Jan Lindhe. Clinical Periodontology

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ORTHODONTICS AND PERIODONTICS • 765

Fig. 31-20. Uprighting and leveling of maxillary and mandibular molars (compare a and f) plus consolidation of

multiple small spaces into one area before placing single-tooth implant for missing maxillary right first premolar

(arrow) in adult female patient.

would still appear sensible to avoid gross interfer-

ences, like raising the bite when a maxillary incisor in

lingual inversion is moved over the mandibular teeth,

and to mitigate evident occlusal interferences on sin-

gle teeth with markedly increased mobility. However,

it may be a futile exercise to try and eliminate all

occlusal trauma during active tooth movement and a

more practical solution is to concentrate on controlling

the inflammation. After appliance removal, however,

occlusal adjustment by selective grinding may be re-

quired. Even though good occlusal function is part of

the orthodontic treatment goal, correct cusp-fossa re-

lationships cannot always be achieved in adults with

orthodontic therapy alone. In general terms, the ad-

justment should be directed toward obtaining even

and stable tooth contacts in centric relation, a straight

forward slide from centric relation to centric occlusion

without any side shifts or lateral deviation, freedom

in centric, smooth gliding contacts in centric and ec-

centric mandibular motion, and elimination of balanc-

ing side interferences (Burgett et al. 1992).

The importance of reducing jiggling of teeth after

orthodontic treatment of patients with moderate to

advanced periodontitis may be significant: (1) tooth

mobility generally increases with loss of support for

the teeth, (2) animal experiments have shown that

bone dehiscences produced by jiggling forces will

regenerate after elimination of the jiggling trauma,

and (3) occlusal adjustment may be a factor in the

healing of periodontal defects, especially bony de-

766 • CHAPTER

fects, after periodontal treatment. Therefore, the

bonded orthodontic retainers, which stabilize the

teeth, may secure optimal conditions for improved

periodontal healing and bone regeneration after the

orthodontic treatment period (Fig. 31-5). In fact, long-

term follow-ups of orthodontic patients with ad-

vanced periodontal tissue breakdown may demon-

strate better periodontal conditions, with marked cre-

stal lamina dura contours, many years after appliance

removal than at the end of the orthodontic treatment

(Figs. 31-7, 31-8). If bonded retainers had not been

used in many such cases, the most affected teeth

would probably have been lost with time.

Molar uprighting, furcation involvement

The problem of mesially tipped mandibular molars

because of non-replacement of missing first molars

has been the subject of many anecdotal reports over

the past 30 years. Tipped molars have been considered

a causative or at least an aggravating factor for future

periodontal tissue breakdown. However, Lundgren et

al. (1992) recently observed that 73 molars that had

remained in a markedly tipped position for at least 10

years, with most molars having been tipped for as

long as 20-30 years, did not constitute an increased

risk for initiation or aggravation of moderate peri-

odontal disease at their mesial surface. The study did

not consider the potential risk for aggravation of al-

ready established advanced periodontitis lesions.This

lack of correlation may not exclude other indications

for molar uprighting, such as functionally disturbing

interferences, paralleling or space problems associ-

ated with prosthetic rehabilitation (Fig. 31-20), or trau

matic occlusion.

In this context it must be emphasized that the ap-

parent angular bone loss along the mesial surface of

tipped molars may be illusive and solely represent an

anatomic variation, since lines drawn from the adja-

cent cemento-enamel junctions appear to parallel the

alveolar crest (Ritchey & Orban 1954). While upright-

ing such a tooth appears to cause a shallowing-out of

the angular defect, with new bone forming at the

mesial alveolar crest, it may merely reflect the inclina

tion of the molar relative to the alveolar bone, and the

attachment level remains unchanged. When there is a

definite osseous defect caused by periodontitis on the

mesial surface of the inclined molar, uprighting the

tooth and tipping it distally will widen the osseous

defect. Any coronal position of bone may be due to the

extrusion component of the mechanotherapy.

Furcation defects generally remain the same or get

worse during orthodontic treatment. For example, if

tipped molars have furcation involvement before or-

thodontic uprighting, simultaneous extrusion may in

crease the severity of the furcation defects, especially

in the presence of inflammation (Burch et al. 1992).

Hence, initial periodontal therapy and maintenance is

essential. The mandibular molar can be split into two

roots, one or both of which may be kept and moved

orthodontically into new positions. However, this is

difficult treatment (Muller et al. 1995).

