WILCKODONTICS

WILCKODONTICS
By- Dr. Chirag Patil
[email protected]
M.D.S in Oral and Maxillofacial Surgery

1. WILCKODONTICS BY- DR. CHIRAG PATIL M.D.S IN ORAL AND MAXILLOFACIAL SURGERY

2. CONTENTS Introduction History Considerations Indication Contraindication Biomechanics Advantages Disadvantages Surgical techniques- - Classical surgical technique - Gingival augmentation technique - Piezocision technique - Modified corticotomy technique - PROPEL alveolar micro- oateoperforation technique - LASER technique Conclusion

3. Periodontically accelerated osteogenic orthodontics Or Corticotomy facilitated osteogenic orthodontics

4. This is based theoretically on the healing pattern of bone known as regional acceleratory phenomenon (RAP).

5. What is Wilckodontics It is a clinical procedure that combines selective alveolar corticotomy , Particulate bone grafting and the application of orthodontic forces.  A llows teeth to be moved 2-3 times further in 1/3rd to 1/4th the time required for traditional orthodontic treatment .

6. William wilcko 1995 Thomas wilcko

7. HISTORY 1800’s - used- surgically assisted orthodontic tooth movement. First Described by- L.C. Bryan 1893 - corticotomy - facilated tooth movement. First introduced by- kole 1959 - mean for rapid tooth movement

8. 1991 - Suya replaced- the osteotomy cuts with corticotomy - Selective Alveolar Decortication (SAD ) A more recent surgical orthodontic therapy was Introduced by Wilcko which included the innovative strategy of combining corticotomy surgery with alveolar grafting in a technique referred to as Accelerated Osteogenic Orthodontics (AOO) ( Wilcko et al., 2000) and more recently called as Periodontally Accelerated Osteogenic Orthodontics (PAOO) ( Wilcko et al., 2008).

9. WILCKODONTICS RESULTS: An increase in width of alveolar bone Shorter treatment time Greater post treatment stability Decreased apical root resorption

10. AGE FACTOR

11. Can be performed at any age. Healthy periodontal situation. Common in adult patients- - Increasing chance of hyalinization - Conversion of collagen fibres is much slower in adults - Periodontal complications -Non-flexible alveolar bone.

12. INDICATIONS Class I with moderate to severe crowding . Class II with extraction Mild class III cases. To facilitate eruption of Impacted teeth. Molar intrusion and Openbite correction. Molar Uprighting . Molar Distalisation . Arch expansion.

13. CONTRAINDICATIONS  Severe class III cases. Active periodontal disease or gingival recession It should not be considered as an alternative for surgically assisted palatal expansion severe posterior cross-bite. It should not be used in Bimaxillary protrusion Inadequately treated endodontic problems

14. HOW DOES IT WORK? Injury to the bone

15. Cortical bone Scarred surgically (Labial and lingual side teeth) Movement followed by grafting Tissue of alveolar bone release Calcium Mineralization

16. New bone (20-55 days) Transient state (soft and less resistance) Movement of teeth is faster with help of orthodontic braces Localized osteoporosis Injury accelerated healing process Soft and hard tissue healing by 2-10 times Regional acceleratory phenomenon (RAP) RAPID TOOTH MOVEMENT

17. RAP Decreased regional bone density Accelerated bone turnover increased Tooth movement (long) completed Alveolar remineralization

18. ADVANTAGES Reduced treatment time Less root resorption due to decreased resistance of cortical bone. More bone support due to the addition of bone graft. Improved periodontal support. History of relapse very low. Less need for extra-oral appliances.

19. DISADVANTAGES Extra-surgical cost. Mild invasive surgical procedure Post-surgical crestal bone loss Recession. Some pain and swelling is expected . Chronic health problems cannot be treated. 

20. SURGICAL TECHNIQUE: Classical surgical technique Corticotomy with gingival augmentation technique Piezocision technique Modified corticotomy technique Osteoperforation technique Laser corticotomy

21. CLASSICAL SURGICAL TECHNIQUE

22. Complete medical review Any systemic and local factors P hase 1 therapy - S caling and root planning - O ral hygiene Clinical and Radiographic Evaluation Full mouth IOPA X - rays. OPG 3D Imaging Can be used in both Maxillary and Mandibular arches.

23. PAOO CONSISTS OF 5 STEPS : Raising of flap. Decortication. Particulate grafting. Closure of flap . Orthodontic Force Application.

24. PRE - OPERATIVE PATIENT PREPARATION Orthodontic archwire was removed in maxilla Mandible there is no need for removal of arch wire due to proper accessibility

25. FLAP DESIGN Proper flap design Proper access Preservation of the gingival form Proper esthetic appearance.

26. Crevicular incision is made buccally and lingually extending at least two to three teeth beyond the area to be treated . F laps were reflected beyond the apices of the teeth not to perforate the flaps Preservation of interdental papilla not to damage any of the neurovascular bundles and muscle attachments. 

