CASE REPORT

Treatment of lateral open bite with vertical

dentoalveolar distraction osteogenesis
€ rk,d and Aynur Arase
Işıl Aras,a Sultan Olmez,b Mehmet Cemal Akay,c Veli Ozgen Oztu
Izmir and Aydın, Turkey

The aim of this article is to describe the surgical, orthodontic, and periodontal treatment of an adult patient with a
lateral open bite, anterior crowding, and gingival recession on the mandibular right lateral incisor. The lateral
open bite, which resisted conventional mechanics, was successfully corrected by the combination of
dento-osseous osteotomies and vertical alveolar distraction using orthodontic multibracket appliances in
conjunction with nickel-titanium archwires and intermaxillary elastics. After the orthodontic treatment, the
denuded root surface of the mandibular right lateral incisor was closed using a coronally advanced flap
technique with platelet-rich fibrin. The results at the 2-year posttreatment follow-up were satisfactory from
both the occlusal and the periodontal standpoints. (Am J Orthod Dentofacial Orthop 2015;148:321-31)

A
lateral open bite that causes functional and
esthetic problems is characterized by infra-
positioned teeth below the occlusal plane
and vertical underdevelopment of the dentoalveolar
processes in the posterior segments. This malocclusion
can result from ankylosed teeth, mechanical interference
with eruption such as tongue thrust, or a disturbance
of the eruption mechanism (primary failure of
eruption). The conventional treatment of a lateral
open bite involving nonankylosed teeth comprises fixed
appliances and intermaxillary elastics to obtain dentoal-
veoler extrusion in the open-bite region.1-3
Cell mobilization, fibrous tissue reaction, and
turnover rate of collagen molecules are slower in adults
than adolescents, and bones are denser in adults. These
factors result in a delayed onset of responses to mechan-
ical forces and increase the potential for complications
such as alveolar bone dehiscence, marginal bone loss,
a
Assistant professor, Department of Orthodontics, Faculty of Dentistry, Ege
University, Izmir, Turkey.
b
Private practice, Izmir, Turkey.
c
Associate professor, Departments of Oral and Maxillofacial Surgery and Ortho-
dontics, Faculty of Dentistry, Ege University, Izmir, Turkey.
d
Assistant professor, Department of Periodontology, School of Dentistry, Adnan
Menderes University, Aydın, Turkey.
e
Professor, Department of Orthodontics, Faculty of Dentistry, Ege University,
Izmir, Turkey.
All authors have completed and submitted the ICMJE Form for Disclosure of
Potential Conflicts of Interest, and none were reported.
Address correspondence to: Işıl Aras, Department of Orthodontics, Faculty of
Dentistry, Ege University, Bornova, 35080 Izmir, Turkey; e-mail, isilaras@
gmail.com.
Submitted, January 2014; revised and accepted, July 2014.
0889-5406/$36.00
Copyright Ó 2015 by the American Association of Orthodontists.
http://dx.doi.org/10.1016/j.ajodo.2014.07.028
gingival recession, and root resorption in orthodontic
treatments of adults, especially when applied to patients
with a thin periodontal biotype or when heavy
orthodontic forces are used.4-6 One way to remove
some of the limitations encountered in tooth
movement and to simplify the orthodontic treatment
and minimize the risk of side effects is distraction
osteogenesis. Case reports have shown that vertical
continuation of dentulous or edentulous alveolar
processes,7-10 extrusion of the ankylosed maxillary
central incisors,11-19 and correction of lateral open
bites caused by vertical canting of the lesser segment
in cleft palate patients20 can be achieved with vertical
distraction osteogenesis.
This article describes an orthodontic treatment com-
bined with distraction osteogenesis using multibracket
appliances in conjunction with nickel-titanium arch-
wires and intermaxillary elastics in an adult patient after
traditional orthodontic therapy proved to be ineffective
for lateral open-bite correction and describes the
periodontal treatment of gingival recession on the
mandibular lateral incisor.
DIAGNOSIS AND ETIOLOGY
The patient was a 23-year-old white woman with the
complaint of a lateral open bite. The extraoral frontal
examination showed no asymmetry. Her forced smile
disclosed a unilateral open bite in the right buccal and
anterior regions, and she had an acceptable gingival
display. She had a straight profile with unstrained lip
closure. We observed that the tongue was interposed be-
tween the teeth on the right side, causing incomplete
vertical eruption of the dentition. The patient recalled
321
322 Aras et al

