevance,
drjoannpaulinegeorge@gmail.com

© International Academy of Periodontology

 Flemingson J. Lazarus et al: A Proposed New Periodontal Disease Classification 85
validity and utility in treating periodontal disease. Some
of our comments are based on observations.
Requisites for an ideal classification system
An ideal classification system must be simple, easy to
understand, easily reproducible and clinically relevant
(Lopez and Baelum, 2003). Such a system can be used in
various applications such as statistical analysis,
treatment planning, surveillance of disease, insurance
claims, etc. (Armitage, 2007).
Discussion of the 1999 American Academy of
Periodontology classification system
Several classification systems have been proposed in
the literature to facilitate categorization, but they have
limitations. The following list highlights some queries
raised regarding the presently accepted and widely used
AAP 1999 classification system. Analysis of this earlier
classification put forth certain questions in our mind
and prompted us to format and present a new and
practical classification.
1) Does the existing periodontal disease
classification system meet the ideal
requirements of a classification system
(Murphy, 1997)?
The present classification does not meet the ideal
requirements and the reasons are explained later in
this commentary.
2) Is there a real need for ideal classification of
periodontal diseases (Pini-Prato, 2011)?
An ideal classification system should help in
diagnosis, prognosis, treatment planning and
organizing health care needs in a simplified and
orderly fashion.
3) Are we in synchrony with classifications from
other dental specialties that serve as
therapeutic guides?
G.V. Black's classification of dental caries clearly
indicates the location of dental caries and acts as a
therapeutic guide for clinicians to devise a possible
treatment plan. This is not the case with the
present periodontal classification system.
4) Has the present etiology-based classification
helped us in better treatment planning?
(Loesche, 1976; Loesche, 1979; Slots, 1979;
Armitage, 1999; Armitage, 2002)
Our understanding of periodontal disease is not
complete enough to base our classification on
etiology (Armitage, 2002; van der Velden, 2005).
Treatment planning to date is based on the non-
specific plaque hypothesis.
5) Within the ambit of the existing classification,
is it possible to diagnose the disease with
certainty and place the patients in at least one
of the disease categories without overlap?
The strict criteria put forward by the 1999 AAP
classification makes it difficult to categorize
without overlapping.
To diagnose a case of aggressive periodontitis,
the person should be systemically healthy.
However, placing all patients with aggressive
periodontitis under this clause is extremely
challenging, as there exists a grey area in declaring a
person as systemically healthy because many
forms of systemic diseases exist in subclinical
form (Armitage, 1999; van der Velden, 2005; Devi
and Pradeep, 2009). Similarly, how can we classify a
10-year-old patient with predominant local factors
and generalized attachment loss but who is
systemically healthy? Is it possible to classify this
condition as chronic periodontitis owing to the
predominant local factors, or should it be placed
under the category of aggressive periodontitis
because the amount of destruction is too much for
that particular age (Devi and Pradeep, 2009)?
There is definite overlap and confusion in these
areas that needs to be addressed.
6) Are we able to diagnose and place aggressive
and chronic periodontitis disease categories
within the limits of the existing classification?
No. The present classification system depends
upon assessing the rate of progression spread over
multiple appointments in order to diagnose
aggressive periodontitis. It is not prudent on our
part to subject the patient to repeated clinical visits
just to place him/her under a specific disease entity
such as aggressive or chronic periodontitis.
Further, determining the rate of progression of
the disease at any given point of time is prone to
erroneous data, as evidence shows that
periodontitis progresses with periods of
quiescence and exacerbation because of various
factors that influence how rapidly periodontal
tissues are destroyed (Loe et al., 1978; Axelsson and
Lindhe, 1981; Lindhe et al., 1983; Albandar et al.,
1986; Papapanou et al., 1989; Brown and Loe,
1993; Gunsolley et al., 1995; Schatzle et al., 2003).
7) Can gingival diseases modified by
medications be included as plaque-induced
gingival diseases?
Gingival diseases modified by medications have
been included under the category “dental plaque-
induced gingival diseases,” which is completely
misleading as they are not dependent on dental
plaque for their manifestation (Loe et al., 1986;
Hallmon and Rossmann, 1999; Mariotti, 1999)
8) Is it vindicated to include a gingival disease
modified by medication category and
simultaneously omit a parallel category on
periodontal disease modified by medications?
In many instances, drug-induced gingival
overgrowth is accompanied by combined pockets
and attachment loss. In such cases two different
diagnoses can be made: a) drug-influenced gingival
86 Journal of the International Academy of Periodontology 2012 14/4
enlargement; b) chronic/aggressive periodontitis.
A simple provision to include periodontal disease
modified by medication could solve the confusion
of two probable diagnoses.
9) The 1999 AAP classification has meticulously
tried to segregate each disease under a
different category, but lists periodontal
abscess as a separate entity. Is this justified?
Periodontal abscesses share their etiology with
periodontal pockets and are merely an exaggerated
clinical manifestation. Nowhere in the field of
medicine is an abscess classified as a disease. It
probably got carved out as a separate entity
because it required a different treatment regime.
This adds muscle to our argument that a
classification based on treatment needs is the order
of the day (Rees, 1998; Meng, 1999)
10) Was there a necessity to separately categorize
diabetes mellitus-associated gingivitis and
exclude the parallel periodontitis category?
The reason cited for this was 'diabetes mellitus-
associated chronic periodontitis' and 'diabetes
mellitus-associated aggressive periodontitis'
would unnecessarily complicate matters and could
not be justified by supporting data (Armitage,
1999). This reason seems unacceptable. First, the
classification by itself is very exhaustive in its
current form and an addition of one more
subcategory for 'diabetes-associated periodontitis'
would not have really mattered. Secondly, in 1993
Loe had labelled periodontal disease as the sixth
complication of diabetes, hence is logical to think
that diabetes mellitus influences gingivitis and
periodontitis in equal measures (Loe, 1993; Lang et
al., 1999; Graves et al., 2007; Preshaw et al., 2007).
11) Is there a separate category called 'smoking-
associated gingivitis or periodontitis'?
There is no category for smoking-associated
gingivitis or periodontitis even though many cross-
sectional and longitudinal studies indicate a strong
relationship between smoking and increased risk
of periodontal breakdown (Bolin et al., 1986;
Soskolne and Klinger, 2001; Taylor, 2001)
12) Can we comfortably diagnose, without
disjointedness, a case of plaque-induced
gingival inflammation superimposed on a
reduced but healthy periodontium without an
iota of doubt as to whether it is periodontitis
or gingivitis, within the framework of the AAP
1999 classification?
An interesting diagnostic dilemma arises when
gingival inflammation occurs in a successfully
treated periodontitis patient during the
maintenance phase of therapy. The inflammation
can be interpreted either as periodontitis or
gingivitis, because at any given point of time the
clinician cannot construe whether the attachment
loss is progressive or stable. This compels the
clinician to inevitably rely on longitudinal records
of periodontal status, including clinical
attachment levels, making the diagnosis
impractical (Beck et al., 1997; Armitage, 1999;
Rivera-Hidalgo, 2003; Newman et al., 2006).
13) Does the existing classification include the
peri-implant diseases?
In spite of rapid advancement in the field of
implantology, there is no provision in the present
classification for the diseases around implants,
leaving a significant void (Armitage, 1999; Devi
and Pradeep, 2009)
14) Is it clinically and practically relevant to
classify 'classical gingival recession' in the
scenarios mentioned below under different
categories?
First scenario: “A treated periodontitis case
currently showing reduced periodontal support
(recession).” If it is superimposed by gingival
inflammation without evidence of further
attachment loss, it should be diagnosed as
gingivitis; otherwise it should be diagnosed as
periodontitis (Machtei et al., 1997; Armitage, 1999;
Rivera-Hidalgo, 2003).
Second scenario: Toothbrush trauma resulting in
recession is classified under non-plaque-induced
traumatic lesion physical injury (Khocht et al.,
1993; Armitage, 1999; Holmstrup, 1999; Rivera-
Hidalgo, 2003; Wolf and Hassell, 2006).
Third scenario: Predisposition to gingival
recession because of anatomical variation
(proclination) is classified under mucogingival
deformities and conditions (Kallestal and Uhlin,
1992; Armitage, 1999; Rivera-Hidalgo, 2003). Any
soft tissue recession occurs only after some form
of osseous dehiscence. Whether this condition
should be classified as a disease or only as a
morphological variation of healthy periodontium
is irrelevant and this induces confusion
(Holmstrup, 1999).
15) Is there a real need to overtly emphasize the
term 'aggressive periodontitis,' especially
when there have been a lot of concerns raised
ever since the term was coined?
Aggressive periodontitis can be considered as
merely a severe form of the same disease. There is
considerable literature to show that both chronic
and aggressive periodontitis have similarities in the
following aspects:s clinical presentation (Armitage
and Cullinan, 2010), microbiology (Armitage,
2010), immunopathogenesis (Armitage et al.,
2010), mechanism of bone loss (Bartold et al.,
2010) and histopathology (Smith et al., 2010). If a
specific therapeutic regime is developed for
aggressive periodontitis, then the use of the term
is justifiable (Van der Velden, 2000; Schatzle et al.,
2003; Meyer et al., 2004; van der Velden 2005).
16) Does the present classification system
 Flemingson J. Lazarus et al: A Proposed New Periodontal Disease Classification 87

Table 1. Proposed New Classification – Key features

Category 1 gingivitis/periodontitis/peri-implant mucositis/peri-implantitis

Plaque-associated gingivitis/periodontitis occurring in an otherwise healthy individual not compounded by
anatomic variations, environmental factors, systemic conditions or iatrogenic causes.
1. Present in adults/children. Age is not a defining criterion.
2. Purely associated with the presence of local factors, but the number of local factors is not a defining criterion.
3. Pathogenesis is mainly microbial in origin.
4. Rate of progression is not a decisive factor and is considered merely as a varied response to the situation.

Category 2 gingivitis/periodontitis/peri-implant mucositis/peri-implantitis

Plaque-or non-plaque-induced gingivitis/periodontitis/peri-implant mucositis/peri-implantitis occurring in a
systemically healthy individual compounded by risk factors such as anatomic variations, environmental factors,
medications and or iatrogenic factors.
1. Can be present in adults/children. Age is not a defining criterion.
2. May or may not be associated with the presence of local factors
3. Rate of progression not considered a criterion in arriving at a diagnosis
In addition to the above-mentioned clinical findings, one or more of the following factors can be present:
A. Anatomic factors: Cervical enamel projections, palatogingival groove, enamel pearls, proximal root
grooves, severely mal-aligned/crowded teeth, root fractures, cervical root resorption, cemental tears
B. Iatrogenic factors: improper restorations and appliances
C. Environmental factors: adverse habits such as smoking, pan chewing, wedging of toothpicks between
teeth, application of fingernail pressure against gingiva, etc.

