A 21-year-old female presented to the orthodontist with the complaint of an anterior open bite (Figure
1A,B,C,D). The patient had received conventional orthodontic treatment for the anterior open bite, except for the maxillary right central incisor tooth. No orthodontic movement was achieved, despite the application of force to the maxillary right central incisor. The patient did not mention any trauma history but reported a finger sucking habit history. A radiographic and clinical examination raised the suspicion of ankylosis (March 8, 2018). Force was applied to the tooth for 6 months, but tooth movement was not achieved. Accordingly, a diagnosis of ankylosis was made (Figure
1E,F,G,H). In fixed orthodontic treatment, the anterior teeth were extruded, and the posterior teeth were intruded. Extraction treatment also reduced the open bite. Extraction of teeth 14, 24, and 34 was planned. The space of tooth right mandibular first molar was not closed to prevent slipping into the lower midline.
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Figure 1: A. Frontal facial view and B. Intraoral frontal view of the patient at the beginning of the first orthodontic treatment. C. Right side and, D. Left side intraoral view of the patient at the beginning of the first orthodontic treatment E. Cephalometric and F. Panoramic films taken at the beginning of orthodontic treatment. G. Panoramic film taken after the first orthodontic treatment. Ankylosis of the right first incisor can be seen. H. Despite the force applied to the right first incisor, no orthodontic tooth movement was observed after the first orthodontic treatment. |
Distractor Design and Surgical Applications: Before the distraction osteogenesis procedure, a custom-made, tooth-borne rigid distractor consisting of an apparatus with a slow expansion screw and bands and brackets was applied. After the model was taken, the central incisor tooth was brought to the desired position in the model, and the set-up process was applied. The band was then attached to the central incisor tooth. Satinless-stell wire (1.2 mm diameter) was then bent appropriately and soldered to the tube bands that would come to the molars and the band on the central tooth. The slow expansion screw of the apparatus was opened before soldering and closed again after soldering. In this tooth-borne custom-made distractor, each rotation corresponded to 0.2 mm of movement (Figure 2A,B,C,D).
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Figure 2: Archwire shaped according to the distractor apparatus A. Occlusal and B. Frontal view. C. Distractor and arch wire made with thick steel wire. D. The molar bands are soldered. |
All surgical procedures were performed under local anesthesia in Fırat University, Faculty of Dentistry, Department of Periodontology, Elazig, Turkiye. Local anesthetic was applied to the vestibular mucosa. A linear incision was made from the junction line of the keratinized gingiva and lip mucosa and from the canine tooth in the right maxilla to the lateral tooth in the left maxilla, by taking bone contact1-4. The mucoperiosteal flap was lifted, exposing the anterior maxilla, including the piriform opening. The nasal mucosa was elevated on the right side. The right maxillary central incisor was ankylosed at the base of the nose. Bone tissue was reached with subperiosteal tunnels in the interdental area. Vertical osteotomies of the mesial and distal parts of the right maxillary central incisor were performed using a thin steel bur. These vertical osteotomies were combined with a horizontal osteotomy under the base of the nose and priform edge. After the osteotomies, mobility of the bone segment was achieved using a chisel and curved osteotome. During the osteotomies, care was taken to protect the periosteum layer on the palatinal side to prevent malnutrition and tissue necrosis. After achieving mobilization of the segment, the mechanism of the custom-made distractor was controlled (Figure 3A,B,C,D). The mucoperiosteal flap was repositioned in its original position and sutured with 3-0 silk suture. An antibiotic (penicillin), analgesic (dexketoprofen), and chlorhexidine mouthwash solution were prescribed after the surgical procedures to prevent infection and pain1-7.
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Figure 3: After raising the mucoperiosteal flap, subapical osteotomy was performed, and it was checked that the distractor moved the segment. A. Extraoral and B. Intraoral views of the patient in frontal angle. C. Extraoral and D. Intraoral views of the patient in occlusal plane. E. Intraoral frontal and F. Intraoral occlusal views of the patient after the distraction period of the patient’s in various angle. G. Extraoral views of the patient after the treatment protocol fully. H. Panaromic radiograph after the treatment protocol fully. I. Demonstration of the subapical osteotomy line during surgery and distraction direction. |
Distraction Protocol: Four days after the surgery, the distraction procedure was started. The distraction rate was 0.6 mm per day. The distractor was activated twice a day for 8-hour periods. The positon of the segment was 1 mm overcorrected. The distraction phase was ended on the 14th day. The moved segment was fixed with arch wires, and the consolidation period then commenced. After 12 weeks of fixation, the arch wires were removed, and orthodontic treatment was completed1-7. A Class I occlusion, with a normal overjet and overbite was obtained. An improved smile profile was obtained by ensuring that the anterior maxillary teeth were placed in the Class I occlusion. Panoramic and cephalometric films taken after the treatment confirmed healthy bone tissue formation around the moving segment (Figure 3E,F,G,H,I).
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