27. DECORTICATION R emoval of the cortical portion of the alveolar bone I nitiate the RAP response N ot to create movable bone segments D ecortications is performed by using low-speed round diamond burs straight diamond bur under the Copious saline irrigation  

28. P erformed at clinical sites without entering the cancellous bone , Prevent damage to underlying structures (maxillary sinus and mandibular canal). L abial and lingual aspects of the alveolar bone . V ertical groove will be placed in the inter radicular space midway between the root prominences.

29. Groove will start from 2 to 3 mm below the crest of the bone 2 mm beyond the apices of the roots 1.5 - 2mm in depth . vertical corticotomies are connected with a semicircular shaped in apical region. 

30. If the alveolar bone of sufficient thickness, solitary perforations may be placed in the alveolar bone Cortical perforation increase blood supply to the graft material. Perforation thickness 1 to 2 mm

31. PARTICULATE GRAFTING C ommonly used for graft material are D eproteinized bovine bone, A utogenous bone Maxillary tuberosity Mandibular symphysis Angle of the mandible Ramus of mandible Exostosis Decalcified freeze-dried bone Allograft Decorticated bone acts to retain the graft material. Platelet rich plasma or calcium sulfate Increase the stability of the graft material.

32. Resorbable grafting materials + antibiotic solution applied directly over the activated bone. Frequently used augmentation grafting mixture : 2 parts demineralized freeze-dried bone (DFDBA) and 1 part bovine bone wetted with clindamycin phosphate solution ( 0.5 mg/ml) applied at a rate of 0.5 to 1 ml of grafting mixture per tooth to be moved. Antibiotic produces soothening effect and prevent the surgical site infection and act as a medium for placement of graft material to the surgical site

33. V olume used is 0.25 to 0.5 ml of graft material per tooth. If excess graft material result in difficulty in full closure of flap.

34. FLAP CLOSURE TECHNIQUE  Non - resorbable interrupted 3-0 sutures without creating excessive tension . Left in place for 1 to 2 weeks . After closer of flap Orthodontic arch wire was secured

35. GINGIVAL AUGMENTATION TECHNIQUE

36. Particularly important to adult patient Gingival recession Dehiscence Graft is harvested by removing a 1 to 2mm thickness from elevated palatal flap or acellular dermal matrix allograft ( alloderm ).

37. PEIZOCISION TECHNIQUE

38. Vercellotti & Podesta (2007) use of Peizosurgery in conjunction with conventional flap elevations to create an environment conducive to rapid tooth movement. Dibart et al(2010) introduced a procedure known as Peizocision Minimally invasive procedure combining microincisions , minimal peizoelectric osseous cuts to buccal cortex only and bone and soft tissue grafting concomitant with tunnel approach

39. PROCEDURE All of the incisions are made only buccally . Ultrasonic instrumentation is used to perform corticotomy cuts through the gingival Micro-incisions Depth of 3 mm. Gingival vertical incision- I nterproximally 15 surgical blade Incision lies over attached gingiva. A tunnel is performed by means of an elevator inserted between the gingival incisions to form sufficient space for receiving the graft.

40. A llograft is then placed I ncision sutured (absorbable sutures 5-0). 

41. ADVANTAGES OF PEIZOCISION Shorter surgical time. Minimally invasive technique . No periodontal complications Post-operative morbidity is less.

42. DISADVANTAGES AND LIMITATIONS Lack of muco - periosteal flap elevation risk of root damage Incisions is keep at least 2 mm from the gingival margin to avoid the formation of gingival cleft. Postoperative scar formation

43. MODIFIED CORTICOTOMY TECHNIQUE

44. Germec et al (2006) introduced Modified Corticotomy . “Conservative ” technique to shorten the treatment time during lower incisor retraction. Corticotomy done only on the buccal side without lingual cuts. Mostly Orthodontic tooth has labial movement.

45. ADVANTAGES Surgical time is less compared to classical technique. Technique is less sensitive. Patient acceptance is more and discomfort (Morbidity) is less.

46. potential for the non - operated lingual surface “ pull” of gingival and periodontal tissues postoperatively presents. IT IS ELIMINATED BY S imple circumferential fiberotomy Supracrestal fiberotomy Transmucosal Perforation with a irrigated Bur If the acceleration of the incisors retraction begins to slow.