Category 3 gingivitis/periodontitis/peri-implant mucositis/peri-implantitis

Plaque- or non-plaque-induced gingivitis/periodontitis occurring in a medically compromised patient wherein the
systemic component may be either a sole contributing factor or a modifying factor
Contributing factors
1. Hematologic: leukemia, acquired neutropenia, others.
2. Genetic disorders: Down syndrome, Papillon-Lefevre syndrome, Chediak-Higashi syndrome, leukocyte
adhesion deficiency syndromes, familial and cyclic neutropenia, histiocytosis syndromes, glycogen storage
diseases, infantile genetic agranulocytosis, Cohen syndrome, Ehlers-Danlos syndrome, hypophosphatasias, etc.
3. Muco-cutaneous lesions: Lichen planus, pemphigoid, pemphigus vulgaris, erythema multiforme, lupus
erythematosus
4. Diseases of viral and fungal origin: herpes virus infections, Varicella zoster, Candida spp. infections, HIV,
histoplasmosis
Modifying factors
1. Female hormone association
2. Diabetes
3. Immune compromised conditions, e.g., HIV, AIDS
4. Vitamin C deficiency
Necrotizing diseases [necrotizing ulcerative gingivitis or periodontitis (NUG or NUP)]. Necrotizing diseases have a
definite bacterial etiology, but they invariably require predisposing factors such as stress, nutritional deficiency,
fatigue, alcohol or drug abuse, or systemic diseases for initiation and progression of the lesions. These predisposing
factors are always associated with immunosuppression.

consider the multifactorial character of
periodontal disease?
All the risk factors are not considered, e.g.,
smoking and diabetes (Armitage, 1999)
17) Can all patients be classified with precision as
to whether they have either localized or
generalized periodontitis?
No. The terms localized and generalized were
introduced by the consensus group at the AAP
1999 classification workshop, where it was decided
to use 30% involvement as the cut-off point. But it
was purely an arbitrary decision and was never
based on any data. The point is - does having two
names in any way benefit or alter the treatment
plan? Or does it create confusion? Armitage
explains it well “A situation where the 30% cut-off
is rigidly used on a classic case of localized
aggressive periodontitis, in which all the incisors
and first molars were affected (a total of 12 teeth),
and if the particular individual has only 28 teeth
present, the calculation of 12/28 becomes 42.9%.
So would this classic case of localized
periodontitis become generalized periodontitis?”
(Armitage and Cullinan 2010). Any cut-off value
can only lead to contradiction and confusion.
Instead, it is better to mention the teeth or areas
88 Journal of the International Academy of Periodontology 2012 14/4
affected by periodontitis, and simply refer it as
periodontitis.
The need for a new classification
In our view, a classification system should be simple,
easy to understand, easy to reproduce and clinically
relevant (Murphy, 1997; Armitage, 1999; Armitage,
2002; Merriam-Webster, 2010). Even though the
present AAP 1999 classification system is widely used
and has stood the test of time, it has its own limitations
and has not fulfilled all the criteria required for an ideal
classification system (Bernier, 1957; Armitage, 1996;
Armitage, 1999; Armitage, 2002; Baelum and Lopez,
2003; Armitage, 2004). With the existing system, there
is lack of clarity among dental students and general
dental practitioners. It becomes difficult to categorize
periodontal disease and restrict it to one type of
classification as it is multifactorial (Michalowicz et al.,
1991; Marazita et al., 1994; Grossi and Genco, 1998;
Monteiro da Silva et al., 1998; Tonetti, 1998; Kinane,
1999; Van der Velden, 2000; Al-Zahrani et al., 2003;
Hujoel et al., 2005; Van der Velden, 2005; Takashiba and
Naruishi, 2006; Boyapati and Wang, 2007). A
classification system should take into account not only
the etiologic factors but also the contributing factors,
risk factors and aggravating factors. So it is a herculean
task to frame a classification that satisfies all the ideal
requirements.
Further, the understanding of the etiopatho-
genesis of periodontal disease has greatly increased
with the ushering in of proteomics and genomics,
changing the way we look at it. However, this newly
acquired knowledge has to be incorporated into the
diagnosis of periodontal disease, which to date we have
failed to do. Despite our claims of better understanding
of periodontal disease and its etiology, our treatment
approach, based on a non-specific plaque hypothesis,
has remained by and large the same over the years,
making the diagnosis component redundant (Loesche,
1979; Newman et al., 2006).
Classification that facilitates easy treatment
planning
Periodontal disease is by and large initiated by
periodontal pathogens and is immensely modulated by
the host response. It is apt on our part to base the
classification mainly on the microbial role. Because the
progression is influenced by various factors such as
systemic diseases, environmental factors and
anatomical variations, these too must be taken into
account to further categorize the conditions.
Progression of the disease, be it chronic or aggressive,
is only a reflection of varied intensity of the condition
and probably represents two arms of the same disease
under the influence of innumerable factors. So the very
terminology depicting the rate of progression or the
extent of the condition has been eliminated from this
classification and only the inciting factors have been
stressed to categorize the conditions. The inclusion of
the inciting factors to classify the condition makes the
etiology and its role very clear, thus facilitating
treatment planning. The new, simpler classification can
act as a silver lining that lacks ambiguity, can be clearly
understood and also facilitates treatment needs.
Periodontal disease has been classified as Category 1, 2
or 3 gingivitis/periodontitis/peri-implant mucositis/
peri-implantitis.
Benefits of the proposed new classification:
This classification aims to bring a clear understanding
of periodontal disease to the patient, general
dentist, periodontist and insurance agencies, and to
facilitate the course of treatment required.
1. The proposed classification system helps to make a
clinical diagnosis for a patient with any periodontal
condition. There is no overlap among the disease
categories. This helps in collection of
epidemiological data, giving a better insight into the
periodontal problems in a given population and
providing the clinician with a better image of the
patient population being treated.
2. Patients will benefit from the proposed new
classification, as theye will understand the root
cause for the periodontal status. For example, a
Category 2 periodontitis patient with a
palatogingival groove will understand that the
anatomic variation is influencing the periodontal
pocket and that it needs correction. Similarly, a
complex periodontitis patient with diabetes will
understand the significance of diabetes to
periodontal health and will aim to control his or her
glycemia.
3. A general dentist will find the new simple
classification handy when it comes to devising a
treatment protocol, as there is no overlapping of
disease categories. This distinguishing feature of
the proposed classification outlines the framework
for easier treatment planning.
4. As dental insurance is gaining prominence
worldwide, a clear and simplified classification will
aid to a great extent in risk profiling of the patient
for the settlement of claims.
5. The proposed classification encompasses the risk
elements associated with periodontitis that were
hitherto not included in the 1999 AAP
classification.
6. This classification has a provision to include peri-
implant conditions.
7. The need for multiple visits to assess the disease
progression to arrive at a diagnosis is no longer
required.
Summary
The search for an ideal classification of periodontal
 Flemingson J. Lazarus et al: A Proposed New Periodontal Disease Classification 89
diseases is a work in progress and the finished product
still seems like a mirage. However, the void in
understanding the etiopathogenesis of periodontal
disease should not hamper or prevent us from having a
simpler classification that facilitates the treatment
needs of the patient. The whole idea of the proposed
classification is to simplify the existing classification
system and eliminate unnecessary confusion. As we are
yet to unravel the complete etiopathogenesis of
periodontal disease, any new classification is bound to
raise certain questions and controversies, which are
inevitable now. With the present knowledge we have
aimed to classify periodontal disease in a simpler
format, which is beneficial to the periodontal fraternity,
general dental practitioners and the patient. To quantify
or grade the progression of periodontal disease does
not come under the scope or ambit of this classification
system. The extent of disease is a clinical presentation
at a particular stage of the disease. The sole discretion
in selecting the treatment plan rests with the clinician
based on clinical picture, radiological features,
associated risk elements and the patient's systemic
condition.
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Journal of the International Academy of Periodontology 2012 14/4:91-96

Efficacy of Chlorhexidine, Metronidazole

and Combination Gel in the Treatment of
Gingivitis - A Randomized Clinical Trial
1 1 1 2
A R Pradeep , Minal Kumari ,Priyanka N and Savitha B. Naik
1 2
Department of Periodontics and Department of Endodontics and
Conservative Dentistry, Government Dental College and
Research Institute, Fort, Bangalore, Karnataka, India

Abstract
Objective: Effective plaque control is essential for prevention of gingivitis and
periodontitis. The aim of this 24-week follow-up parallel study was to evaluate the
efficacy of three topical gels in the treatment of gingivitis as compared to placebo gel.
Methods: One hundred twenty subjects diagnosed with chronic generalized gingivitis
were selected and randomly divided into four groups: Group 1 – placebo gel, Group 2 –
chlorhexidine (CHX) gel, Group 3 – metronidazole (MTZ) gel and Group 4 –
chlorhexidine-metronidazole (CHX-MTZ) gel. Clinical evaluation was undertaken using
the gingival index (GI) of Löe and Silness and the plaque index (PI) at baseline, 6 weeks, 12
weeks and 24 weeks. Microbiological analysis was also done at the same time intervals. A
subjective evaluation was also undertaken by questionnaire. Results: Groups treated with
all three gels (CHX, MTZ and CHX-MTZ) showed significant clinical and microbiological
improvement as compared to the group treated with a placebo gel. The reduction in PI, GI
and microbiological count in the group treated with the CHX-MTZ combination gel was
significant when compared to those treated with CHX and MTZ gels. Conclusion: Topical
application of CHX or MTZ alone or in combination may have a role in the management
of gingivitis.