In a thorough study of periodontal condition

around tipped mandibular molars before prosthetic

replacement, Lang (1977) reported that after comple-

tion of the hygiene phase, significant pocket reduction

(mean 1.0 mm) was noted on all surfaces. In addition,

a further significant reduction in pocket depth (mean

0.6 mm), associated with a gain of clinical attachment

(

mean 0.4 mm), was found on the mesial and lingual

aspects of the molars as a result of the orthodontic

uprighting. He concluded that uprighting of tipped

molars is a simple and predictable procedure, pro-

vided excellent plaque control is maintained.

Kessler (1976), on the other hand, stated that up-

righting of mesially inclined molars is not a panacea,

and showed some cases in which evident bone loss

and furcation involvement developed during the or-

thodontic uprighting procedure. Because of the furca

tion involvement and increased mobility, these teeth

were no longer considered suitable as abutments, al-

though they were properly uprighted. Radiographic

indications that furcation involvement may develop

between the roots at the end of orthodontic molar

uprighting is evident also in other studies, even when

extrusive movement of the tipped molars has been

avoided (Diedrich 1989). However, it is not unlikely

that this radiolucent area reflects immature bone.

Conclusion

As risks may be involved in orthodontic uprighting of

mesially tipped molars in cases with periodontal le-

sions along their mesial surface, or with furcation

involvement, the indications for molar uprighting

must be apparent. Excellent oral hygiene is required

during the orthodontic treatment, with careful consid

eration of the force distribution, and avoiding extru-

sion as much as possible. The developments of regen

erative techniques may make it possible in the future

to obtain better outcomes in orthodontic therapy of

periodontally compromised patients.

Tooth movement and implant esthetics

Osseointegrated implants may be used (1) to provide

anchorage for orthodontic tooth movement and later

serve as abutments for restorative treatment, and (2)

to replace single missing teeth. The use of implants as

anchors for orthodontic treatment is discussed in

Chapter 43, and will not be dealt with here.

It is difficult to achieve esthetically satisfactory re-

sults with artificial crowns on single-tooth implants,

and the orthodontist may play a role in the interdisci-

plinary treatment planning team of specialists. There

are at least three areas where orthodontics may be

considered:

• redistribution of the available space in the dental

ORTHODONTICS AND PERIODONTICS • 7

Fig. 31-21. Orthodontic improvement of periodontal soft and hard tissues associated with implant placement and a

large anterior defect in young adult female patient. As in Fig. 31-15 the periodontal tissues will follow the selec-

tively extruded incisor incisally (a-c), and thus improve the possibilities for a successful connective tissue graft

from the palate when the gingival papillae is reconstructed. Note the more incisal relationship of bone level relative

the implant in the radiographs before and after treatment (arrows in d,e).

arch when tooth positions for implant placement are

not optimal

•

orthodontic ridge augmentation by vertical tooth

movement

•

orthodontic ridge augmentation by horizontal

tooth

movement.

Redistribution of space

Orthodontic movement of neighboring teeth to opti

mal

positions is often required in association with

placement

of implants substituting missing maxillary

central or

lateral incisors (Spear et al. 1997). Another

common indication is a lack of adequate space for the

implant. Fig. 31-20 illustrates a typical case with mul-

tiple small spaces between the teeth and not enough

room to place an implant in the maxillary first premo

lar

region.

Ridge

augmentation - vertical movement

During selective orthodontic extrusion of one single

tooth, both the alveolar bone and the soft periodontal

tissues will follow the extruded tooth in an incisal

direction, as discussed under forced eruption earlier in

this chapter. By this means, it is possible to signifi-

768 • CHAPTER

Fig. 31-22. Orthodontic ridge aug

mentation before implant place-

ment. Since the buccolingual

width of the alveolar bone on the

left side of the mandible was too

narrow for an implant, the second

premolar was orthodontically ro-

tated and moved mesially. Note

that the bone volume on the ten-

sion side of the mesially moved

premolar is markedly greater than

that on the pressure side (arrows).

It will now be possible to place

the implant in the position pre-

viously occupied by the second

premolar.

cantly improve the periodontal tissue esthetics associ

ated with fabrication of prosthetic crowns on single

implants (Fig. 31-21). The technique of "orthodontic

extraction" of a hopeless incisor or molar may be

useful to improve the results for single-tooth implants

in patients in whom one or more teeth are to be

extracted. Following progressive grinding of the ex-

truded tooth to prevent it from jiggling, new peri-

odontal tissues are generated that provide improved

conditions for the implant, after extraction of the ex-

truded tooth (Fig. 31-15).

