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Treatment outcome analysis of speedy surgical orthodontics for adults with maxillary protrusion
HyeRan Choo,a Hyun-A Heo,b Hyun-Joong Yoon,c Kyu-Rhim Chung,d and Seong-Hun Kime Philadelphia, Pa, and Suwon and Seoul, Korea

Introduction: The purposes of this study were to quantify the treatment outcomes of speedy surgical orthodontic treatment for adults with maxillary protrusion and to identify the key factors inuencing the efcacy of speedy surgical orthodontic biomechanics. Methods: Twenty-four adults with maxillary or bimaxillary protrusion were treated with speedy surgical orthodontics, including maxillary perisegmental corticotomy followed by the orthopedic en-masse retraction against C-palatal miniplate anchorage. The average total treatment time was 20 months (range, 11-42 months). Lateral cephalograms were taken at pretreatment, just after the perisegmental corticotomy, and at posttreatment to evaluate the skeletal and soft-tissue changes. The Pearson correlation analysis was used to identify the relationships between hard-tissue, soft-tissue, and perisegmental corticotomy variables. Results: The maxillary central incisors were retracted by 9.19 6 0.31 mm and retroclined by 19.73 6 1.17 . The change of the maxillary alveolar ridge angle was 13.97 6 1.04 . The extrusion tendency of the retracted maxillary incisors was minimal, measured as 1.17 6 0.36 mm. The width of the buccal corticotomy showed statistically signicant correlations with the angular change of the maxillary central incisors and the maxillary alveolar ridge angle. The retrusion of the maxillary central incisors and the maxillary alveolar ridge angle were the 2 hard-tissue variables that most closely correlated with retrusion of the upper lip. Conclusions: Speedy surgical orthodontic treatment can be an effective modality for adults with severe maxillary protrusion. (Am J Orthod Dentofacial Orthop 2011;140:e251-e262)

T
a

wo types of orthodontic treatment are commonly considered for adults with maxillary protrusion: rst premolar extractions followed by conventional orthodontic therapy with tooth-borne maximum anchorage, and orthodontic therapy in conjunction with orthognathic surgery. In both scenarios, relatively long treatment times are often unavoidable because the decreased cancellous bone volume and blood supply

Director of Craniofacial Orthodontics, The Childrens Hospital of Philadelphia; clinical associate, University of Pennsylvania Department of Orthodontics, Philadelphia. b Clinical fellow, Division of Oral and Maxillofacial Surgery, Department of Dentistry, Catholic University of Korea, Seoul, Korea. c Associate professor, Division of Oral and Maxillofacial Surgery, Department of Dentistry, Catholic University of Korea, Seoul, Korea. d Professor and chairman, Department of Orthodontics, Ajou University School of Medicine, Suwon, Korea. e Associate professor, Department of Orthodontics, College of Dentistry, Kyung Hee University, Seoul, Korea. The authors report no commercial, proprietary, or nancial interest in the products or companies described in this article. This study was in partial fulllment of the requirements of a thesis by Hyun-A Heo at the Catholic University of Korea. Reprint requests to: Seong-Hun Kim, Department of Orthodontics, College of Dentistry, Kyung Hee University, #1 Hoegi-dong, Dongdaemun-gu, Seoul 130-701, Republic of Korea; e-mail, bravortho@gmail.com. Submitted, November 2009; revised and accepted, June 2011. 0889-5406/$36.00 Copyright 2011 by the American Association of Orthodontists. doi:10.1016/j.ajodo.2011.06.029