Key words: chlorhexidine, clinical trial, gingivitis, metronidazole

Introduction of chemical antiplaque agents and remains one of the

most effective topical antiseptics reported to date that
Periodontal diseases are infections initiated by bacterial
has been successfully used for treating plaque-related
biofilms that form on the surfaces of teeth in close
gingivitis (Schiott et al., 1970; Löe and Schiott, 1970;
proximity to the supporting tissues. The susceptibility
Quirynen, 2001). Chlorhexidine has been reported to
to periodontitis is influenced by many factors such as
have some reversible local side effects, such as staining
smoking, diabetes and genetics, and prevention of
of the teeth and tongue and desquamation of the oral
gingival inflammation prevents periodontitis (Kinane
mucosa. Staining is largely dose-dependent, whereas
and Attstrom, 2005). Periodontal disease can be
desquamation of the oral mucosa and perturbation of
prevented by maintaining effective plaque control at
taste is largely concentration-dependent (Brecx et al.,
home (Sheiham, 1997). The rationale for the use of
1993).
antiplaque agents as adjuncts to mechanical cleaning
Metronidazole (MTZ) has antibacterial effects
methods is based on two factors. First, plaque is the
primarily exerted on Gram-positive and Gram-negative
major etiological factor in gingivitis (Syed and Loesche,
obligate anaerobes (Goodson, 1994). Some studies
1978). Second, the prevalence of gingivitis and
have tested the efficacy of systemic MTZ (Palmer et al.,
evidence from studies suggest that mechanical cleaning
1998; Noyan et al., 1997) during periodontal disease
methods are inadequate (De La Rosa et al., 1979;
while others have tested the topical application of MTZ
Macgregor and Rugg-Gunn, 1979; Addy et al., 1987).
directly into the infected pocket either alone
Chlorhexidine (CHX) remains the gold standard
(Pedrazzoli et al., 1992; Stelzel, 1997) or as an adjunct to
Correspondence to: A. R. Pradeep, Professor and Head mechanical debridement (Awartani et al., 1998; Riep et
Department of Periodontics, Government Dental College al., 1999).
and Research Institute,Fort, Bangalore-560002. To date, there is no study comparing the topical
Karnataka, India effects of CHX gel, MTZ gel and the combination of
E-mail: periodonticsgdcri@gmail.com
CHX and MTZ gel in gingivitis subjects. This study is
Fax: 08026703176,Ph: +919845081190

© International Academy of Periodontology

92 Journal of the International Academy of Periodontology 2012 14/4
designed to compare the efficacy of topically applied
CHX, MTZ and the combination of these two gels over
a period of 24 weeks in subjects with gingivitis.
Materials and methods
After ethical approval was granted by the Institutional
Ethical Committee and Review Board of the
Government Dental College and Research Institute,
Bangalore, 132 dentate subjects (67 males and 65
females who reported to the Department of
Periodontics, Government Dental College and
Research Institute, Bangalore) were recruited for this
double-blinded, parallel, randomized, controlled
clinical trial conducted from June to December 2011.
All randomly screened participants were informed
about the nature of the study and signed an informed
consent form. Group sample sizes were decided by
power analysis with 95% power and a significance level
of 0.05.
Subjects diagnosed with chronic generalized
gingivitis, aged 25–40 years and having at least 20
natural teeth, with no history of periodontal therapy or
previous use of antibiotics or anti-inflammatory
medication within the preceding six months, were
included in the study. All patients fulfilled the clinical
criteria of a gingival index (GI; Löe and Silness, 1963) >
1, probing depth ≤ 3 mm and clinical attachment loss =
0, with no evidence of radiographic bone loss. Subjects
with known allergies to the constituents of the
formulation, haematological disorders or other
systemic illnesses, alcoholics, immunocompromised
subjects, pregnant or lactating females, subjects
undergoing orthodontic treatment and subjects who
used tobacco in any form were excluded.
Each subject was randomly assigned by a
computer-generated numbering sequence to one of the
four groups (33 subjects in each group). Placebo gel
(Charak Pharmaceuticals, Bangalore, India); CHX gel
(1% w/w; ICPA, Mumbai, India); MTZ gel (10 mg;
Lekar Pharmaceuticals, Mumbai, India) and CHX-
MTZ gel (CHX [0.25% w/w] and MTZ [10 mg];
Indoco (Warren), Mumbai, India).
Patients accepted to participate in the study
returned for a baseline examination. Patients were told
not to perform any oral hygiene (including chewing
gum) for eight hours prior to the baseline and follow-up
examinations. Patients were assessed for plaque using
the plaque index (PI) using the Tureskey modification
of the Quigley Hein Index (Quigley and Hein, 1962;
Tureskey et al., 1970) and gingival inflammation using
the GI (Löe and Silness, 1963). Following the
assessments, all subjects received scaling and
prophylaxis to remove plaque, calculus and extrinsic
stain.
The gels were dispensed to subjects by a dental
assistant not involved in the study. All tubes had a plain
white covering labeled only with lot numbers to ensure
proper blinding of the product from the patients and
the examiner. Subjects were instructed to apply a pea-
sized amount of gel gently with the index finger to the
gums an hour after regular brushing and to leave it for
five minutes before rinsing. Subjects were also asked to
refrain from all other unassigned forms of oral hygiene
aids, including dental floss, chewing gum or oral rinses
during the study. No oral hygiene instructions such as
brushing and flossing were given to the patients to
exclude the influence of improved oral hygiene
practices on the results.
The clinician, who was blinded to the gels assigned
to the subjects, conducted all the examinations and
scorings. Subjects were assessed for GI and PI in the
same dental unit under identical conditions at baseline,
6 weeks, 12 weeks and 24 weeks. Intra-examiner
calibration was performed on 20 patients before the
study and the intra-examiner agreement was 95.2% (κ =
0.905).
Apart from the clinical evaluation, a subjective
evaluation was also undertaken at each visit using a
questionnaire relating to the taste and flavour of the
gels or any adverse effect experienced after use. To
check for compliance, the participants were asked to
return their assigned gel tubes so that the investigator
could verify the amount of gel that was used.
At the baseline and at each visit, a dental plaque
sample was collected from each subject. Each volunteer
was asked to gargle with saline to remove any food
debris. The plaque was collected from the buccal
groove of the lower first molar tooth using a sterile
paper point such that the standardized length of the
paper point (colored area) touched the tooth for 5
seconds. This specimen was immersed in 1 ml of
phosphate buffered saline (PBS). These plaque
specimens were vortexed for 10 sec and immediately
subcultures were performed on Mitis Salivarius (MS)
agar for streptococcus species and gelatin-
metronidazole-cadmium medium (GMC) for
Actinomyces species.
Colonies of Streptococcus sanguis, S. mitis, S.
intermedius, S. oralis, Actinomyces viscosus and A. naeslundii
were identified based on colony morphology. Colonies
with similar morphology were counted using a colony
counter: the numbers were recorded and the total
microbial count was taken into account.
Statistical analysis
Analysis of data was carried out using SPSS 10.5 (SPSS
version 10.5, SPSS, Chicago, IL). The values of
different parameters collected are expressed as mean ±
standard deviation (SD). Normality of continuous data
was tested using the Kolmogorov Smirnov test. Mean
changes from baseline to 6 weeks, 12 weeks and 24
weeks were also calculated. Comparisons among the
four treatment groups and within each treatment group
were performed using one-way ANOVA.
 A R Pradeep et.al.: Efficacy of CHX, MTZ and Combination Gel in Gingivitis 93

Table 1. Plaque index scores, gingival index scores and microbiological counts for all groups
at different follow-up visits

Parameter Group Baseline 6 wks 12 wks 24 wks

PI Placebo 4.31 ± 0.45 4.19 ± 0.45 4.03 ± 0.47 4.06 ± 0.46

CHX 4.52 ± 0.44 3.54 ± 0.35 2.96 ± 0.26 2.48 ± 0.42
MTZ 4.48 ± 0.44 3.94 ± 0.39 3.03 ± 0.34 2.71 ± 0.32
CHX-MTZ 4.54 ± 0.44 3.25 ± 0.41 2.45 ± 0.43 2.13 ± 0.38

GI Placebo 1.84 ± 0.30 1.79 ± 0.32 1.68 ± 0.31 1.65 ± 0.29

CHX 1.89 ± 0.32 1.24 ± 0.33 1.12 ± 0.32 0.86 ± 0.33
MTZ 1.86 ± 0.31 1.43 ± 0.27 1.22 ± 0.33 0.99 ± 0.30
CHX-MTZ 1.87 ± 0.33 1.01 ± 0.38 1.06 ± 0.36 0.51 ± 0.29

Microbial Placebo 33.36 ± 1.59 33.00 ± 1.26 32.50 ± 1.01 32.20 ± 1.32
counts MTZ 33.13 ± 0.94 23.33 ± 2.14 19.53 ± 1.20 14.37 ± 1.50
4
(x 10 ) CHX 33.43 ± 1.19 21.37 ± 1.69 13.33 ± 2.07 9.37 ± 1.50
CHX-MTZ 33.23 ± 1.52 17.27 ± 1.74 10.33 ± 1.37 6.63 ± 1.50

CHX, chlorhexidine; CHX-MTZ, chlorhexidine-metronidazole combination; GI, gingival index; MTZ,

metronidazole; PI, plaque index

Results showed significant improvement in clinical and

microbiological parameters compared to the placebo
Twelve subjects did not complete the study and were
gel group.
excluded from the analysis. There were no significant
The predominant Gram-positive species
differences among the groups with respect to any
associated with gingivitis include S. sanguis, S. mitis, S.
parameter at baseline. There was a gradual decrease in
intermedius, S. oralis, A. viscosus and A. naeslundii (Moore
the PI and GI scores in all the groups over a period of
and Moore, 1994). Therefore, these organisms were
24 weeks (Table 1).
specifically cultured to assess the microbiology.
A significant reduction in mean PI was observed in
CHX is considered as the gold standard (Schiott,
all groups at all time intervals except in the placebo
1970) antiplaque agent because of its substantivity and
group between 12 and 24 weeks. A significant reduction
is used as a positive control in the present study. CHX
was also observed in GI for all groups between the 6-
has a wide spectrum of activity encompassing Gram-
week and 12-week time intervals and between the 12-
positive and Gram-negative bacteria. In the current
week and 24-week time intervals except in the placebo
study, a significant reduction in PI and GI scores at all
group. There was no significant reduction in GI
time intervals was noticed with the use of both CHX
between any time intervals in the placebo group.
and CHX-MTZ gels, and a significant reduction in
Microbial counts also showed significant reduction
microbial counts also was found. CHX acts on the cell
in all groups at all time intervals except in the placebo
walls of the microorganisms by changing their surface
group (Tables 2 and 3).
structures (Brecx and Theilade, 1984).
On subjective evaluation, about 21% of subjects
In the current study there was significant reduction
reported an unpleasant taste and discolouration of
in PI, GI and microbial counts in the MTZ group as
teeth following the use of CHX gel and 3% with CHX-
compared to the placebo group. It is known that
MTZ gel.
cytotoxic metabolites of MTZ directly interact with
bacterial DNA, and possibly other macromolecules,
Discussion resulting in cell death (Goodson, 1994). Studies have
The purpose of this study was to assess and compare shown that CHX gel is significantly more active than
the clinical and microbiological effects of CHX, MTZ placebo, or a control substance, in controlling plaque in
and a combination of these two gels applied over a different patient groups (Löe and Schiott, 1970;
period of 24 weeks in subjects with gingivitis. All three Quirynen et al., 2001)
treatment gel groups (CHX, MTZ and CHX–MTZ) Lander et al. (1986) investigated the impact of an
94 Journal of the International Academy of Periodontology 2012 14/4

Table 2. Mean change from baseline in plaque index and gingival index scores at different
follow-up visits

