The International Journal of Periodontics & Restorative Dentistry

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 345

Regeneration of Multiple Adjacent

Bone Dehiscences with Guided Tissue
Regeneration After Orthodontic
Proclination: A Corrective Treatment
Approach

Hilal Uslu Toygar, DDS, PhD* Gingival recession is defined as the

Beyza Hancioglu Kircelli, DDS, PhD** exposure of the root surface by an api-
cal shift in the position of the gingiva.1
Numerous studies have shown that
irreversible recession can be caused by
fixed appliance therapy in 1.3% to 10%
of treated cases.2,3 Orthodontic tooth
movement in a labial direction in mon-
Transverse expansion or proclination of the teeth are valid alternatives to extraction keys4 and dogs5 has been shown to
in cases of crowding, but lack of stability and development of bone dehiscences
result in loss of marginal bone and con-
have been demonstrated as side effects subsequent to anterior displacement of the
nective tissue attachment, as well as in
incisors. The aim of this study was to repair the osseous dehiscence associated with
gingival recession.
incisor proclination. The multiple adjacent bone dehiscences were treated with a
Transverse expansion or proclina-
titanium membrane and bone matrix. Exposed root surfaces were covered with
newly formed tissues. The patients in this study are the first to demonstrate the tion of the teeth are valid alternatives
treatment of bone dehiscences that may occur as a result of orthodontic proclina- to extraction in cases of crowding, but
tion. (Int J Periodontics Restorative Dent 2010;30:345–353.) lack of stability and development of
bone dehiscences have been demon-
strated as side effects subsequent to
anterior displacement of the mandibu-
lar incisors. Mills6 claimed that only in
a particular situation is it possible to
move the teeth out of the ”alveolar
housing,” and Wennström et al7 stated
that teeth cannot be moved out of the
”dentoalveolar envelope.”
*Assistant Professor, Department of Periodontology, Faculty of Dentistry, Baskent
University, Ankara, Turkey. It is widely accepted that 2 mm of
**Assistant Professor, Department of Orthodontics, Faculty of Dentistry, Baskent University, keratinized gingiva is enough to with-
Ankara, Turkey. stand orthodontic forces and prevent
recession, but preexisting mucogingi-
Correspondence to: Dr Hilal Uslu Toygar, Baskent University, Adana Uygulama ve
Arastirma Merkezi, Kışla Sağlık Yerleşgesi, Kazim Karabekir m, 59 s, no. 91, 01120 Yuregir, val defects can be exacerbated during
Adana, Turkey; fax: +90 322 3227979; email: usluhilaladana@yahoo.com. tooth movement.8 Therefore, it is

Volume 30, Number 4, 2010

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346
important to recognize and correct the
areas of actual or potential stress
before orthodontic therapy.
Experimental studies in monkeys4
and dogs5 have demonstrated that
bone dehiscences can be produced in
the alveolar bone when the mandibu-
lar incisors are moved anteriorly.
Development of a bone dehiscence is
an etiologic factor in the pathogenesis
of recession, supported by the findings
of many studies.9–11 It has been sug-
gested that the development of bone
dehiscences and gingival retraction
during excessive proclination of the
mandibular incisors seems to be
inevitable, especially in patients with a
thin alveolar housing.9
Several different techniques have
been described for covering the
exposed root surfaces and increasing
the dimensions of the keratinized tis-
sue in gingival recession defects.
Periodontal regeneration can be
achieved by a variety of surgical pro-
cedures, including bone grafts, bone
substitutes, and guided tissue regen-
eration (GTR). A number of studies
have shown that the use of both non-
resorbable and resorbable mem-
branes improved the soft tissue
condition of gingival recession defects
in terms of clinical attachment gain,
recession depth reduction, and
increase in keratinized tissue.12–16
The aim of this study was to repair
the osseous dehiscence associated
with incisor proclination via GTR and a
bone grafting procedure to prevent
future soft tissue fenestration and to
support the anterior facial esthetic
appearance.
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Method and materials
Patients and their parents were
informed of the exact nature of all pro-
cedures and the associated risks and
benefits and subsequently signed an
informed consent form. Patients were
motivated on oral hygiene instructions
and modifications to ensure effective
plaque control measures.
Patient 1
A 13-year-old girl (Fig 1) was referred
to the Department of Orthodontics,
Baskent University, with the complaint
of protruding maxillary teeth and
esthetic concerns when she smiled.
She presented with a characteristic
Angle Class II, division 2 malocclu-
sion: uprighted maxillary central
incisors and proclined lateral incisors,
a retrusive mandible, uprighted
mandibular incisors, a deep overbite,
and a deep curve of Spee (Fig 1a). The
patient was treated by nonextraction
procedures. A bite-jumping device
was considered to correct the Class II
relationship. After both the mandible
and maxilla were aligned and leveled
with sequential nitinol archwires, a
Jasper Jumper (American Orthodon-
tics) was applied. At the time of appli-
cation, 0.017 ⫻ 0.025-inch stainless
steel continuous archwires were
inserted and cinched back in the max-
illary and mandibular arches, respec-
tively. Despite the effectiveness of the
Class II correction, the significant pro-
clination of the mandibular incisors
demanded use of the appliance. In
this patient, the Jasper Jumper was
activated to 4 mm according to the