Ridge

augmentation — horizontal movement

If an implant cannot be placed because of reduced

buccolingual ridge thickness after a previous extrac-

tion, one option is to move a premolar into the eden-

tulous space and to place the implant in the position

previously occupied by the premolar (Spear et al.

1997). The buccolingual volume of the new bone on

the tension side will be markedly greater than that on

the pressure side (Fig. 31-22). This is an alternative to

surgical ridge augmentation (GBR or bone graft). Fig.

31-22 shows a case in which the mesial movement and

uprighting of a mandibular first premolar provided

new bone of adequate width for implant placement in

previously atrophied alveolar bone area. Similar

generation of bone can be obtained in patients who

have no molars by moving a terminal premolar dis-

tally in the dental arch.

GINGIVAL RECESSION

Labial recession

"Normal" age changes

Gingival recession, with exposure of cementum on

facial surfaces of teeth, may occur on single or multi-

ple teeth. Many factors have been implicated in the

etiology, including plaque, position of the tooth in the

arch, faulty toothbrushing, traumatic occlusion, high

frenum or muscle attachments, lack in dimension of

gingiva, lip pressure, etc. (Baker & Seymor 1976). It is

difficult to see a single cause of, or a solitary mecha-

nism in the development of, labial gingival recession.

Two basic types of recession may occur, one related to

periodontal disease, or to factors associated with peri

odontal disease, and the other relating to mechanical

factors, including toothbrushing.

Labial gingival recessions are always accompanied

by alveolar bone dehiscences, and there is a direct

correlation between the millimetric extension of labial

bone dehiscences and the corresponding gingival re-

cessions (Bernimoulin & Curilovic 1977). It has been

postulated that a root dehiscence may establish an

environment which, for one reason or another, may

predispose to gingival recession (Wennstrom 1990).

The position in which a tooth erupts through the

alveolar process has a profound influence on the

amount of gingiva that will be established around the

tooth. When a tooth erupts close to the mucogingival

line, only a minimal width, or complete lack, of

gingiva may be observed labially, and localized gingi-

val recessions may occur in patients at a young age.

Thus the "normal" age changes that will then take

place are important. Longitudinal monitoring of labial

gingival dimensions during the development of the

dentition has shown that provided adequate plaque

control is established and maintained, a significant

increase of the gingival height will generally occur.

Spontaneous improvement of localized mandibular

labial recessions is the rule rather than the exception,

and in some teeth the recessions were totally elimi-

nated during a 3-year observation period (Andlin-

Sobocki et al. 1991). Also, spontaneous changes of

tooth positions in a buccolingual direction will affect

the gingival dimension.These alterations in gingival

dimensions are similar to, albeit less pronounced than,

those observed during orthodontic treatment (see be

low).

Favorable tooth movements, and tissue factors

Alterations of mucogingival dimensions may occur

ORTHODONTICS AND PERIODONTICS • 769

Fig. 31-23. Thin labial gingiva on prominent mandibular right central incisor (a,b) spontaneously became thicker

when the incisor was orthodontically moved lingually and aligned (c) after premolar extractions. (d) shows condi

tion after appliance removal.

during orthodontic treatment. Contrary to beliefs in

the past, these changes are independent of the apico-

coronal width of the keratinized and attached gingiva.

Wennstrom et al. (1987) found no relationship be-

tween the initial width of keratinized gingiva and the

tendency for development of gingival recession dur-

ing orthodontic tooth movements in monkeys. In-

stead, it is the buccolingual thickness (volume), which

may be the determining factor for the development of

gingival recession and attachment loss at sites with

gingivitis during orthodontic treatment.

A tooth that is facially positioned within the alveo-

lar process may show an alveolar bone dehiscence

with a thin covering soft tissue. When such a tooth is

moved lingually during orthodontic treatment, the

gingival dimensions on the labial aspects will increase

in thickness (Figs. 31-23, 31-24). Furthermore, because

the mucogingival junction is a stable anatomical land

mark and the gingiva is anchored to the supracrestal

portion of the root, it will follow the tooth during the

movement lingually and will consequently get an

increase in gingival height (decreased clinical crown

height).