Parameter Group Baseline - 6 wks Baseline - 12 wks Baseline - 24 wks

PI Placebo 0.12 ± 0.20 0.28 ± 0.22 0.25 ± 0.19

CHX 0.98 ± 0.54 1.56 ± 0.47 2.04 ± 0.66
MTZ 0.54 ± 0.27 1.45 ± 0.50 1.77 ± 0.48
CHX-MTZ 1.29 ± 0.60 2.09 ± 0.49 2.41 ± 0.59

GI Placebo 0.05 ± 0.55 0.16 ± 0.48 0.19 ± 0.45

CHX 0.65 ± 0.36 0.77 ± 0.33 1.03 ± 0.46
MTZ 0.43 ± 0.35 0.64 ± 0.47 0.87 ± 0.38
CHX-MTZ 0.86 ± 0.40 0.81 ± 0.39 1.36 ± 0.46

Microbial Placebo 0.36 ± 2.09 0.53 ± 1.61 0.73 ± 1.55

counts CHX 12.06 ± 1.74 20.10 ± 1.99 24.07 ± 1.53
(x 104) MTZ 9.8 ± 2.61 13.6 ± 1.59 18.77 ± 1.74
CHX-MTZ 15.96 ± 2.30 22.90 ± 1.86 26.60 ± 2.44

CHX, chlorhexidine; CHX-MTZ, chlorhexidine-metronidazole combination; GI, gingival index; MTZ,

metronidazole; PI, plaque index

Table 3: Intra-group comparison of change from baseline at various follow-up visits

Parameter Group 6 wks vs 12 wks 6 wks vs 24 wks 12 wks vs 24 wks
(p-value) (p-value) (p-value)

PI Placebo 0.004* 0.011* 0.568

CHX < 0.001* < 0.001* 0.002*
MTZ < 0.001* < 0.001* 0.014*
CHX-MTZ < 0.001* < 0.001* 0.027*

GI Placebo 0.690 0.549 0.973

CHX 0.184 < 0.001* 0.014*
MTZ 0.056 < 0.001* 0.043*
CHX-MTZ 0.600 < 0.001* < 0.001*

Microbial Placebo 0.725 0.725 0.725

counts CHX < 0.001* < 0.001* < 0.001*
(x 104) MTZ < 0.001* < 0.001* < 0.001*
CHX-MTZ < 0.001* < 0.001* < 0.001*

*Statistically significant difference. CHX, chlorhexidine; CHX-MTZ, chlorhexidine-metronidazole combination;

GI, gingival index; MTZ, metronidazole; PI, plaque index

irrigant on clinical and microbiological parameters by
randomly irrigating non-debrided pockets with a single
dose of 0.2% CHX gel, 0.2% CHX solution or
physiological saline. There were no differences between
sites treated with the gel or the solution at any time.
Recently, a study has shown that 0.2 % CHX gel
therapy may be an option to treat and prevent gingivitis
and reduce yeast counts in children infected with HIV
(Machado et al., 2011). Pannuti et al. (2003) indicated
that the use of a 0.5% CHX gel was effective in
reducing interdental gingival bleeding in special
patients as compared to a placebo gel. The
improvement seen in the current study in the CHX gel
group was in accordance with the previous studies.
The reduction in plaque and gingivitis scores in the
placebo group can be attributed to the Hawthorne
effect (Jeffcoat, 1992).
Several studies have tested the topical application
 A R Pradeep et.al.: Efficacy of CHX, MTZ and Combination Gel in Gingivitis 95
of MTZ directly into the infected pocket either alone
(Pedrazzoli et al., 1992; Stelzel et al., 1997) or as an
adjunct to mechanical debridement (Awartani and
Zulqarnain, 1998; Riep et al., 1999).
In one study MTZ administered via the systemic
route during a 28-day period was found to effectively
decrease plaque and gingivitis development in dogs
(Heijl and Lindhe, 1979). Riep et al. (1999)
demonstrated that there were no significant differences
between treatment with MTZ dental gel plus scaling
and root planing (SRP) and SRP alone.
In a study that compared a simplified oral hygiene
regime (SRP and Bass brushing) with this same regime
plus 0.02% CHX, 0.05% MTZ and inactive control
solutions delivered supra-gingivally by a pulsating water
jet irrigator, significant improvements were seen in all
parameters for all the groups. CHX was found to be
better in reducing PI at all times except at day 84.
Although the differences were statistically highly
significant, clinically the differences between groups
were relatively small, except for a CHX effect on PI
(Aziz-Gandour et al., 1986).
Recently, a study comparing the clinical and
microbiological effects of 1% CHX gel, 1% MTZ gel,
and placebo gel in persistent pockets concluded that
probing depth was significantly reduced by the same
amount in all groups, although mean pocket reductions
were greater in the CHX and MTZ group in
comparison to the placebo (Perinetti et al., 2004).
In accordance with the previous study, the current
study also showed no significant differences in PI and
GI between the CHX and MTZ gel groups at the 12-
week and 24-week time intervals, indicating that the
MTZ gel is equally as efficacious as the CHX gel.
However, the combination gel (CHX-MTZ) group
showed a significant reduction in PI, GI and microbial
counts when compared to the CHX and MTZ gel
groups, indicating that the combination gel
demonstrates an additive effect of both components.
In the current study 21% of subjects reported an
unpleasant taste and discolouration of teeth following
the use of CHX gel. Three percent of those using the
combination gel reported the same thing. The tooth
staining is thought to be the result of a local
precipitation reaction between tooth-bound CHX and
chromogens found within foodstuffs and beverages
(Brecx et al., 1993).
Conclusion
The current study has shown that topical CHX gel,
MTZ gel and combination gel (CHX-MTZ) can reduce
PI, GI and microbiological counts over a period of 24
weeks. Moreover, the combination gel has been shown
to be more efficacious than the CHX gel, which is the
gold standard of antiplaque agents. However, topical
gel application cannot be a substitute for mechanical
plaque control. Further long-term studies are required
to see whether the use of a topical gel will eventually
result in a clinically relevant reduction in chronic
periodontitis.
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Journal of the International Academy of Periodontology 2012 14/4:97-104

Corticotomy-facilitated Orthodontics
in Adults Using a Further
Modified Technique
1 2 1
Eatemad A. Shoreibah , Ahmed E. Salama , Mai S. Attia , and
3
Shahira M. Al-moutaseum Abu-Seida
1
Department of Oral Medicine, Periodontology, Oral Diagnosis
and Radiology; 2Department of Orthodontics, Faculty of Dental
Medicine (Girls Branch), Al Azhar University; 3Faculty of Oral
and Dental Medicine (2002) -Ain Shams University, Cairo, Egypt

Abstract
Aim: To evaluate the effect of corticotomy-facilitated orthodontics (CFO) in adults using a
further modified technique versus traditional therapy in orthodontic tooth movement.
Methods: Twenty adult orthodontic patients with moderate crowding of the lower anterior
teeth were randomly divided and treated with either a modified technique of corticotomy-
facilitated orthodontic tooth movement (Group I) or conventional orthodontic therapy
(Group II). Total treatment time was calculated in weeks from the time of activation of the
orthodontic appliance immediately following the corticotomy procedure to the time of
debracketing. Clinical periodontal parameters and standardized periapical radiographs
were recorded at baseline, post-orthodontic treatment (time of debracketing) and six
months post-operatively. The primary radiographic variables were root length and bone
density. Results: Treatment duration for patients in both groups ranged from 14-20 weeks.
There was a statistically significant difference between the two groups regarding the
treatment duration: 17.5 ± 2.8 weeks in the CFO group and 49 ± 12.3 weeks in the
conventional orthodontic therapy group. No significant changes occurred in clinical
probing depth in either group at any time interval. The net percentage of change that
occurred in bone density from baseline to six months post-treatment was not statistically
significantly different between the two groups. Group I demonstrated a net decrease in
bone density of 21.8%, while Group II demonstrated a net decrease of 37.2%. Group I
demonstrated an average net decrease in root length of 0.02 ± 0.10 mm, while Group II
demonstrated an average net decrease of 1.4 ± 0.8 mm, which was not statistically
significantly different. Conclusion: The results of the current study suggest that
corticotomy-facilitated orthodontic tooth movement using a further modified technique
significantly reduces the total time of treatment. In addition, the incidence of root
resorption and adverse effect on teeth investing tissues associated with orthodontic tooth
movement were reduced. Moreover, the acceleration of tooth movement through the
proposed technique motivated patient cooperation.

Key words: Corticotomy-facilitated orthodontics, traditional therapies, adult

patients, root resorption, alveolar bone density, follow-up studies

Introduction which resorb old bone, and osteoblasts, which make

The use of conventional orthodontics is accomplished
by moving the root of a tooth through its surrounding
bone in the jaw of a patient. The medullary bone has a
good blood supply and is highly populated with
pluripotential cells that can convert to osteoclasts,
Correspondence to: Eatemad A. Shoreibah,
Professor of Oral Medicine, Periodontology, Oral Diagnosis
and Radiology, Faculty of Dental Medicine (Girls Branch)
Al Azhar University, Cairo, Egypt.
Tel: 02-25163770-01001748191
e-mail: eshoreibah@yahoo.com
new bone. This vital nature of the medullary bone gives
it the ability to respond in a dramatic and timely fashion
to physical insult, such as the forces used to move teeth.
The alveolar bone remodels around a tooth being
moved in response to pressure from one side as the
tooth is pressed against it, and in response to tension
from the opposite side of the tooth as the tooth moves
away from the alveolar bone on that side (Proffit and
Fields, 2004). So it would seem that the roots of the
teeth should move rapidly during conventional
orthodontic treatment because they extend down into