Fig 1. Pretreatment extraoral and intraoral photographs.

Fig 2. Pretreatment dental casts.

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Aras et al 323

Fig 3. Pretreatment radiographs.

no history of trauma and showed no signs of temporo-

Table. Cephalometric values
mandibular joint dysfunction. Her dental history con-
sisted of many amalgam fillings. She had not sought Two years
orthodontic treatment before. She had poor oral hygiene Pretreatment Posttreatment posttreatment
and gingival recession on the mandibular right lateral SNA ( ) 71.6 71.5 71.5
SNB ( ) 73.5 73.3 73.4
incisor because of a thin labial biotype and inadequate ANB ( ) 1.9 1.8 1.9
oral hygiene. The intraoral and dental cast examinations Wits (mm) 6.0 3.8 3.7
in the sagittal direction showed Class I molar relation- SNGoGn ( ) 44.9 44.5 44.3
ships on both sides and at the left canines, with a Class U1-SN ( ) 102.5 106.3 106.6
II relationship for the right canines. Overjet was 1.5 mm. IMPA ( ) 80.0 87.8 87.8
Upper lip-S 5.5 4.1 4.0
There was a mild crossbite in the right premolar region line (mm)
with no other buccal crossbite or scissors-bite, and the Lower lip-S 3.0 2.2 2.2
maxillary and mandibular midlines were coincident line (mm)
with each other and with the facial midline. Vertically,
she had an open bite extending from the right first molar No history of trauma was recalled. Also, the possibil-
to the right central incisor with a peak value of 6.5 mm at ity of primary failure of eruption was ruled out because
the lateral incisor region, and a 4-mm opening at the the anomaly did not include the molars. Although the
canine-first premolar region. The cast analysis showed vertical skeletal dimensions were increased, because
space discrepancies of 3.5 mm in the maxillary arch there was dentoalveolar compensation on the left since
and 4.2 mm in the mandibular arch (Figs 1 and 2). we postulated that the orofacial dysfunction (tongue
The lateral cephalometric analysis showed a skeletal thrust) was the main etiologic reason for this regional
Class III relationship (ANB, 1.9 ; Wits appraisal, 6 open bite.
mm) with bimaxillary retrognathism relative to the fron-
tal cranial base (SNA, 71.6 ; SNB, 73.5 ). The patient had
a hyperdivergent skeletal pattern (SNGoGn, 44.9 ). TREATMENT OBJECTIVES
Although the inclination of the maxillary incisors was The main treatment objectives were to (1) correct the
normal (1-SN, 102.5 ), the mandibular incisors were unilateral open bite by extrusion of the maxillary and
retroclined (IMPA, 80 ). She had a straight profile with mandibular teeth, (2) resolve the maxillary and
retruded upper and lower lips (lower lip to the S-line, mandibular crowding, (3) obtain Class I molar and
3 mm; upper lip to the S-line, 5.5 mm). All third canine relationships with normal overjet, overbite, and
molars were impacted (Fig 3; Table). symmetrical dental arches, (4) improve the periodontal