47. Alternative approach introduced by Park et al (2006 ), I ncisions directly through the gingiva and bone using a combination of surgical blades and a surgical mallet. Decrease surgical time No flaps or sutures. only cortical incisions. DISADVANTAGES - No benefits of bone grafting - Aggressive . - Dizziness and vertigo

48. PROPEL ALVEOLAR MICRO – OSTEOPERFORATION TECHNIQUE 49

49. Perform corticotomy procedure. Novel technique that creates micro - osteopeforations . Micro-invasive procedure which accelerate orthodontics. Chair side procedure Does not require any advanced training

50. The instrument provides a surgical stainless-steel lead edge uniquely designed and used to atraumatically perforate the alveolus directly through keratinized gingiva as well as movable mucosa. No need of flaps surgery, bone grafting, or any suturing

51. Micro- osteoperforations (MOP) Cytokine cascade is activated Increasing levels of cytokine activity around a tooth Increase in osteoclast activity Increased rate of tooth movement.

52. THE IDEAL TREATMENT DEVICE FOR MICRO-OSTEOPERFORATION SHOULD BE – provide control to the operator Remain sharp through multiple perforations H ave a depth limiter to ensure penetration Temporary anchorage devices Miniplants Burs   Disadvantage- Instrument is high cost ($149). N ot viable alternatives to performing micro- osteoperforation .

53. MICRO-OSTEOPERFORATIONS WITH PROPEL 54 Proactive or reactive Doctor-controlled Localized No recovery time Shorter treatment More predictable

54. STEPS FOR MICRO-OSTEOPERFORATION 55 1. Evaluate Treatment area Locate roots, the mandibular nerve and maxillary sinuses. Micro- Osteoperforation depths are determined by bone and soft tissue thickness. Micro- Osteoperforations should penetrate through the cortical plate into cancellous bone. 2. Chlorhexidine rinse Two times for one minute each 3. Anesthetize & PROPEL Treatment area can be anesthetized using either a Topical or Local Infiltrative anesthetic.

55. How to use PROPEL 56 Remove from the sterile package and turn the Adjustable Depth Dial to the preferred setting 3mm, 5mm, or 7mm by holding the driver body and rotating the dial clockwise Hold the PROPEL Device against the gingiva . Apply gentle pressure to engage the leading edge while turning the device handle clockwise. Check engagement by releasing pressure 4. Continue to turn until the desired depth is reached for penetration of the cortical plate into cancellous bone 5. The LED Depth Stop indicator will illuminate when desired depth is reached 6. Rotate the device counter-clockwise to remove

56. How Deep to PROPEL 57 PROPEL has three depth settings: 3 mm, 5 mm and 7 mm. The correct depth should be selected based on the thickness of the gingiva and alveolar bone in the treatment area. The anterior is usually 3 mm or less and the posterior is generally 5 mm or 7 mm. Recommended perforation depth Ref: Baumgartner et al.

57. HOW MANY MICRO-OSTEOPERFORATIONS 58 Where possible perform 1-3 micro- osteoperforations depending on proximity of anatomical structures. Perforations can be made buccal or lingual in linear or triangular patterns.

58. WHERE TO PERFORATE: BUCCAL OR LINGUAL Buccally or lingually .   Buccal access is simplest approach, Depending on desired movement and patient ’ s oral anatomy.

59. LASERS COMMONLY USED TO ACCELERATE TOOTH MOVEMENT Lasers potentially useful for accelerating tooth movement are low-level lasers or “low intensity level laser” (LILL). The therapy performed with these lasers is called low-level lasers therapy (LLLT). LLLT operates in the range of power output milliwatts ( mW ).

60. Hibst et al (1988) were the first to report the use of the Erbium: Yttrium Aluminium Garnet( Er : YAG) laser for ablation of dental hard tissues. Advantage: It had Dual ability to ablate soft and hard tissues with minimal damage No damage of surrounding tissue. Faster bone repair(healing) than conventional bur drilling. Suitable alternative for defect and root surface debridement in conjunction with periodontal surgery.

61. The er,cr;ysg laser device was used to deliver an energy range about 300 mj at pulse rates of 20 hz . Bone cutting was performed under water-spray cooling for absorption of laser radiation. Duration of laser for penetration was between 0.25 - 0.5 second It was in a noncontact manner with a 2 mm distance. The proportion of air and water was 40% and 20% respectively.

62. It Creates a clear, dry field with no bleeding , Decreasing the possibility of infection. Less trauma in the surgical field. Post-operative swelling , scars and pain is minimal. ADVANTAGES OF LASER CORTICOTOMY

63. DISADVATANGE High cost compared to conventional method. Loss of Attached gingiva. Periodontal defects short interdental distance . Subcutaneous hematomas of the face and the neck post-operative swelling and pain.

64. CONCLUSION Mops significantly increased the expression of cytokines and chemokines known to recruit osteoclast precursors and stimulate osteoclast differentiation. Mops increased the rate of canine retraction. Patients reported only mild discomfort locally at the spot of the mops. At days 14 and 28, little to no pain was experienced. It is effective, comfortable, and safe procedure Reduce orthodontic treatment time by 62%.

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