© International Academy of Periodontology

98 Journal of the International Academy of Periodontology 2012 14/4
the jawbone and are surrounded by the soft and vital
medullary bone (Suya, 1991).
An undesirable sequela that can occur as a
consequence of conventional orthodontics is referred
to as apical root resorption. Apical root resorption is a
function of not only pressure but also time. That is to
say, the longer it takes to complete the orthodontic
work, the more root resorption that can potentially be
expected. This is most often seen in retraction cases,
and results in an unfavorable crown-to-root ratio.
Severe root resorption can lead to irreversible mobility
of the teeth, and at times even the loss of the teeth
themselves (Gantes et al., 1990; Brezniak and
Wasserstein, 1993a; Brezniak and Wasserstein, 1993b).
According to the American Association of
Orthodontists (AAO), the length of comprehensive
orthodontic treatment ranges between approximately
18 – 30 months, depending on treatment options and
individual characteristics (AAO, 2007; Sanjideh et al.,
2010). Attempts to shorten the time needed for tooth
movement can be divided into three categories: 1) local
administration of chemicals; 2) physical or mechanical
stimulation of the alveolar bone, such as the use of
direct electrical current or magnets; and 3) surgery,
including dental distraction and alveolar corticotomies
(Oliveira et al., 2010).
A technique developed by the Wilckos, called the
Wilcko orthodontics system or accelerated osteogenic
orthodontics (AOO), is similar to a single-tooth
corticotomy except that it is extended to all the teeth to
be moved during orthodontic treatment (Wilcko et al.,
2009). The investigators suggested that the design of
corticotomy and perforations was intended to
maximize the trauma to the alveolus and to promote
ample bleeding compared to creating blocks of bone.
No luxation of teeth was performed following the
corticotomy procedure, and no clinically significant
periodontal problems were identified during the active
treatment time. Clinically, no disruption of the vitality
of teeth was observed, no alveolar crest height changes
occurred, and no significant apical root resorption was
detected on the periapical radiographs (Sebaoun et al.,
2008).
It was thought the teeth moved faster because the
resistance of the cortical bone was reduced by the
surgical procedure (Kole, 1959; Suya, 1991; Germec et
al., 2006), but it was found that surgical healing
occurred mainly as reorganizing activity and accelerated
bone turnover at the surgical site: this is called “regional
accelerated phenomenon” (RAP), a term initially
coined to describe rare cases of fracture healing
(Wilcko et al., 2001), and defined as the remodeling of
soft and hard tissue to return the surgical site to a
normal state (Yaffe et al., 1994). The term “regional”
refers to the demineralization of both the cut site and
adjacent bone; the term “acceleratory” refers to an
exaggerated or intensified bone response in cuts that
extend into the marrow (Lee et al., 2008). The teeth in
the corticotomy group move in a manner similar to
conventional orthodontics tooth movement, but at a
faster rate (Wilcko et al., 2001). Various researchers have
focused on controlling the microenvironment of the
alveolar bone by using the RAP in an attempt to reduce
tissue resistance. The transient osteoporotic condition
involves increased release of calcium, decreased bone
density, and increased bone turnover, all of which
would facilitate tooth movement. This mechanism
based on the RAP differed from the classical concepts
of tooth movement, such as the pressure-tension
theory, the bone-bending theory, the mechanostat
theory, and bony block movement (Kim et al., 2009).
The mandibular anterior region is a critical site
when the blood supply is considered. The periodontal
angioarchitectures are different in the labial and lingual
surfaces of the lower incisors, and the density of the
capillary networks is unequal. Therefore, corticotomy
procedures may require some modification in this
sensitive area. In the mandible, where the roots of the
anterior teeth are close and surgical access to the lingual
aspect of the bony structures is limited, a modified
corticotomy technique can be safely used (Germec et
al., 2006).
This study aimed to evaluate whether patients who
undergo selective alveolar corticotomy using a further
modified technique as part of their orthodontic
treatment have similar outcomes to patients who
undergo traditional orthodontic therapies.
Materials and methods
A total of 20 adult orthodontic patients (17 females and
3 males) with an age range of 18.4 to 25.6 years and with
moderate crowding of the lower anterior teeth
participated in the study. The participants were selected
from patients seeking orthodontic treatment in the
outpatient clinic of the Orthodontic Department,
Faculty of Dental Medicine for Girls, Al-Azhar
University-Girls Branch.
The criteria for inclusion in the study were as
follows: 1) crowding of the lower anterior teeth only,
ranging from 3-5 mm; 2) good oral hygiene; 3) skeletal
class I; 4) adequate gingival thickness (evaluated using a
periodontal probe; De Rouck et al., 2009); 5) no acute
periodontal involvement; 6) no previous orthodontic
treatment; 7) no previous periodontal surgeries; 8) no
regular administration of any medication.
The participants were divided into two groups:
Group I was treated with a fixed standard edgewise
orthodontic appliance accompanied by a further
modified corticotomy operation in a non-extraction
treatment plan. Group II was treated with a fixed
standard edgewise orthodontic appliance alone in a
non-extraction treatment plan. All patients were given
information about the proposed treatment and were
asked to sign a consent form approved by the local
ethics committee.
 Eatemad A. Shoreibah et al: Corticotomy-facilitated Orthodontics in Adults 99

Initial periodontal therapy consisted of full mouth barely reached the medullary bone, and horizontal
scaling utilizing both hand and ultrasonic instruments subapical cuts were not performed. Flaps were
under local anesthesia. Four to six weeks following the repositioned at their original pre-surgical site and
initial phase of treatment, a re-evaluation was sutured. Post-operative care consisted of a prescription
performed to assess periodontal condition. The for a systemic antibiotic, an antiedematous drug, and
following data were recorded for all patients: extra-oral
and intra-oral photographs, an orthodontic study
model, a digital panoramic radiograph and a
standardized digital lateral cephalometric radiograph.

Measurements
Clinical and radiographic parameters were recorded the
day of surgery, immediately post-treatment (at the time
of debracketing) and six months post-treatment.
Clinical measurements were made with a William's
probe and recorded to the nearest millimeter.
Radiographic measurements were assessed as follows:
bone density (BD) was assessed using the DBSWIN
software, which is a part of the recently introduced
VistaScan system. The mean gray value in each region Figure 1. Radiographic measurement of bone density
of interest was calculated (256 gray levels of color
resolution) by assigning the gray value 0 to black, and
the value 256 to white. To measure bone density, linear
density measurements were performed by drawing a
line parallel to the root surface. The line extended from
the apex of the alveolar crest to the level of the apex of
the root. A line was drawn midway between every two
lower anterior teeth. The grey level along each line was
recorded at the beginning of the line, at the middle, and
at the end. The average of the three readings was
calculated to obtain the mean average density (grey
level) along this line (Figure 1). The measurement of the
root length was done by measuring the distance
between the cemento-enamel junction (as a reference Figure 2. Radiographic measurement of root length.
point) to the apex of the root (Figure 2).
Passive installation of an orthodontic appliance
was performed, including direct bond pre-adjusted
brackets (Roth prescription; 0.022 x 0.028 inches) from
the right mandibular second premolar to the left
mandibular second premolar, using chemical cure
orthodontic adhesive and banding of the mandibular
first molars. The appliance was not activated pre-
surgically.
The corticotomy technique used in this study for
Group I is a modification of the basic corticotomy Figure 3. Reflection of labial alveolar flap.
technique described by Wilcko et al. (2009), and it was
performed under local anaesthesia: intracrevicular full
thickness flaps were reflected labially from the distal
surface of the lower right canine to the distal surface of
the lower left canine. The flaps were reflected beyond
the apices of the lower anterior teeth (Figure 3).
Selective alveolar decortication was performed in the
form of vertical grooves through the labial cortical
plate of bone using a small round stainless steel surgical
bur. (Figure 4). The vertical grooves started 1-2 mm
below the alveolar crest and extended 1-2 mm below
the apices of the teeth. The decortication grooves Figure 4. Interradicular alveolar decortication grooves.
100 Journal of the International Academy of Periodontology 2012 14/4
analgesic for seven days (Dziak, 1993; Wilcko et al.,
2001; Wilcko et al., 2003). Patients were instructed to
rinse twice daily for two minutes for a period of two
weeks using 0.12% chlorhexidine gluconate.
A
B complete the major orthodontic movements within the
C different measurements within each group.
D Probing depth
Figure 5. Case presentation: A) Pre-treatment intra-
oral photographs; B) Post-treatment intra-oral
photographs; C) Pretreatment bone density analysis
using DBSWIN software; D) Post-treatment bone
density analysis using DBSWIN software and six
months post-treatment, demonstrating a net increase
in bone density.
Orthodontic tooth movement was initiated
immediately after the surgical procedure by installation
of a nickel-titanium archwire 0.012". Orthodontic
adjustments were performed every 2 weeks. Nickel-
titanium archwires 0.012", 0.014", 0.016", and 0.018"
were used for leveling and alignment. Stainless steel
archwires up to size 0.019" x 0.025" were used for
finishing (Figure 5).
The second group was treated conventionally with
standard edgewise orthodontic appliances alone in a
non-extraction treatment plan. The first molars on
both sides were banded and brackets were bonded on
the premolars, canines and incisors. A nickel-titanium
archwire was passed through the teeth of the
mandibular arch in an attempt to align them.
The orthodontic appliances, once activated, are
adjusted periodically, as needed, to move the teeth
toward their desired positions. With this procedure
there is a three to four month window of opportunity
to complete the major orthodontic movements at an
accelerated rate. After that point, the teeth move at
conventional orthodontic rates. Thus, the orthodontic
appliances must be adjusted frequently enough to
first two to four months of treatment. Satisfactory
movement has occur red with adjustments
approximately every two weeks. Before debonding, the
dentition was stabilized with rigid arch wires.
Statistical analysis
The collected data were tabulated and statistically
analyzed using SPSS analytic software (SPSS, IBM
Company). Student's t-test was used to test the effect of
group on different measurements within each interval.
Paired t-tests were run to test the effect of intervals on
Results
Total treatment time was calculated in weeks from the
time of activation of the orthodontic appliance
immediately following the corticotomy procedure to
the time of debracketing. Treatment durations for
patients were a mean of 17.5 weeks and 49 weeks for
Group I and Group II respectively. There was a
statistically significant difference in total treatment time
between the two groups (Figure 6).
Within each group, there was a significant difference in
probing depths at different time intervals. However,
within Group I there was no significant difference in
probing depths during the retention period
(immediately post-treatment to six months post-
treatment). In both groups there was a significant
difference in probing depths between the beginning of
treatment and six months post-treatment (Table 1 and
Figure 7).
 Eatemad A. Shoreibah et al: Corticotomy-facilitated Orthodontics in Adults 101

Table 1. Comparison of pocket depths in the two groups

Group Group I Group II p

Period Mean SD SE Mean SD SE

Pre-operative 1.28 0.47 0.15 1.82 0.48 0.15 0.059

Post-operative 1.12 0.42 0.13 1.76 0.46 0.15 0.175

6 months 1.86 0.15 0.05 1.70 0.32 0.10 0.329

Group I, corticotomy-facilitated orthodontic tooth movement; Group II - corticotomy-facilitated
orthodontic tooth movement and bone grafting material.
Mean duration (weeks)

Test Control
Figure 6. Mean treatment duration values in the two groups.

Group I Group II

2
1.8
Mean Probing Depth

1.6
1.4
1.2
1
0.8
0.6
0.4
0.2
0
Pre-operative Post-operative 6 months

Figure 7. Mean changes in probing depth in the two groups.