Fig 1e Newly formed tissue was seen
around the root surfaces.
manufacturer’s instructions (approxi-
mately 250 to 300 g of force). In 4
months, a Class I canine and molar
relationship was achieved and the
appliance was removed. At the end of
the bite-jumping treatment, mandibu-
lar incisor inclination, according to the
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347
Figs 1a and 1b Patient 1 (left) before
orthodontic treatment and (right) after pro-
clination of the incisors.
Figs 1c and 1d After flap elevation, (left)
the bone dehiscences and (right) the posi-
tion of the incisors in the alveolar housing
could be seen.
Fig 1f Clinical photograph 1 year after
the GTR procedure.
Fig 1g Superimposition of the initial and fi-
nal tracings indicating the incisor inclinations.
mandibular plane, was increased by
14.6 degrees (Fig 1b). A GTR proce-
dure was performed after removal of
the Jasper Jumper. Active compre-
hensive orthodontic treatment lasted
24 months.
Volume 30, Number 4, 2010
348
Fig 2a (left) Clinical photograph of patient
2 before orthodontic treatment.
Fig 2b (right) Flap elevation was per-
formed and the bone dehiscences could be
seen.
Fig 2c New tissue formed under the Fig 2d Clinical photograph 3 months after
membrane. membrane removal.
Patient 2
A 22-year-old woman (Fig 2) was
referred with the complaint of severe
discrepancy between her anterior
maxillary and mandibular teeth and a
resulting difficulty in biting with her
anterior teeth. She presented with a
characteristic Angle Class II, division 1
malocclusion: a constricted and
v-shaped maxillary arch, a small and
retrusive mandible, normally inclined
maxillary incisors, slightly protruded
mandibular incisors, a severely in-
creased overjet and overbite, and a
deep curve of Spee (Fig 2a). The pa-
tient was planned to receive orthog-
natic surgical treatment. After surgically
assisted maxillary expansion was per-
formed with a Hyrax-type appliance,
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Fig 2e Superimposition of the initial and fi -
nal tracings indicating the incisor inclinations.
the maxilla was aligned and leveled
with sequential nitinol archwires. In the
mandibular arch, alignment at the
anterior teeth was achieved with niti-
nol archwires. Then, a utility arch, fab-
ricated from a 0.016 ⫻ 0.022-inch Blue
Elgiloy (Rocky Mountain Orthodon-
tics), was used for leveling the curve of
Spee via incisor intrusion. After align-
ment and leveling of the mandible,
incisor inclination, according to the
mandibular plane, increased by 7
degrees. The GTR procedure was per-
formed at that stage. Mandibular
advancement and a Class I relationship
were obtained with a bilateral sagittal
splint osteotomy, which was performed
2 months after the regenerative pro-
cedure. Comprehensive orthodontic
treatment lasted 30 months.
 349

Table 1 Mean (range) clinical measurements of the incisors before and after the GTR procedure
Baseline 8 wk 12 mo
(before GTR (during reentry (after GTR
procedure) procedure) procedure)
GRD AG BDD GT BDD GRD AG GT
Patient 1 0.5 mm 0.83 mm 4.33 mm 0.43 mm 1 mm 0.33 mm 2 mm 0.95 mm
(0–1 mm) (0–1 mm) (3–7 mm) (0.2–0.8 mm) (0–2 mm) (0–1 mm) (1–3 mm) (0.5–1.2 mm)
Patient 2 0.5 mm 2.33 mm 5 mm 0.71 mm 0.33 mm 0.16 mm 2.66 mm 1.38 mm
(0–1 mm) (1–4 mm) (5–8 mm) (0.5–1.4 mm) (0–1 mm) (0–1 mm) (2–4 mm) (1.3–2 mm)
GRD = gingival recession depth; AG = width of the attached gingiva; BDD = bone dehiscence depth; GT = gingival tissue thickness.