American Journal of Orthodontics and Dentofacial Orthopedics August 2015  Vol 148  Issue 2
324
Fig 4. Persisting open bite after 6 months of leveling.
conditions of the mandibular right lateral incisor, and (5)
achieve stable treatment results.
TREATMENT ALTERNATIVES
The primary treatment option to achieve dentoalveo-
lar extrusion was to use conventional orthodontics,
including a multibracket system and intermaxillary
elastics. Other options would be immediate reposition-
ing of the teeth with segmental osteotomies and
corticotomy-assisted orthodontic treatment. Also, surgi-
cal osteotomies followed by distraction osteogenesis to
overcome the various shortcomings of conventional
orthodontic treatment, such as the long treatment
time and the limited amount of tooth movement, could
be efficient alternatives.
TREATMENT PROGRESS
Before commencement of the orthodontic treatment,
the patient was advised to consult a periodontist
because of her poor overall oral hygiene and gingival
recession on the mandibular right lateral incisor.
Full-mouth scaling was performed by the periodontist.
Periodontal surgery to cover the root was recommended
after active orthodontic treatment because there is a risk
of recurrence of gingival recession during treatment as
the tooth is being moved; additionally, a well-
positioned tooth will simplify the achievement of a
correct gingival contour.21 Moreover, the patient was
referred to the oral surgeon for removal of the mandib-
ular right third molar to aid in the uprighting of the first
molar. We placed 0.018-in preadjusted edgewise appli-
ances simultaneously in both arches, and 0.012-in,
0.014-in, and 0.016-in nickel-titanium archwires were
used for leveling and aligning. Additionally, the patient
was instructed to use 100-g intermaxillary elastics from
the palatal buttons on the maxillary right premolars to
the buccal hooks on the mandibular right premolars;
the elastics also acted as a barrier to the tongue thrust.
Although the maxillary teeth were almost leveled and
aligned by 6 months after the start of treatment, no
August 2015  Vol 148  Issue 2 American Journal of Orthodontics and Dentofacial Orthopedics
Aras et al
leveling was achieved at the right segment of the
mandibular arch extending from the second premolar
to the canine (Fig 4). It was postulated that the more
compact structure of the mandibular bone compared
with the maxilla together with the interference by the
tongue thrust resisted the efforts to extrude the
posterior teeth when light forces were used. The other
possibility was ankylosis of the mandibular right
canine and premolars. When confronted with these
possibilities, we planned to move the teeth with the
supporting bone via osteotomies followed by distraction
osteogenesis.
SURGICAL PROCEDURE
Mandibular unitooth and segmental osteotomies
were performed using a Lindermann single-piece car-
bide bur (Dental Burs USA, Napa, CA) after a mucoper-
iosteal flap was reflected under local anesthesia.
Vertical cuts were made on both the mesial and distal
interproximal areas of the teeth in the mandibular right
quadrant starting from the first molar and ending at the
distal aspect of the right canine, beginning 2 to 3 mm
below the alveolar crest and extending 3 mm beyond
the estimated root apex. Additionally, a segmental os-
teotomy ending at the mesial aspect of the left canine
with a vertical cut was incorporated at the incisors.
Then a buccal horizontal cut was made 3 mm below
the root apices connecting the vertical cuts and extend-
ing from the distal aspect of the right first molar to the
mesial aspect of the left canine. These cuts were made
as deep as possible into the bone from the labial side.