There was no statistically significant difference
between the two groups in probing depths at each time
interval. Six months post-treatment, Group I
demonstrated an average net decrease in probing depth
of 1.86 ± 0.15 mm, while Group II demonstrated a
mean net decrease in probing depth of 1.70 ± 0.32 mm.
Bone density and root length
Within the two groups, there were no significant
differences in the amount of change in bone density
during different time intervals. The difference between
the two groups regarding the amount of decrease in
bone density from immediately post-treatment to six
months post-treatment was not statistically significant.
The mean decrease in bone density for Group I was
29.4%, while it was 46.0% for Group II (Table 2 and
Figure 8). The net percentage change in bone density
from the beginning of treatment to six months post-
treatment was not statistically different between the two
groups. Six months post-treatment, bone density values
of Group I treated with the modified corticotomy
technique were 21.8% less than pretreatment values,
while bone density values of Group II treated with
102 Journal of the International Academy of Periodontology 2012 14/4

Table 2. Changes over time in bone density of each group

Group Period Mean difference (%) SD p

Pre-operative – Post-operative -29.4 23 0.026*
Test Post-operative – 6 months 7.6 10.8 0.096
Pre-operative – 6 months -21.8 14.9 0.041*
Pre-operative – Post-operative -46.0 20.3 < 0.001*
Control Post-operative – 6 months 8.8 7.3 0.070
Pre-operative – 6 months -37.2 19.2 0.004*

*p ≤ 0.05

Test Control

120
Mean bone density

100
80
60
40
20
0
Pre-operative Post-operative 6 months

Figure 8. Changes in mean bone density of the two groups over time.

Table 3. Changes in root length in the two groups

Group Test Control

p -value
Period Mean SD SE Mean SD SE

Pre-operative – Post-operative -1.5 0.8 0.3 -13.5 4.9 1.6 0.002*

Post-operative – 6 months -1.3 2.5 0.8 -1.8 3.4 1.1 0.784
Pre-operative – 6 months -1.5 0.9 0.3 -10.7 9.5 3 < 0.001*
*p ≤ 0.05

conventional orthodontic therapy were 37.2% less than an average net decrease in root length by 1.7 ± 9.5 mm
pretreatment values (Table 2 and Figure 8). (Table 3 and Figure 9).
With regard to root length, Group I showed a
statistically significantly higher mean percent decrease Discussion
in root length than Group II through the whole study
Corticotomy has been employed for several decades in
period (pre-operative to six months post-treatment).
an attempt to shorten orthodontic treatment times.
Group I demonstrated an average net decrease in root
Treatment of a large group of adult patients using this
length of 1.5 ± 0.9 mm, while Group II demonstrated
modified surgical procedure was reported in 1991 and
 Eatemad A. Shoreibah et al: Corticotomy-facilitated Orthodontics in Adults 103
Mean % Change in Root Length
-2
-4
-6
-8
-10
-12
-14
-16
Pre-operative-
Post operative
Figure 9. Mean percentage change in root length in the two groups
was referred to as “corticotomy-facilitated
orthodontics” (Sebaoun et al., 2008).
The selective alveolar decortication induces
increased turnover of alveolar spongiosa. The surgery
resulted in a substantial increase in alveolar
demineralization, a transient and reversible condition
that will result in osteopenia. The osteopenia enables
rapid tooth movement because teeth are supported by
and moved through trabecular bone. When
orthodontic tooth movement is completed, an
environment is created that favors alveolar re-
mineralization (Sebaoun et al., 2008).
The results of this study revealed that the
conventionally treated group had a mean treatment
duration of 49 weeks while the corticotomy-facilitated
group had a mean treatment duration of 17.5 weeks.
This correlates with previous studies that indicated that
the initial acceleratory phase is much greater in the
corticotomy group than in the control group, with
differences in tooth movement evident during the first
weeks. In the study reported by Sanjidehet et al. (2010),
the corticotomy side showed twice as much tooth
movement compared with the control side by the tenth
day.
Kole (1959) said that most cases with corticotomy
are completed in twelve weeks or less, but upon
examination of the cases it appeared that the fine
finishing movements that are employed before an
orthodontic case would be considered completed were
absent (Lino et al., 2006).
The modifications in corticotomy-facilitated
orthodontic tooth movement reduce both the amount
of removed bone and the operation time (Germec et al.,
2006). Participants in Germec's study presented with
crowding of the lower anterior teeth that ranged from
3-5 mm. Crowding was resolved and orthodontic
treatment was completed by dental expansion only,
without using any other means of gaining space, in 14-
20 weeks. Their result is equivalent to results reported
in previous studies in which moderate and severe
crowding was treated without extraction by
Test Control
Post-operative- Pre-operative-
6months 6 months
corticotomy/osteotomy-assisted orthodontics and in
shorter periods of time (Hajji et al., 2001 and Wilcko et
al., 2001). This finding could be explained by the
expansion of the envelope of tooth movement
following corticotomy, which was suggested in a study
by Ferguson et al. (2006).
In the present study, patients treated with
conventional orthodontics showed higher rates of
apical root resorption than patients treated with
corticotomy-facilitated orthodontics. These results
were in agreement with previous studies, in which
almost all of them agreed that there is always less apical
root resorption in the corticotomy cases (Kole, 1959;
Germec et al., 2006). Kole (1959) had attributed this to
the bone block theory, where the creation of a thin layer
of bone over the root surface in the direction of the
intended tooth movement will facilitate the movement.
The same physiologic conditions that provide for the
facilitated tooth movement will also provide for
decreased apical root resorption. The obvious decrease
in apical root resorption rates may also be attributed to
the reduction of treatment duration and, subsequently,
the periods of force application over the teeth and their
roots.
No difference in bone density was detected in the
two groups of the present study. Although the initial
decortication protocol of AOO that was used by the
Wilcko brothers did not include augmentation alveolar
grafting, the retention images demonstrated that a
minimally adequate amount of mineralized alveolar
bone would return if the soft tissue periodontal
envelope remained intact (Ferguson et al., 2007).
El-Mangoury et al. (1987) has suggested that
crowding in the anterior region of the mandibular arch
is a predisposing factor for the initiation and
progression of periodontal diseases. Difficulty in
maintaining oral hygiene can result in a greater
accumulation of dental plaque, which is considered a
primary etiologic agent in inflammatory periodontal
disease. The existing evidence suggests that
orthodontic therapy results in small detrimental effects
104 Journal of the International Academy of Periodontology 2012 14/4
on the periodontium. In general, the evidence does not
seem to support the claim that orthodontic therapy
results in overall improvement in periodontal health
(Dannan, 2010).
Furthermore, Wilcko et al. (2001) and Gantes et al.
(1990) showed that there is no loss of alveolar bone and
no periodontal pocketing accompanying
corticotomies. This is in agreement with the results of
the present study and the results of other studies, like
those of Kole (1957) and Fischer (2007), for example.
In the present study, the absence of pockets and bone
loss may be attributed to the strict oral hygiene
measures applied to all patients, a gingival biotype ≥ 1
mm, and further modifications of the corticotomy
technique, in addition to the treatment of crowding.
Conclusions
The further modified corticotomy used in the present
study significantly enhanced the rate of tooth
movement, reduced patient complaints and reduced
treatment time. Moreover, apical root resorption was
greatly reduced and the modified corticotomy did not
affect bone density any more than conventional
orthodontics.
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Journal of the International Academy of Periodontology 2012 14/4:105-113

Clinical and Radiographic Evaluation of

Bone Grafting in Corticotomy-facilitated
Orthodontics in Adults
Eatemad A. Shoreibah1, Samir A. Ibrahim2, Mai S. Attia1 and May
3
M. Nabil Diab
1
Department of Oral Medicine, Periodontology, Oral Diagnosis
2
and Oral Radiology. Department of Orthodontics, Faculty of
Dental Medicine (Girls Branch), Al Azhar University; 3Faculty of
Oral and Dental Medicine (2002)-Ain Shams University, Cairo,
Egypt

Abstract
Aim: To evaluate the effect of bone grafting in corticotomy-facilitated orthodontics in
adults, using a further modified conventional corticotomy technique. Methods: Twenty
adult orthodontic patients with moderate crowding of the lower anterior teeth were
equally divided into two groups and treated with either a modified corticotomy-facilitated
orthodontic tooth movement alone (Group I) or modified corticotomy-facilitated
orthodontic tooth movement combined with bone grafting (Group II). Total treatment time
was calculated in weeks from the time of activation of the orthodontic appliance
immediately following the corticotomy procedure to the time of debracketing. Clinical
periodontal parameters and standardized periapical radiographs were recorded at
baseline, post-orthodontic treatment (debracketing time) and six months post-operatively.
The primary radiographic variables were root length and bone density. Results: Treatment
duration for patients in both groups ranged from 14-20 weeks. There was no statistically
significant difference between the two groups in clinical parameters at each time interval.
The net percentage of change that occurred to bone density from baseline to six months
post-orthodontic treatment was statistically significantly different between the two
groups. Group I demonstrated a net decrease in bone density of -17.59%, while Group II
demonstrated a net increase in bone density of 25.85%. Group I demonstrated an average
net decrease in root length of -0.056 mm ± 0.025, while Group II demonstrated an
average net decrease in root length of -0.050 mm ± 0.026, which was not statistically
significantly different.
Conclusion: The results of the current study suggest that corticotomy-facilitated
orthodontic tooth movement significantly reduces the total time of treatment. In addition,
the incidence of apical root resorption and periodontal problems associated with
orthodontic tooth movement were reduced. The incorporation of bone graft material
significantly increased the alveolar bone density in adult patients.

Key words: Corticotomy- facilitated orthodontics, bone grafts, alloplasts, root

resorption, alveolar bone density, follow-up studies.