Conclusion

It follows that in cases with a thin (delicate) gingiva

caused by a prominent position of the teeth, there is

no need for a preorthodontic gingival augmentation

procedure. Neither in the case of labial gingival reces-

sions should a mucogingival surgical procedure be

performed before orthodontic therapy, when the po-

sition of the tooth is improved by the treatment. The

recession, as well as the bone dehiscence, will decrease

as a consequence of the lingual movement of the tooth

into a more proper position within the alveolar bone.

If still indicated at the end of orthodontic therapy, the

surgical procedure will have a higher predictability of

success than if it had been performed before the tooth

movement (Wennstrom 1996).

Unfavorable tooth movements,

and tissue factors

Orthodontic movements of teeth

away

from the geneti

cally determined envelope of the alveolar process are

risk movements for development of mucogingival

problems, particularly in thin bone and gingival tis-

sues. During frontal and lateral expansion of teeth,

tension may develop in the marginal tissues due to the

forces applied to the teeth. This stretching may result

in thinning of the soft tissues. However, recession-

type defects will not develop as long as the tooth is

moved within the alveolar bone. If, however, the ex-

pansion results in the establishment of a bone dehis

cence, the volume (thickness) of the covering soft

tissue must be considered as a factor that may influ-

ence the development of soft tissue recessions. This

may be true both during and after the active orthodon

tic treatment period. The labial orthodontic tooth

movement

per se

will not cause soft tissue recession.

770 • CHAPTER 31

ORTHODONTICS AND PERIODONTICS • 771

However, the thin gingiva that will be the conse-

quence of such movement may serve as a locus mino

ris resistentia to developing soft tissue defects in the

presence of bacterial plaque and/or mechanical trau-

ma caused by improper toothbrushing techniques, or

orthodontic correction of marked rotations of the in-

cisors.

For stability reasons as well, expansion in the

mandibular arch should normally be avoided, if pos-

sible. If frontal expansion is still performed in associa

tion with orthodontic therapy, the buccolingual thick-

ness of the hard and soft tissues should be evaluated.

If surgical intervention is considered necessary in or-

der to reduce the risk for development of soft tissue

recessions, this should aim at increasing the thickness

of the covering tissue (e.g. grafts), and not the apico-

coronal width of the gingiva.

Conclusion

Before any kind of orthodontic therapy is started, it is

important to check the buccolingual thickness of the

bone and soft tissues on the pressure side of all teeth,

which are to be moved. When tissues are delicate and

thin, careful instructions in adequate plaque control

measures should be provided, and controlled before

and during treatment as well as after removal of the

fixed appliances, in order to reduce the risk for devel-

opment of labial gingival recession.

Interdental recession

Esthetic considerations with regard to defect papillae

Until recently, most clinical emphasis with regard to

gingival recession was given to the labial defects. If

left untreated, most labial gingival recessions will not

progress significantly with time, at least if oral hy-

giene is good, and the main indication for treatment

the esthetic implications for the patient. From an

esthetic point of view, however, it would appear that

interdental recession, manifest as more or less pro-

nounced empty spaces ("dark triangles") between the

teeth, would be equally or more important. Compared

with a labial recession, in most patients the loss of

interdental papillae would be more visible, both in

normal conversation and upon smiling.

Since quality of life (esthetics and lack of pain) has

become increasingly more important in recent years

in selection of periodontal therapies, disfigurement of

the gingival papillae during orthodontic treatment of

periodontal patients must be avoided, if possible. The

development of interdental recession during ortho-

dontic treatment in adults may be caused by one of

three factors: (1) advanced periodontal disease, by the

tissue destruction or due to pocket elimination by

surgery, (2) triangular tooth shape due to abnormal

interproximal wear of teeth in crowded positions be-

fore the orthodontic treatment, and (3) diverging roots

of teeth due to improper bracket placement. To begin

with, there is an obvious difference in dental esthetics

between patients with advanced periodontitis who

have been treated according to "old" and "new" con-

cepts for periodontal therapy. In the past, pocket elimi

nation by gingivectomies frequently resulted in ad-

vanced root exposure and complete loss of interdental

papillae (Fig. 31-7). However, even with careful non-

surgical periodontal therapy in the preparation of

patients with advanced periodontal disease for ortho-

dontic treatment, the clinical outcome of the interdis-

ciplinary treatment will normally result in marked

interdental recessions, if special precautions are not

taken (see below)

Clinical options

for treatment

There are only a few options available for the treat-

ment of interdental gingival recession associated with

orthodontic treatment in the periodontal patient:

mucogingival surgery, using coronally positioned

flaps and GTR techniques (Pini Prato et al. 1992)

the provision of a gingival prosthesis

orthodontic paralleling of the roots of neighboring

teeth

mesio-distal enamel reduction ("stripping").