Hence, single-tooth osteotomies consisting of the
mandibular right first molar and the second and first
premolars, as well as a segmental osteotomy comprising
the right canine and incisors were done (Fig 5). During
the osteotomies, great care was taken not to injure the
lingual periosteum and mucosa. The alveolar segments
were mobilized with an osteotome. The mucoperiosteal
flap was then closed without repositioning the mobilized
segments.
Aras et al
Fig 5. Osteotomy line used.
Also, 2 titanium screws (diameter, 2.3 mm; length,
13 mm; Surgi-tec, Ghent, Belgium) were implanted
between the roots of the canine and first premolar and
the second premolar and first molar in the maxilla. These
screws were used as anchors during distraction of
mandibular dento-osseous segments (Fig 6).
There were several postoperative considerations. After
callus formation, at day 7, loading of the distraction force
began with intermaxillary elastics with 200 g of force on
the 0.016-in mandibular nickel-titanium archwires. The
positions of the elastics were as follows: (1) extending
from the anterior screw to the mandibular right canine
and first premolar, and (2) extending from the posterior
screw to the mandibular right second premolar and first
molar, both in triangular configuration (Fig 7). The
patient was instructed to change the elastics twice a day.
Three weeks after force application, the lateral open
bite had almost vanished, with only 1 mm of vertical
opening at the lateral, canine, and first premolar regions
(Fig 8). Subsequently, 0.016-in stainless steel wires were
placed in the mandibular arch, and triangular and box
elastics were prescribed for 2 more weeks to improve
the vertical bite. After adequate space was achieved
with open coil springs and interproximal stripping of
the anterior teeth, the rotated mandibular left lateral
incisor was bracketed. Throughout this stage, the
posterior intermaxillary elastics were maintained for
stabilization of the distracted dento-osseous segments.
After the mandibular dental arch was aligned and the
vertical relationship of the incisors had improved, short
Class II elastics on 0.016 3 0.016-in stainless steel
maxillary and mandibular archwires were used for 2
months to correct the Class II canine relationship and
to obtain good interdigitation of the posterior segment
(Fig 9). Thereafter, 0.016 3 0.022-in stainless steel
archwires were placed, and the elastics usage was
terminated for 4 months to determine the open-bite
relapse potential. After 19 months of treatment, the fixed
orthodontic appliances were removed, and maxillary and
mandibular circumferential clear retainers were placed
(Figs 10 and 11).
American Journal of Orthodontics and Dentofacial Orthopedics
325
Fig 6. Location of the screws used as anchors for inter-
maxillary elastics.
Fig 7. Application of the elastics from the screws to the
mandibular teeth.
PERIODONTAL THERAPY
Before the orthodontic treatment, periodontal
therapy, consisting of oral hygiene instructions, scaling,
and root planing, was done by a periodontist, and the
patient was seen every 6 months. At the end of the
orthodontic treatment, the patient was referred to the
same periodontist for surgical treatment of the gingival
recession on the mandibular lateral incisor (Fig 12, A).
The recession depth was 4 mm. The coronally advanced
flap technique and a platelet-rich fibrin membrane were
used to cover the denuded root surface under local
anesthesia.22 Briefly, just before the surgery, intravenous
blood was collected in 4 vials (10 mL) without anticoag-
ulant and immediately centrifuged at 3000 revolutions
per minute for 12 minutes with the fibrin clot forming
in the middle part of the tube. The fibrin clot was