Clinical assessments
Clinical parameters were recorded
immediately prior to surgery and 1
year postoperative. Patients under-
went initial therapy consisting of oral
hygiene instructions, scaling, and root
planing. There were no pathologic
periodontal pocket formations (prob-
ing depth ≤ 3 mm) or interdental bony
defects between the mandibular
canines.
A periodontal probe (PCP-UNC
15, Hu-Friedy) was used to assess: (1)
gingival recession depth (GRD): the
distance from the cementoenamel
junction to the gingival margin; (2)
width of the attached gingiva (AG):
the distance from the mucogingival
junction to the gingival sulcus
(assessed using the visual method
described by Guglielmoni et al17); (3)
bone dehiscence depth (BDD): the
distance from 1 mm apical to the
cementoenamel junction to the bone
margin at the midbuccal aspect of the
defect; and (4) gingival tissue thick-
ness (GT): the distance between the
gingival sulcus base and the mucogin-
gival junction at the midbuccal level
(assessed according to the method of
Joly et al 18 ). GRD and AG were
recorded at the midbuccal level using
a caliper (Castroviego-CLC4, Hu-
Friedy) before GTR and during the
reentry procedure (measured to ± 0.1
mm). BDD was recorded at the mid-
buccal level with a caliper after flap
reflection. Clinical indices and the aver-
age of these scores were recorded at
the two mandibular canines and four
incisors. The highest and lowest scores
from these teeth are shown in Table 1.
Surgical procedure
All procedures were performed by the
same surgeon. Following adequate
local administration of an anesthetic
(2% lidocaine with 1:100,000 epi-
nephrine), a sulcular incision was
made on the labial aspect of the
mandible. A full-thickness flap was
elevated vestibularly and the root sur-
faces were planed with hand instru-
ments (Universal curette 4R-4L, Carl
Martin) (Figs 1c, 1d, and 2b). The sur-
gical technique used was a GTR pro-
cedure combined with graft materials.

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350
The alveolar bone surrounding the
root surfaces was decorticated with a
periodontal chisel (Ochsenbein
1913/1, Carl Martin). Demineralized
bone matrix (Grafton, Osteotech) was
applied uniformly on the exposed
root surfaces. A titanium membrane
(Cytoflex Mesh, Unicare Biomedical)
was positioned at the height of the
cementoenamel junction and was
trimmed to cover 2 to 3 mm of the sur-
rounding alveolar bone to ensure the
stability of the wound and the graft
material. No sutures or pins were used
for membrane fixation or stabilization.
The buccal flap was positioned coro-
nally to cover the membrane com-
pletely and closed using sling sutures.
The patients were advised to discon-
tinue mechanical oral hygiene proce-
dures during the 10 days of healing to
avoid any trauma at the surgical site.
Chemical plaque control was under-
taken with a 0.12% chlorhexidine glu-
conate mouthwash for 2 weeks.
Postsurgical medications included
500 mg amoxicillin twice daily for 7
days and analgesics. All sutures were
removed after 10 days. The patients
were then placed on a routine main-
tenance schedule tailored to their
individual needs.
The nonresorbable titanium mem-
branes were removed after 8 weeks.
Reentry incisions were made 1 mm
apical to the gingival margin. The flap,
which was tightly integrated to the tita-
nium membrane, was elevated until
the membrane could be seen com-
pletely, with attention given to avoid
rupturing the flap. The titanium mem-
brane was removed carefully to pre-
vent damaging the newly formed
tissue under the membrane (Figs 1e
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and 2c). BDD measurements were
repeated before flap closure. The flap
was repositioned coronally to cover
and protect the tissue regenerated
around the root surfaces. The sutures
were removed after 1 week.
Results
The changes in the clinical indices are
shown in Table 1. All surgical sites
exhibited minimum postoperative
barrier exposure with no signs of
inflammation. Membrane exposure
increased during the 8-week healing
period with soft tissue perforation.
In patient 1, the thickened peri-
odontal tissue covered the exposed
roots, which had silhouettes reflected
from the gingiva before the surgical
procedure. The attached gingiva
increased significantly during 1 year of
follow-up (Fig 1f). In patient 2, all
exposed root surfaces were covered
with newly formed tissues. The thick-
ness of the gingiva and the width of the
attached gingiva increased versus
baseline (Fig 2d).
Inclination of the incisors of both
patients after orthodontic treatment is
shown in Figs 1g and 2e.
Discussion
Although many etiologies have been
proposed for localized gingival reces-
sions, the trauma caused by tooth-
brushing and gingival lesions
associated with plaque must be con-
sidered to be the two most important
causative factors. Recessions occur-
ring as a result of plaque-associated