Introduction adverse effect on efforts to remodel bone, particularly

Conventional orthodontic treatment in adults usually
results in problems such as marginal bone loss, gingival
recession, root resorption, and prolonged treatment
time (Newman, 1973; Midgeer et al., 1981; Sharpe et al.,
1987; Behrents, 1988; Melsen, 1991). In addition, the
characteristics of the anterior alveolar bone have an
Correspondence to: Eatemad A. Shoreibah,
Professor of Oral Medicine, Periodontology, Oral Diagnosis
and Radiology, Faculty of Dental Medicine (Girls Branch)
Al Azhar University, Cairo, Egypt.
Tel: 02-25163770-01001748191
e-mail: eshoreibah@yahoo.com
in adult maxillary protrusion cases. The anatomic limits
set by the cortical plates of the alveolus at the level of
the apices act as orthodontic walls (Handelman, 1996).
Post-treatment results show less remodeling than
desired, in addition to severe resorption, when
conventional orthodontic treatment is performed
alone (Handelman, 1996).
To avoid these complications, and meet the
patient's demand for a short treatment time,
corticotomy-facilitated orthodontics is considered.
Cor ticotomy-facilitated or thodontics is a
physiologically driven process, and an uninterrupted

© International Academy of Periodontology

106 Journal of the International Academy of Periodontology 2012 14/4
vascular supply to the areas operated upon is critical in
maintaining the vitality of the hard and soft tissues.
“Mobilization” of any outlined single-tooth blocks of
bone (luxation) is absolutely contraindicated. It can lead
to intrapulpal and intraosseous morbidity and will not
increase the distance that the tooth can be moved. The
luxation can also jeopardize the integrity of the
neurovascular bundle exiting the apex of the teeth and
result in devitalization (Wilcko et al., 2008). The alveolar
corticotomy technique has been revised and changed
over the years to eliminate possible risks of the
procedure, such as periodontal damage and
devitalization of the teeth and osseous segments
because of inadequate blood supply (Köle, 1959;
Generson 1978; Suya, 1991).
Orthopedist Harold Frost recognized that surgical
wounding of osseous hard tissue results in striking
reorganizing activity adjacent to the site of injury in
osseous and/or soft tissue surgery. He collectively
termed this cascade of physiologic healing events the
"regional acceleratory phenomenon" (RAP; Frost,
1989). Following surgical wounding of cortical bone,
RAP potentiates tissue reorganization and healing by
way of a transient burst of localized hard and soft tissue
remodeling leading to a transient catabolic condition
(Shih and Norrdin, 1985). For bone, this transient
osteoporosis means increased mobilization of calcium,
decreased bone density, and increased bone turnover,
all of which facilitate more rapid tooth movement
(Wilcko et al., 2001). The tissues formed in the alveolus
surrounding the area of desired tooth movement
respond efficiently to biomechanical forces, and teeth
move rapidly. Medullary bone osteopenia is highest
nearest the decortication sites, and as long as the teeth
continue to move, complete alveolar recalcification is
possible (Ferguson et al., 2006). It has been
demonstrated that the residual soft tissue matrix has the
ability to induce remineralization after the cessation of
tooth movement (Nyman et al., 1985).
In 2001, Wilcko et al. described selective alveolar
decortication with augmentation grafting combined
with orthodontic treatment. They trademarked their
technique as accelerated osteogenic orthodontics
(AOO), or periodontally accelerated osteogenic
orthodontics (PAOO). Although bone tissue shows a
good regenerative capacity that results in restoration of
its structural and mechanical properties, this capacity
for repair may be impaired by poor blood supply,
mechanical instability, and the presence of other tissues
with higher proliferative activity (AboElsad et al., 2009).
PAOO has contributed to greater stability of
orthodontic clinical outcomes and less relapse.
Nazarov (2003), using the objective grading system
(OGS) sanctioned by the American Board of
Orthodontics (ABO), observed no differences in non-
extraction therapies immediately after treatment
between PAOO and non- PAOO groups. At six months
post-treatment, three of the nine OGS variables
(alignment, marginal ridges, and total score) were
significantly better in the PAOO group, and no relapse
was demonstrated. Ferguson et al. (2006) suggested that
the limits of orthodontic treatment can be expanded 2-
to 3-fold in all dimensions except retraction following
PAOO, and that the stability of these positions is
probably due to loss of tissue memory from high
turnover of the periodontium as well as increased
thickness of the alveolar cortices from the
augmentation grafting.
This new orthodontic method includes the
advantages of corticotomy surgery and alveolar
augmentation. Very frequently there are preexisting
alveolar inadequacies such as fenestration and
dehiscence over the root surfaces. As long as the root
surfaces in these defects are vital and there has been no
apical epithelial migration, these alveolar deficiencies
can be corrected with alveolar augmentation. In
addition, after opening the gingival flap, a larger than
expected amount of fenestration and dehiscence may
be noted. Because the tooth movement is “buccal to the
alveolar bone,” grafts of lyophilized material would
minimize the risks associated with such movement.
Moreover, different authors suggest that the bone
grafts are aimed at increasing alveolar volume so that
even if very large expansions were implemented to
resolve severe crowding, the roots would still have
sufficient support (Wilcko, 2001, Wilcko et al., 2009,
Ferguson et al., 2007).
Biocompatible tissue-bonding bioactive glasses
(BAGs) were first introduced as bone graft materials in
the early 1970s (Wilson et al., 1993). Glasses with SiO2
content between 53 and 56 mol% form a
hydroxycarbonated apatite layer and bond to bone but
not to soft tissues; the apatite gel layer on the surface of
the bioactive glass particles attracts osteoprogenitor
cells and osteoblasts, thus stimulating bone formation
(Hench et al., 1991). The success of BAGs is due to the
bioactivity of the material, which is the result of its
composition. An increase of SiO2, a decrease of alkali,
or the addition of Al2O3 can control the durability or
water resistance of the glass and influence its long-term
reliability (Pereira et al., 1994).
The aim of the present study was to evaluate the
effect of bone grafting in corticotomy-facilitated
orthodontics (CFO) in adults using a further modified
corticotomy technique.
Materials and methods
A total of 20 adult orthodontic patients (16 females and
4 males) with an average age range of 24 years and six
months, with moderate crowding of the lower anterior
teeth were selected from patients seeking orthodontic
treatment in the outpatient clinic of the Orthodontic
Department, Faculty of Dental Medicine for Girls, Al-
Azhar University-Girls' Branch.
The participants were equally and randomly
 Eatemad A. Shoreibah et al: Evaluation of Corticotomy-facilitated Orthodontics in Adults 107
divided into two groups. Group I was treated with a
modified technique of corticotomy-facilitated
orthodontic tooth movement only, while Group II was
treated with a modified technique of corticotomy-
facilitated orthodontic tooth movement and bone
grafting material. The criteria needed for inclusion in
the study were as follows: 1) crowding of the lower
anterior teeth, ranging from 3-5 mm (skeletal class I); 2)
good oral hygiene; 3) adequate gingival thickness
(evaluated using a periodontal probe; De Rouck et al.,
2009); 4) no acute periodontal involvement; 5) no
previous orthodontic treatment; 6) no previous
periodontal surgeries; 7) no regular administration of
any medication.
All patients were given information about the
proposed treatment and were asked to sign a consent
form approved by the local ethics committee. Initial
periodontal therapy consisted of full mouth scaling
under local anesthesia utilizing both hand and
ultrasonic instruments. Four to six weeks following the
initial phase of treatment, a reevaluation was
performed to assess the periodontal condition. The
following data were recorded for all patients: extra-oral
and intra-oral photographs, an orthodontic study
model, a digital panoramic radiograph and a
standardized digital lateral cephalometric radiograph.
Clinical and radiographic parameters were
recorded the day of surgery, immediately post-
treatment (at the time of debracketing) and six months
post-treatment. Clinical measurements were made with
a William's probe and recorded to the nearest
millimeter. Radiographic measurements were assessed
as follows: bone density (BD) was assessed using the
DBSWIN software, which is a part of the recently
introduced Vistascan system. The mean gray value in
each region of interest was calculated (256 gray levels
of color resolution) by assigning the gray value 0 to
black, and the value 256 to white (Yokota et al., 1994).
To measure bone density, linear density measurements
were performed by drawing a line parallel to the root
surface. The line extended from the apex of the alveolar
crest to the level of the apex of the root. A line was
drawn midway between every two lower anterior teeth.
The grey level along each line was recorded at the
beginning of the line, at the middle, and at the end. The
average of the three readings was calculated to obtain
the mean average density (grey level) along this line. The
measurement of the root length was done by measuring
the distance between the cemento-enamel junction (as a
reference point) to the apex of the root. A comparison
between the linear measurements prior to treatment,
post-treatment, and after six months of retention was
done to determine the extent of apical root resorption
after the corticotomy-facilitated orthodontic tooth
movement for both study groups (Rennington et al.,
1989).
Passive installation of an orthodontic appliance
was performed, including direct bond pre-adjusted
brackets (Roth prescription; 0.022 x 0.028 inches) from
the right mandibular second premolar to the left
mandibular second premolar, using chemical cure
orthodontic adhesive and banding of the mandibular
first molars. The appliance was not activated pre-
surgically.
The corticotomy technique used in this study is a
modification of the corticotomy technique described
by Wilcko et al. (2009), and it was performed under local
anesthesia. For the two study groups: intracrevicular
full thickness flaps were reflected labially from the distal
surface of the lower right canine to the distal surface of
the lower left canine. The labial flap was reflected
beyond the apices of the lower anterior teeth (Figure 1).
The lingual flap was not elevated and the lingual bone
was left intact. Selective alveolar decortication was
performed in the form of vertical grooves through the
labial cortical plate of bone, using a small round
stainless steel surgical bur (Figure 2). The vertical
grooves started 1-2 mm below the alveolar crest, and
extended 1-2 mm below the apices of the teeth,
Decortication grooves barely reached the medullary
bone; horizontal subapical cuts were not performed.
After the completion of the corticotomy procedure,
bioactive glass was mixed with blood from the surgical
site in a sterile dappen dish until a sandy consistency
was obtained (Figure 3). The resultant coagulum was
transferred in increments and applied directly over the
bleeding bone (Figure 4). Flaps were repositioned at
their original pre-surgical site and sutured.
Orthodontic tooth movement was initiated
immediately after the surgical procedure by installation
of a nickel-titanium archwire 0.012". Orthodontic
adjustments were performed every 2 weeks. Nickel-
titanium archwires 0.012", 0.014", 0.016", and 0.018"
were used for leveling and alignment. Stainless steel
archwires up to size 0.019" x 0.025" were used for
finishing.
Post-operative care consisted of a prescription for
a systemic antibiotic, an antiedematous drug, and
analgesic for seven days (Dziak, 1993; Wilcko et al.,
2001; Wilcko et al., 2003). Patients were instructed to
rinse twice daily for two minutes for a period of two
weeks using 0.12% chlorhexidine gluconate.
Statistical analysis
The collected data were tabulated and statistically
analyzed using SPSS analytic software (SPSS, IBM
Company). Student's t-test was used to test the effect of
group on different measurements within each interval.
Paired t-tests were run to test the effect of intervals on
different measurements within each group.
Results
Total treatment time was calculated in weeks from the
time of activation of the orthodontic appliance
immediately following the corticotomy procedure to
108 Journal of the International Academy of Periodontology 2012 14/4

Figure 3. Bioglass mixed with blood from the

Figure 1. Reflection of labial alveolar flap. surgical site to obtain a sandy consistency.

Figure 2. Interradicular alveolar decortication Figure 4. Bone graft material application.

grooves.