Of these techniques, the mucogingival surgery as-

pects are discussed in Chapter 27, and will not be

commented on here. The gingival prosthesis may be

useful in cases of markedly compromised dentitions,

where the psychological implications of having pro-

nounced retractions are serious. It may be regarded as

a last resort. In contrast, the mesio-distal contouring

of teeth is a very useful technique to routinely improve

the esthetic results achieved by orthodontic treatment

in most adult and adolescent patients (Figs. 31-3, 31-4,

31-6, 31-25).

Benefits of mesiodistal enamel reduction

("stripping")

Introduced by Tuverson in 1980, mesio-distal recon-

touring of teeth has now become a routine procedure

in orthodontics. It is generally performed on three

indications: (1) treatment of slight-to-moderate

crowding without arch expansion, (2) correction of

width discrepancies (so-called TSD = tooth size dis-

crepancies) between maxillary and mandibular teeth,

and (3) to prevent interdental recession from develop-

ing during orthodontic treatment. The principle in-

Fig. 31-24. Marked labial gingival recession on prominent left mandibular canine in female young adult patient (a

c). After extraction of two premolars and the left central incisor (sic!), the mandibular arch was leveled orthodonti

cally (d). (e) and (f) show the clinical condition towards end of orthodontic therapy, and (g-h) at follow-up 1 year

ter appliance removal. Note spontaneous improvement of gingival recession (f-h).

772 • CHAPTER 31

volved in stripping is to recontour those teeth which

for one reason or another have abnormal morphology,

towards an ideal anatomical shape (Figs.

31-6, 31-25).

In doing so, a good occlusion with optimal tooth

contact point relationships and normal interdental

gingival papillary contours will be achievable (Figs.

31-

5, 31-6, 31-25).

In many adult patients with malocclusion, particu-

larly in cases with crowded and overlapping incisors,

the crowns of the incisors are much wider at their

incisal edges than at the cervical region. As the crowd

ing is unraveled by orthodontic levelling in these

instances, the contact point between the incisors will

become located in the incisal 1 mm, and a more or less

evident space develops above the interproximal con-

tacts of the incisors. Similar, or even more pronounced,

loss of the interdental papillae between the maxillary

and mandibular incisors, is commonly seen after or-

thodontic treatment in patients with advanced peri-

odontal destruction.

Short-term (Zachrisson & Mjor

1975)

and long-term

(

> 10 years)(Thordarson et al.

1991)

follow-up studies

after extensive grinding of teeth have demonstrated

that no harmful side-effects are observed subsequent

to the procedure, provided adequate cooling is used

during the grinding and the prepared surfaces are

made smooth and self-cleansing. After the diastema is

created, the space between the teeth is closed ortho-

dontically. As this occurs, the roots of neighboring

teeth come closer together, the contact area is length-

ened, and the reduced papilla can fill out the small

space between the teeth (Tarnow et al.

1992).

In pa-

tients with advanced periodontal disease, it is not

always possible to restitute all papillae in the denti-

tion. Even if it is not possible to eliminate the interden

tal recession completely after the orthodontic treat-

ment, the esthetic appearance is in most patients sub

stantially improved by stripping (Figs.

31-3, 31-4).

MINOR SURGERY ASSOCIATED

WITH ORTHODONTIC THERAPY

Several forms of minor periodontal surgery may be

used to improve or stabilize the results achieved by

orthodontic treatment of malocclusion. More than

years ago, Edwards

(1970)

described clinical tech-

niques to help prevent rotational relapse, re-opening

of closed extraction spaces (Edwards

1971),

and a

simple yet effective technique for frenotomy (Ed-

wards

1977).

At about the same time, a gingivectomy

technique to increase clinical crown length for esthetic

improvement of orthodontic results in specific situ-

ations was reported (Monefeldt & Zachrisson

1977).

Removal of gingival invaginations in extraction sites

following orthodontic space closure has also been a

subject of considerable interest to orthodontists.

Fiberotomy

The problem of relapse of orthodontically treated

teeth

in general, and rotated teeth in particular, has

been

well recognized for years. Methods to reduce the

occurrence of rotational relapse may include (1) com-

plete correction, or overcorrection, of rotated teeth,

(2)

long-term retention with bonded lingual retainers,

and

(3)

the use of fiberotomy.