separated from the lower part of the centrifuged blood,
and the fibrin membrane was obtained by pressing the
clot. The recession defect was scaled using Gracey
curettes, and an intrasulcular incision was made around
the vestibular aspect of the tooth and connected with 2
vertical incisions near the interdental areas. Split, full,
and split flap incisions were made in a coronal-apical
direction. Gingival tissue adjacent to the root defect
on the interproximal bone was raised full thickness,
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326
Fig 8. Three weeks of force application and closure of the bite.
Fig 9. Short Class II elastics to obtain interdigitation.
whereas the most apical portion of the flap was raised
split thickness to allow coronal repositioning of the
flap without tension. All papillae were de-epithelialized
to create a connective tissue bed. The fibrin membrane
was positioned over the recession defect just below the
cementoenamel junction (Fig 12, B) and sutured with
6-0 propylene sutures. Stabilization of the blood clot
was achieved by the application of gentle pressure for
2 minutes. The gingival flap was repositioned with its
margin located on the enamel and sutured (Fig 12, C).
The sutures were removed after 7 days, and coverage
of the root surface was obtained.
TREATMENT RESULTS
At the termination of treatment, the asymmetric
appearance on smiling was resolved. Class I canine and
molar relationships with good interdigitation of the
lateral segments, normal overjet, a 3-mm overbite, and
well-aligned and symmetric dental arches were obtained
(Figs 10 and 11). The distracted teeth showed no
gingival recession, except for the mandibular right
lateral incisor, which also had gingival recession before
the treatment. The distracted teeth were vital when
checked with electric pulp testers. The suspicion of
ankylosis was ruled out because the teeth responded to
the orthodontic forces after bone healing.
No important skeletal changes were seen in the
cephalometric appraisal because no intervention was
undertaken to correct the sagittal discrepancy. Likewise,
the hyperdivergent skeletal pattern was consistent
August 2015  Vol 148  Issue 2 American Journal of Orthodontics and Dentofacial Orthopedics
Aras et al
throughout the treatment. Although the maxillary
incisors proclined by an acceptable amount (1-SN,
106.3 ), the mandibular incisors almost reached their
ideal value (IMPA, 87.8 ) as a consequence of the efforts
to resolve the anterior crowding. Even though the upper
lip still had a retrusive soft tissue value, the facial profile
showed a mild improvement (lower lip to the S-line,
2.2 mm; upper lip to the S-line, 4.1 mm). The
panoramic radiograph confirmed that the roots of all
teeth were parallel with no obvious evidence of the
root resorption. Also, the bone levels of the extruded
teeth relative to the adjacent teeth were corrected as a
result of distraction, and the mandibular right first molar
was uprighted (Fig 13, Table).
At 2 years posttreatment, the posterior occlusion
appeared to be stable, with a minimal relapse of the
incisor open bite and a slight Class II relationship
of the right canines. No problems were observed
concerning the vertical levels of the gingival margins
(Fig 14).
The pretreatment, posttreatment, and 2-year post-
treatment cephalometric records and superimpositions
showed that no skeletal changes had occurred. The
maxillary and mandibular incisors were proclined and
extruded slightly during treatment, with a minimal
relapse of the extruded maxillary incisors (Fig 15, Table).
DISCUSSION
Patients with a vertical growth pattern and posterior
rotation of the mandible might end up with an open-bite
Aras et al 327