Group I
1.9
1.769
1.7
1.576
1.5
1.202
1.3 1.21
1.198 1.149
1.1
0.9
0.7
0.5
Preoperative Post orthodontic After 6 months
treatment

Figure 5. Mean probing depth at different intervals within each group.

the time of debracketing. Treatment durations for
patients in both groups ranged from 14-20 weeks with a
mean of 17 weeks for Group I and 16.67 weeks for
Group II. There was no statistically significant
difference regarding the total treatment time between
the two groups.
Probing depth
Within each group, there was a significant difference in
probing depths at different times (Figure 5). In Group I,
there was no significant difference in probing depth
during the retention period (immediately post-
treatment to six months post-treatment). Within both
groups there was a significant difference between the
participants regarding the net amount of change in
probing depth that occurred from the beginning of
treatment until six months post-treatment. (Table 1 and
Figure 6)
There was no statistically significant difference
between the two groups regarding the change that
occurred in probing depth in each time interval. Six
months post-treatment, Group I demonstrated a mean
net decrease in probing depth of -1.427 ± 0.237 mm,
while Group II demonstrated a mean net decrease in
probing depth of -1.559 ± 0.164 mm (Figure 6).
 Eatemad A. Shoreibah et al: Evaluation of Corticotomy-facilitated Orthodontics in Adults 109

Table 1. Descriptive statistics (mean ± SD) and test of significance for the change in probing depth
during each interval of time within each group (paired t-test).

Group Treatment time Mean SD p

Preoperative – Post-orthodontic treatment -1.378 0.152 0.001**
Group I Post-orthodontic treatment – After 6 months -1.049 0.157 0.410
Preoperative – After 6 months -1.427 0.237 0.001**
Preoperative – Post-orthodontic treatment -1.477 0.148 0.001
Group II Post-orthodontic treatment – After 6 months -1.082 0.061 0.004*
Preoperative – After 6 months -1.559 0.164 0.001**
Group I, corticotomy-facilitated orthodontic tooth movement; Group II, corticotomy-facilitated
orthodontic tooth movement and bone grafting material. *p < 0.01, **p < 0.001

Table 2. Descriptive statistics (mean ± SD) and test of significance for the percentage
changes in bone density between the two groups
Group I Group II
p
Mean SD Mean SD
Preoperative – post-orthodontic treatment -41.501 14.157 -42.580 12.543 0.870
Post-orthodontic treatment – After 6 months 47.632 35.082 128.311 56.485 0.003*
Preoperative – After 6 months -17.596 5.774 25.849 15.644 0.001**

Group I, corticotomy-facilitated orthodontic tooth movement; Group II, corticotomy-facilitated

orthodontic tooth movement and bone grafting material. *p < 0.01, **p < 0.001.

Group I Group II

0
Preoperative Postoperative 6 months
-0.2
postoperative
-0.4
Mean Probing Depth

-0.6
-0.8
-1
-1.2
-1.4
-1.6
-1.8

Figure 6. Mean changes in probing depth in the two groups.

Bone density
Within the two groups, there were significant
differences in the change in bone density during
different intervals of time. During the period of active
tooth movement (from pre- to post-treatment) both
groups demonstrated similar percentages of decrease
in bone density. The mean decrease in bone density for
Group I was -41.50% while it was -42.58 % for Group
II. The difference between the two groups regarding
the increase in bone density from immediately post-
treatment to six months post-treatment was statistically
significant. The mean increase in bone density for
Group I was 47.6% while it was 128.3% for Group II.
The net percentage change in bone density from the
beginning of treatment to six months post-treatment
was statistically significantly different between the two
groups. Six months post-treatment, bone density values
in Group I were -17.59% less than pre-treatment values,
while bone density values of Group II were 25.85%
more than pre-treatment values (Table 2 and Figure 7).
110 Journal of the International Academy of Periodontology 2012 14/4

Table 3. Descriptive statistics (mean ± SD) and test of significance for the changes in root length
between the two groups. There were no significant differences between time intervals in either group
Group I Group II
p
Mean SD Mean SD
Preoperative – post orthodontic treatment -0.040 0.025 -0.035 0.024 0.718
Post orthodontic treatment – After 6 months -0.017 0.009 -0.015 0.010 0.694
Preoperative – After 6 months -0.056 0.025 -0.050 0.026 0.625

Group I, corticotomy-facilitated orthodontic tooth movement; Group II, corticotomy-facilitated

orthodontic tooth movement and bone grafting material.

Group I Group II

140
128.311
120
100
80
60 47.632
42.58
Bone Density

40
25.849
20
0
-20
-17.596
-40
-41.501
-60
Preoperative-post Post orthodontic Pre-operative - After 6
orthodontic treatment treatment - After 6 months
months

Figure 7. Mean percentage changes in bone density in the two groups.

Group I Group II

-0.01

-0.015
-0.02 -0.017
Bone Density

-0.03

-0.35
-0.04
-0.04

-0.05
-0.05
-0.056
-0.06
Preoperative-post Post orthodontic Pre-operative - After 6
orthodontic treatment treatment - After 6 months
months

Figure 8. Mean changes in root length in the two groups

There was no significant difference between the
two groups regarding average root length values
obtained pre-treatment, post-orthodontic treatment,
and six months post-treatment. The difference
between the two groups regarding the net amount of
root resorption was also statistically insignificant.
Group I demonstrated an average net decrease in root
length of -0.056 mm ± 0.025, while Group II
demonstrated an average net decrease in root length of
-0.050 mm ± 0.026 (Table 3 and Figure 8).
 Eatemad A. Shoreibah et al: Evaluation of Corticotomy-facilitated Orthodontics in Adults 111
A in the form of dots, grooves, or both (Generson et al.,
B the operation time. Participants in this study presented
C showed extreme cooperation and compliance in
D E
Figure 9. Case presentation. A) Pre-treatment intra-
oral photographs; B) Post-treatment intra-oral
photographs; C) Pre-treatment bone density analysis
using DBSWIN software; D): Post-treatment bone
density analysis using DBSWIN software and six
months post-treatment, demonstrating a net
increase in bone density.
Discussion
Some complications have been reported after extensive
corticotomies (Gantes et al., 1993). Some adverse
effects were caused by reduced blood flow or thermal
damage during the surgical procedures (Oliveira et al.,
2008; Akay et al., 2009). Thus, in this study, a further
modified corticotomy technique was proposed.
In conventional corticotomy techniques,
corticotomy cuts were performed labially and lingually
1978; Ferguson et al., 2007; Wilcko et al., 2001; Wilcko et
al., 2009). In some studies the grooves did not include
the alveolar crest (Duker, 1975; Suya, 1991; Germec et
al., 2006). The further modified technique proposed in
our study minimized the possible risks of the
corticotomy procedures. To secure the advantages of
maintaining the lingual mucosa and lingual bone intact,
corticotomy was performed on the labial side only of
the lower anterior region.
The modifications that were done in the current
study reduced both the amount of removed bone and
with crowding of the lower anterior teeth that ranged
from 3-5 mm. Crowding was resolved and orthodontic
treatment was completed by dental expansion only,
without using any other means of gaining space, in 14-
20 weeks. This result is equivalent to results from
previous studies in which moderate and severe
crowding were treated without extraction and in
shorter periods of time by corticotomy/osteotomy-
assisted orthodontics (Hajji, 2000; Wilcko et al., 2001).
This finding could be explained by the expansion of the
envelope of tooth movement following corticotomy,
which was suggested in a study by Ferguson et al. (2006).
In the present study, three of 20 patients were
excluded because of their failure to maintain several
consecutive appointments. The remaining patients
respecting the scheduled appointments, maintaining
good oral hygiene, and complying with the instructions
given to them. The high internal motivation the patients
had mostly resulted from their high expectations of a
much shorter treatment time than conventional
orthodontic treatment had to offer. This assumption is
supported by previous studies that reported that better
patient cooperation and acceptance were possible
advantages when lengthy orthodontic treatment was
avoided (Machado et al., 2002; Hassan et al., 2010).
Another study states that the increase in the
distance that the teeth can be moved translates to a
dramatic reduction in the need for extractions and
perhaps some orthognathic surgery (Wilcko et al.,
2008).
Following the corticotomy procedure, and during
the period of active tooth movement, both groups
demonstrated a significant decrease in bone density as a
consequence of the corticotomy procedure.
112 Journal of the International Academy of Periodontology 2012 14/4
Corticotomy invokes an RAP, where a transitional
condition of increased calcium mobilization, decreased
bone density, and increased bone turnover are
observed (Frost, 1989; Bogoch et al., 1993). Such
findings are in accordance with previous studies that
reported a significant decrease in bone density
following corticotomy-facilitated tooth movement
(Wilcko et al., 2003; Pham-Nguyen et al., 2006; Ferguson
et al., 2006; Lei Wang et al., 2009).
There was a significant difference between the two
groups regarding the increase in bone density recorded
six months after the cessation of tooth movement; the
greater increase was recorded for Group II. The use of
a bone graft with the further modified corticotomy
demonstrated a net increase in bone density of around
25.8%. This could be because of the incorporation of
bone graft material into the corticotomized bone in
Group II. This assumption is supported by the findings
of previous studies stating that bone graft materials
have a beneficial effect during bone formation because
of alkalinization, increase in collagen synthesis and
crosslinking, and hydroxyapatite for mation
(Samachson, 1969; Silver et al., 2001). Previous studies
on corticotomy-facilitated orthodontics with
augmentation grafting reported the incorporation of
bone graft material into the new layer of bone and its
beneficial effect on repair of bone deficiencies,
increasing the volume of the alveolar bone (Ferguson et
al., 2007; Wilcko et al., 2001; Wilcko et al., 2008),
expanding the limits of tooth movement (Ferguson et
al., 2006), and long-term stability (Ferguson et al., 2006;
Ferguson et al., 2007; Wilcko et al., 2008).
Apical root resorption detected in some of the
participants in both study groups was negligible and
statistically insignificant. The absence of any
significant apical root resorption has been reported in
previous studies as an advantage of CFO in
comparison to traditional orthodontics (McFadden et
al., 1989; Machado et al., 2002; Wilcko et al., 2003; Ren et
al., 2007; Moon et al., 2007 and Hassan et al., 2010) and
results from two factors. The first factor is the short
treatment duration that results from the corticotomy
procedure. This assumption is supported by previous
studies on CFO that reported decreased incidence of
root resorption with decreased duration of treatment
(Machado et al., 2002; Ren et al., 2007; Moon et al., 2007;
Hassan et al., 2010). The second factor is the decreased
bone density during tooth movement that also results
from the corticotomy procedure. This assumption is
supported by previous studies that reported that the
corticotomy-induced decrease in bone density was
responsible for the decreased incidence of root
resorption (Machado et al., 2002).
In the present study, not only was there no
deterioration of periodontal health, participants in
both groups demonstrated an improvement in probing
depths. These results are in accordance with a previous
study on CFO that reported that the shortened
treatment time is advantageous to the patient's
periodontal health (Wilcko et al., 2008).
In conclusion, the further modified corticotomy-
facilitated orthodontic technique with bone grafting
resulted in favorable clinical and radiographic
outcomes (Figure 9). Within the limits of this study, the
modified technique with bone grafting resulted in a
significant reduction in total treatment time, increased
the alveolar bone density, and reduced the incidence of
root resorption and periodontal problems associated
with orthodontic tooth movement.
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