periodontal disease are found at sites
where the gingival tissue is thin and
where the alveolar bone is either thin
or absent.19
Hamp et al 20 suggested that
mandibular incisors would be most
likely to exhibit pathologic recession
because of the tooth-arch relation-
ships, which result in labially promi-
nent teeth covered with a thin or
nonexistent labial plate of bone and
inadequate or absent keratinized gin-
giva. Maynard and Ochsenbein21 and
Maynard22 pointed out the importance
of the attached gingiva in children and
suggested that soft tissue augmenta-
tion may be necessary in any stage of
orthodontic treatment to prevent
attachment loss and root exposure
when the keratinized tissue and
attached gingiva are insufficient.
Shiloah et al23 presented a case of
Class I, division 1 malocclusion treated
on a nonextraction basis with a
mandibular utility arch. They demon-
strated recession labially on a
mandibular incisor, presumably
because of proclination through the
labial plate. In the present study,
patient 2 presented with protruded
mandibular incisors at the beginning of
treatment; after alignment and intru-
sion with the utility arch, mandibular
incisor proclination increased by 7
degrees.
Many techniques have been used
for gingival augmentation coronal to
the recession. GTR has also been sug-
gested for the treatment of reces-
sions.24–27 To obtain regeneration
using a membrane technique, ade-
quate space must be maintained
between the membrane and the root
surface. It is difficult to create enough
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space for formation of new tissues
using the membrane technique
because the gingival recession defects
are nonspacemaking. The use of a
graft material underneath the mem-
brane may help to create space.
Cortellini et al28 reported 3.66 mm of
new connective tissue attachment
associated with 2.48 mm of new
cementum and 1.84 mm of bone
growth histologically. Although differ-
ent spacemaking graft materials have
been used in combination with mem-
branes, the number of these studies
are very limited.25–27 Dodge et al25
used GTR with demineralized freeze-
dried bone allograft and found that
the mean osseous dehiscence area
coverage with hard tissue was 75% for
a polylactide membrane plus a
polyglactin root-lining mesh and de-
mineralized freeze-dried bone allograft
and 30% for polylactide resorbable
membrane sites.
Duval et al27 reported significant
root coverage and improvements in
keratinized tissue, tissue thickness,
and bone level after using a bioab-
sorbable membrane with or without
the use of a demineralized freeze-
dried bone allograft. They suggested
that the space maintained underneath
the membrane provided the increase
in tissue thickness.
The results of Pini Prato et al29
suggest that keratinized tissue dimen-
sions may increase slightly for years
when using the GTR technique for
root coverage because of the apical
movement of the mucogingival junc-
tion. The attached gingiva also
increased in the two patients in the
present case, but the increase in gin-
gival thickness was more significant
351
after the surgical procedure (0.67 mm
for patient 1 and 0.52 mm for patient
2). The gingival margins were posi-
tioned coronally according to base-
line; the bony dehiscences were
restored. The full restoration of the
lost periodontal tissues via GTR and
grafting will supply a long-lasting posi-
tion for the gingival margins.
These two patients are the first to
demonstrate the treatment of bone
dehiscences at the labial cortex of
mandibular incisors that may occur as
a result of orthodontic proclination by
application of a titanium membrane
and bone graft. Several investigators
have used titanium-reinforced barrier
membranes in mucogingival recession
defects.29–32 They observed significant
gains in bone and alveolar crest level
around the bone dehiscences.
Titanium-reinforced expanded poly-
tetrafluoroethylene membrane was
used to facilitate the creation and
maintenance of the space for GTR.
Titanium membranes are used clini-
cally with bone substitution material
underneath, which may blur the pas-
sive malleability and possible micro-
movements caused by the pressure of
the mucoperiosteal flap. Strietzel et
al33 evaluated the healing pattern of
bone defects covered by different
membrane types and suggested that,
following the application of dense bar-
rier material, the defects were occu-
pied by new woven bone, beginning
at the defect walls. In the current study,
a titanium barrier membrane was used
because of its good spacemaking and
tissue-integration properties.
Volume 30, Number 4, 2010
352
Conclusion
Resorption of the labial bone of the
alveolar process, distribution of the
mucogingival junction, reduction of
the width of the attached gingiva, and
gingival recession caused by proclin-
ation of the mandibular incisors are all
unwanted results of orthodontic tooth
movement. Orthodontic treatment
must respond to the functional and
esthetic needs of the patient.
Recession yields in an increased crown
length, which is a serious esthetic
problem. Restoration of the labial
alveolar process and mucogingival
junction with combined regenerative
procedures (GTR and hard tissue
grafting) after orthodontic treatment
requiring incisor proclination is the
supplementary treatment protocol of
choice to obtain complete and satis-
factory results.
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