Fig 10. Posttreatment extraoral and intraoral photographs.

Fig 11. Posttreatment dental casts.

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328
Fig 12. A, Gingival recession on the mandibular lateral incisor; B, position of the fibrin membrane over
the recession defect; C, repositioning of the gingival flap.
malocclusion, depending on the extent of the vertical
dentoalveolar compensation. Whereas the vertical
dentoalveolar compensation was complete on the left
side of the jaws, no compensation, including a negative
compensation, was present on the right side at the
canine and premolar levels because of this patient's
tongue thrust. Thus, the lateral open bite was
associated with vertical underdevelopment of the
dentoalveolar process; similar to a previous case report,
dentoalveolar extrusion was planned as the treatment
goal.3
In a previous case report, an 18-year-old patient
with a 3-mm unilateral open bite involving the
maxillary posterior teeth and a crossbite was treated
successfully with conventional mechanics including
intermaxillary elastics. However, for our patient, this
method was ineffective in closing the lateral open bite.
This could be a result of the following. The apical
third of the root might have been anchored more
firmly in a denser mandible compared with the maxilla
and might have resisted the efforts to extrude the
canine and the premolars with elastics.4 Also, a
tongue-thrusting habit in the open-bite space acting
as a barrier to the vertical movement of the teeth must
be considered.
In orthodontic treatments of adults and cleft palate
patients, and in some special situations such as atrophic
alveolar processes and ankylosed teeth, segmen-
tal osteotomies,23-25 corticotomy-assisted orthodontic
treatment,26 and vertical distraction osteogenesis11-20
are the surgical alternatives. The immediate
repositioning of a tooth or teeth with the supporting
bone through a 1-stage procedure of segmental
osteotomy can risk the blood supply of the segment and
can be limited by the mucosa's restricted ability to extend
up to the vertical correction,11,24 especially resulting in
osseous and gingival margin problems; therefore,
osteodistraction remains the therapy of choice to cover
greater distances of correction, as for this patient.14,16,20
Although 2-stage segmental osteotomies or corticoto-
mies, first performed on the palatal side and repeated 3
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Aras et al
weeks later on the buccal side, can provide a successful
outcome, the advantage of distraction is that it is
completed in a 1-stage procedure on the buccal side
only, maintaining the lingual periosteum and
mucosa.23,26 Without interfering with the blood supply
of the teeth and the alveolar segment, the distracted
segment can be repositioned gradually under the control
of the orthodontist.20
Vertical traction of dento-osseous blocks can be
achieved by nickel-titanium archwires,16,17,20 vertical
extrusion bends,11 stainless steel archwires with
T-loops,18 or a simple distraction device.12-15,19
Ohkubo et al18 used stainless steel archwires with
T-loops that were activated once every 7 to 14 days,
exerting a force of 300 to 400 g to produce vertical
distraction of the maxillary central-incisor osseous
block, although some authors prefer nickel-titanium
archwires that deliver constant and light forces.16,17,20
We supposed that the distraction osteogenesis for the
mandibular posterior teeth should probably be
undertaken with a higher force than that applied for
the maxillary incisor. In this patient, intermaxillary
elastics exerting 200 g of force at the mandibular right
segment and nickel-titanium archwires were used for
the distraction osteogenesis.
In conventional orthodontics, extrusion constitutes
the type of tooth movement that requires minimal forces
(35-60 g) to bring the alveolar bone and gingival tissues
along with the tooth.27 Heavy forces and a rapid rate of
movement can cause a risk of gingival recession and
denudation of the root, especially in adults, because
their gingival tissues cannot proliferate as fast.4 Because
the cortical bone was thin on the labial side of the
mandibular anterior teeth, with gingival recession on
the mandibular right lateral incisor, distraction
osteogenesis was planned for the mandibular anterior
teeth as well because traditional extrusion could have
been more risky regarding their periodontal health.
Eventually, the gingival margins of the distracted teeth
became healthy with no complications such as loss of
tooth vitality and denudation of the root surface because
Aras et al 329

Fig 13. Posttreatment radiographs.

Fig 14. Intraoral and extraoral photographs at 2 years posttreatment.