Two soft-tissue periodontal entities may influence

the stability: the principal fibers of the periodontal

ligament, and the supra-alveolar fibers. Whereas the

fibers of the periodontal ligament and transseptal

groups remodel efficiently and histologically com-

pletely in only

months after orthodontic rotation

of teeth, the supra-alveolar fibers are apparently more

stable, with a slow turnover. Since the gingival soft

tissues are composed primarily of non-elastic col-

lagenous fibers, the exact mechanism by which the

gingival soft tissues may apply a force capable of

moving the teeth is as yet unknown. From a practical

and clinical point of view, however, the supracrestal

gingival tissues seemingly do contribute to rotational

relapse, as evidenced by the effect of the circumferen-

tial supracrestal fiberotomy (CSF) technique.

Basically this technique consists of inserting a scal

pel into the gingival sulcus and severing the epithelial

attachment surrounding the involved teeth. The blade

also transects the transseptal fibers by interdentally

entering the periodontal ligament space. Various

modifications of the original CSF technique have been

described, in which the scalpel is inserted below the

gingival margin, or the cut is reduced to interdental

vertical incisions buccally and lingually (Fig.

31-26).

neither case are surgical dressings indicated, and

clinical healing is usually complete in

7-10

days.The

fiberotomy procedure is not recommended during

active tooth movement, or in the presence of gingival

inflammation. When performed in healthy tissues af-

ter orthodontic therapy, there is negligible loss of at-

tachment (Edwards

1988).

The long-term effectiveness of fiberotomy was

evaluated in a prospective follow-up study over a

period of

years by Edwards

(1988).

The degree of

crowding was examined for CSF and control cases at

4-6

years and at

12-14

years after treatment. A signifi-

cant effect of the fiberotomy was observed at both time

intervals. The surgical procedure was more successful

in the maxillary than in the mandibular anterior re-

gion; more effective in alleviating rotational than

labiolingual relapse; and more useful in reducing re-

lapse in cases with severe rather than mild irregularity

of teeth. There was no clinically significant increase in

sulcus depth, nor signs of gingival labial recession.

Frenotomy

The contribution of the maxillary labial frenum to the

etiology of a persisting midline diastema, and to re-

ORTHODONTICS AND PERIODONTICS • 773

Fig. 31-25. Adult female patient with maxillary crowding and large overjet (a,b). After premolar extractions, ortho

dontic distalization of canines resulted in the development of marked interdental recessions in the anterior region

(c). Marked triangular incisor morphology and uneven incisal edges necessitated extensive recontouring (c,d) to al

low gingival fill-in after treatment (e,f).

opening of diastemas after orthodontic closure, is con-

troversial. The probability for diastema closure in the

long run is the same whether or not frenectomy is

performed. However, very hyperplastic types of fre-

num, with a fan-like attachment, may obstruct di-

astema closure and should be relocated.

In the past, the most common surgical procedure

was

frenectomy,

an excision-type operation, which was

often carried over to the palatal aspects. However, a

frequently observed complication may be an undesir-

able loss of the interdental papilla between the maxil-

lary central incisors. For this reason, the

frenotomy

(Fig.

31-27), which represents a more gentle operation, will

produce esthetically preferable results. With freno-

tomy, the attachment of the frenum to gingiva and

periosteum is severed, and the insertion of the frenum

774 • CHAPTER 31

Fig. 31-26. Adult male patient with median diastema, small teeth, and low attaching frenum (a,b), in whom several

different types of minor surgeries were performed (d) in order to improve and stabilize the orthodontic treatment

result (c). Gingivectomy over four incisors increased crown length. Note healing with intact stippling 2 months

later (e,f). The surgical procedure also comprised frenotomy and fiberotomies with interdental vertical cuts (d).

is relocated several millimeters up onto the alveolar may be combined with fiberotomy and gingivectomy

mucosa.

If a marked sutural bone cleft is observed in

(Fig. 31-26).

the pretreatment radiographs, the cut is extended to

sever the fibers within the coronal part of the mid-

palatal suture.Tissue healing after a frenotomy proce-

Removal of gingival invaginations (clefts)

dure is usually uneventful (Fig. 31-27). To further

reduce the relapse tendency and/or increase clinical Incomplete adaptation of supporting structures dur

crown

height of single or several teeth, the frenotomy ing orthodontic closure of extraction spaces in adults