American Journal of Orthodontics and Dentofacial Orthopedics August 2015  Vol 148  Issue 2
330
Fig 15. A, Pretreatment (black line), posttreatment (green line), and 2-year posttreatment (red line)
superimposed cephalometric tracings; B, local superimpositions: maxilla and mandible.
of the ability of distraction osteogenesis to regenerate
soft tissues simultaneously with growth of the alveolar
process. Also, no injury to the lingual mucoperiosteum
and preservation of the lingual and buccal attached
gingivae are of the utmost importance to maintain basic
periodontal health.
The connective tissue graft is the most predictable
procedure for the treatment of recession defects and is
called the gold standard.28 However, the connective
tissue graft technique requires a second surgery to
harvest the graft; this is associated with surgical
challenges for the clinician. Also, donor site availability
is limited, and the procedure causes discomfort for
patients. Because of these limitations of connective
tissue grafts, a coronally advanced flap with a platelet-
rich fibrin membrane was chosen to close the denuded
root surface in this patient. The platelet-rich fibrin
membrane contains platelets, growth factors, and
cytokines that may enhance the healing potential of
the soft tissues. However, the initial thickness of the
flap and the type of dissection alter the success of
connective tissue microcirculation, and the interposition
of the platelet-rich fibrin membrane may restrict the
collateral circulation, which is essential for a thin flap
to revascularize and heal.29
Although correction of an anterior open bite is prone
to some relapse,30 the 2-year posttreatment evaluations
of the previous patient3 and our patient showed good
August 2015  Vol 148  Issue 2 American Journal of Orthodontics and Dentofacial Orthopedics
Aras et al
stability of the lateral open-bite correction. Cabrera
et al3 reported that the teeth maintained in position
with intermaxillary elastics for 5 months and subsequent
application of leveling archwires for an additional
5 months reduced the relapse tendency resulting from
supra-alveolar fibers. However, these procedures
lengthen the orthodontic treatment. Although the active
orthodontic treatment was reported to be 2 years
9 months with conventional mechanics,3 our patient
with a more severe lateral open bite was treated in
1 year 7 months. The short active treatment time and
the stability of the open bite correction in our patient
can be attributed to the distraction osteogenesis. We
think that the minimal relapse of the incisor open bite
and a shift toward a Class II canine relationship at the
right side were attributable to the maxillary incisors
and canines rather than to the distracted mandibular
teeth.
CONCLUSIONS
The combination of dento-osseous osteotomies
and vertical dentoalveolar distraction with a nickel-
titanium archwire and intermaxillary elastics aided in
closing the lateral open bite that resisted conventional
orthodontics. The advantages of this method were
good gingival margins of the distracted teeth, reduced
time of orthodontic treatment, stable results, and lower
costs with no dental complications.
Aras et al
REFERENCES
1. Proffit WR, Vig KW. Primary failure of eruption: a possible cause of
posterior open-bite. Am J Orthod 1981;80:173-90.
2. Kapoor AK, Srivastava AB, Singh BP. Bilateral posterior open-bite.
Abbreviated case report. Oral Surg Oral Med Oral Pathol 1981;51:
21-2.
3. Cabrera MC, Cabrera CA, de Freitas KM, Janson G, de Freitas MR.
Lateral open-bite: treatment and stability. Am J Orthod Dentofa-
cial Orthop 2010;137:701-11.
4. Thilander B, Rygh P, Reitan K. Tissue reactions in orthodontics. In:
Graber TM, Vanarsdall RL, Vig KWL, editors. Orthodontics. Current
principles & techniques. 4th ed. St Louis: Elsevier; 2005. p. 145-220.
5. Roberts WE. Bone physiology, metabolism, and biomechanics in
orthodontic practice. In: Graber TM, Vanarsdall RL, Vig KWL, ed-
itors. Orthodontics. Current principles & techniques. 4th ed. St
Louis: Elsevier; 2005. p. 221-92.
6. Vercellotti T, Podesta A. Orthodontic microsurgery: a new surgi-
cally guided technique for dental movement. Int J Periodontics
Restorative Dent 2007;27:325-31.
7. Chin M, Toth BA. Distraction osteogenesis in maxillofacial surgery
using internal devices: review of five cases. J Oral Maxillofac Surg
1996;54:45-53.
8. Gaggl A, Shultes G, K€archer H. Distraction implants—a new possi-
bility for the augmentative treatment of the edentulous atrophic
mandible: case report. Br J.Oral Maxillofac Surg 1999;37:481-5.
9. Hidding J, Lazar F, Z€oller JE. The vertical distraction of the alveolar
bone. J Craniomaxillofac Surg 1998;26:72-3.
10. Gaggl A, Schultes G, K€archer H. Distraction implants: a new oper-
ative technique for alveolar ridge augmentation. J Craniomaxillo-
fac Surg 1999;27:214-21.
11. Isaacson RI, Strauss RA, Bridges-Poquis A, Peluso AR, Lindauer SJ.
Moving an anklylosed central incisor using orthodontics, surgery
and distraction osteogenesis. Angle Orthod 2001;71:411-8.
12. Kinzinger GS, J€anicke S, Riediger D, Diedrich PR. Orthodontic fine
adjustment after vertical callus distraction of an ankylosed incisor
using the floating bone concept. Am J Orthod Dentofacial Orthop
2003;124:582-90.
13. Kofod T, W€ urtz V, Melsen B. Treatment of an ankylosed central
incisor by single tooth dento-osseous osteotomy and a simple
distraction device. Am J Orthod Dentofacial Orthop 2005;127:72-80.
14. Huck L, Korbmacker H, Niemeyer K, Kahl-Nieke B. Distraction os-
teogenesis of ankylosed front teeth with subsequent orthodontic
fine adjustment. J Orofac Orthop 2006;67:297-307.
15. Alcan T. A miniature tooth-borne distractor for the alignment of
ankylosed teeth. Angle Orthod 2006;76:77-83.
16. Chang HY, Chang YL, Chen HL. Treatment of a severely ankylosed
central incisor and a missing lateral incisor by distraction
osteogenesis and orthodontic treatment. Am J Orthod Dentofacial
Orthop 2010;138:829-38.
American Journal of Orthodontics and Dentofacial Orthopedics
331
17. Dolanmaz D, Karaman AI, Pampu AA, Topkara A. Orthodontic
treatment of an ankylosed maxillary central incisor through oste-
ogenic distraction. Angle Orthod 2010;80:391-5.
18. Ohkubo K, Susami T, Mori Y, Nagahama K, Takahashi N, Saijo H,
et al. Treatment of ankylosed maxillary central incisor by single-
tooth dento-osseous osteotomy and alveolar bone distraction.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;111:
561-7.
19. Kim Y, Park S, Son W, Kim S, Kim Y, Mah J. Treatment of an
ankylosed maxillary incisor by intraoral alveolar bone distrac-
tion osteogenesis. Am J Orthod Dentofacial Orthop 2010;138:
215-20.
20. Yen SL, Yamashita DD, Gross J, Meara JG, Yamazaki K, Kim TH,
et al. Combining orthodontic tooth movement with distraction os-
teogenesis to close cleft spaces and improve maxillary arch form in
cleft lip and palate patients. Am J Orthod Dentofacial Orthop
2005;127:224-32.
21. Ricci G, Silvestri M, Tinti C, Rasperini G. A clinical/statistical
comparison between the subpedicle connective tissue graft
method and the guided tissue regeneration technique in root
coverage. Int J Periodontics Restorative Dent 1996;16:538-45.
22. Aroca S, Keglevich T, Barbieri B, Gera I, Etienne D. Clinical evalu-
ation of a modified coronally advanced flap alone or in combina-
tion with a platelet-rich fibrin membrane for the treatment of
adjacent multiple gingival recessions: a 6-month study. J Perio-
dontol 2009;80:244-52.
23. Burk JL, Provencher RF, McKean TW. Small segmental and uni-
tooth osteotomies to correct dentoalveolar deformities. J Oral
Surg 1977;35:453-60.
24. Medeiros PJ, Bezerra AR. Treatment of an ankylosed maxillary
incisor by single-tooth dento-osseous osteotomy. Am J Orthod
Dentofacial Orthop 1997;112:496-501.
25. Chae JM, Paeng JY. Orthodontic treatment of an ankylosed maxil-
lary central incisor through single-tooth osteotomy by using inter-
dental space regained from microimplant anchorage. Am J Orthod
Dentofacial Orthop 2012;141:e39-51.
26. Hwang DH, Park KH, Kwon YD, Kim SJ. Treatment of Class II open
bite complicated by an ankylosed maxillary central incisor. Angle
Orthod 2011;81:726-35.
27. Proffit WR, Fields HW. Contemporary orthodontics. 3rd ed. St
Louis: Mosby; 1986. p. 296-325.
28. Nelson SW. The subepithelial connective tissue graft. A bilaminar
reconstructive procedure for the coverage of denuded root sur-
faces. J Periodontol 1987;68:779-90.
29. Hwang D, Wang HL. Flap thickness as a predictor of root coverage:
a systematic review. J Periodontol 2006;77:1625-34.
30. Greenlee GM, Huang GJ, Chen SS, Chen J, Koepsell T, Hujoel P.
Stability of treatment for anterior open bite. Am J Orthod Dento-
facial Orthop 2011;139:154-69.
August 2015  Vol 148  Issue 2