in adults typically result in slower tooth movement.1,2 Orthodontic treatment for adults can be complicated if the dentition is compromised with periodontitis or multiple restorations, or if the patient refuses to wear conventional labial orthodontic appliances for a long period of time.3 Therefore, the anterior segmental osteotomy technique has become popular because it compensates for the limitations of conventional orthodontic biomechanics and decreases the total treatment time in adults who need orthodontic therapy.3-7 Since the inception of the original anterior segmental osteotomy technique in 1921,4 Wassmund,5 Cuper,6 and Wunderer7 have reported various modications.1-3 However, anterior segmental osteotomy infrequently has serious risks and challenges, such as anterior alveolar necrosis, tooth devitalization, and the need for general anesthesia.3,8,9 As an alternative, in 1959, Kle10 introduced various clinical corticotomy applicao tions where the osteotomy is limited to the cortical bone level, retaining the continuity of medullary bone and minimizing the tissue damage on teeth and periodontium during orthodontic tooth movement. A corticotomy has been shown to reduce complications and morbidity rates when compared with orthognathic surgery or anterior segmental osteotomy because of its operational simplicity.11,12 Therefore, the corticotomy
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became popular as an aid that could overcome the biologic limits of conventional orthodontic therapy without involving full osteotomies. In addition, Suya11 redened in 1991 the concept of rapid tooth movement by demonstrating the effectiveness of the tooth-embedded bony block movement after corticotomy. He named this concept corticotomy-facilitated orthodontics. Expanding on the concept of Suya11 to shorten conventional orthodontic treatment, Lee et al,13 Chung et al,14-16 Chung,17 and Kanno et al18 introduced the novel concept of speedy surgical orthodontics, which involved a perisegmental corticotomy, a C-palatal miniplate, and a C-palatal retractor as key components in treating maxillary protrusion for adults. Although both speedy surgical orthodontics and corticotomyfacilitated orthodontics use a perisegmental corticotomy, in the former technique, the corticotomized bone block includes 6 maxillary anterior teeth instead of a single tooth. More importantly, speedy surgical orthodontics can induce a bone-bending effect by applying the heavy orthopedic force against a palatal temporary skeletal anchorage device (Fig 1).15,16,19,20 Recently, temporary skeletal anchorage devices such as orthodontic miniscrews and miniplates have replaced extraoral anchorage devices that rely signicantly on patient compliance.21-23 Advances in temporary skeletal anchorage device designs and applications have enabled orthodontists to use absolute anchorage and heavy forces without biomechanical side effects during orthodontic therapy. In speedy surgical orthodontics, the bending of the retracted maxillary segment is often achieved within 3 to 6 months after the perisegmental corticotomy. Therefore, the orthodontic tooth movements immediately after the orthopedic retraction often occur within the time frame inuenced by the regional acceleratory phenomenon of Frost.24 This results in relatively faster tooth movement during the last stage of speedy surgical orthodontic therapy. Compared with the accelerated osteogenic orthodontics of Wilcko et al,25 which rely primarily on Frosts regional acceleratory phenomenon to facilitate individual tooth movements during the total orthodontic therapy, the speedy surgical orthodontic technique of Chung14-17 targets a dramatic change of tooth position by a perisegmental corticotomy and orthopedic bone bending followed by facilitated individual tooth movement. Although many studies have reported cephalometric evaluations of the various derivatives of surgically assisted orthodontic therapies, such as accelerated osteogenic orthodontics, corticotomyfacilitated orthodontics, anterior segmental osteotomy, and orthognathic surgery, few investigative efforts have

qualitatively and quantitatively described the outcome of speedy surgical orthodontic treatment. The purposes of this study were, therefore, to assess the clinical effects of speedy surgical orthodontic treatment and to identify the elements for the successful application of speedy surgical orthodontic biomechanics in the treatment of adults with maxillary or bimaxillary protrusion.
MATERIAL AND METHODS

The study subjects included 24 Asian women (average age, 27.3 years; range, 19-41 years) with maxillary or bimaxillary protrusion. All patients were evaluated and conrmed by their primary dentists to have been maintaining excellent dental and periodontal health in the last 6 months. This study was approved by the institutional review board of Uijeongbu St. Mary's Hospital of the Catholic University of Korea. The inclusion criteria for this study were (1) nongrowing women, (2) no signs or symptoms of temporomandibular joint disorder, (3) no unrestorable dental caries or congenitally missing teeth, (4) no craniomaxillofacial deformities affecting the normal palatal anatomy, and (5) no history of surgery or treatment that could have affected facial softtissue changes. Of the 24 patients included in this study, 19 were treated with a maxillary perisegmental corticotomy followed by an orthopedic en-masse retraction combined with a mandibular anterior segmental osteotomy with rigid xation surgical plates. Another 4 patients were treated with a maxillary perisegmental corticotomy followed by an orthopedic en-masse retraction and a mandibular corticotomy only. Only 1 patient was treated with a maxillary perisegmental corticotomy followed by an orthopedic en-masse retraction with no mandibular surgery. Perisegmental corticotomy removes both the buccal and the palatal cortical bone in a continuous linear form around the teeth to be retracted. The perisegmental corticotomy in this study was performed under local anesthesia in 2 stages on an outpatient basis. The rst corticotomy was made on the palatal side. After reecting a full-thickness palatal periosteal ap, the cortical bone was cut horizontally 5 mm above the apices from the maxillary right rst premolar to the left rst premolar, by using a round bur 4 mm in diameter. The second corticotomy (buccal corticotomy) was performed approximately 2 weeks after the palatal corticotomy. After the labial full-thickness mucoperiosteal ap was elevated, a horizontal corticotomy was made from 1 maxillary rst premolar to the other, parallel to the nasal oor and approximately 5 mm above the root apices of the 6 maxillary anterior teeth. The 2 vertical buccal corticotomies were then made on the root of the

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Fig 1. A, Three-dimensional cone-beam computed tomography image of corticotomized anterior maxilla and C-palatal miniplate (arrows indicate the corticotomized area); B, schematic illustrations of perisegmental corticotomy and alveolar bone bending.

maxillary rst premolar until they met the horizontal corticotomy. Both maxillary premolars were then extracted. The depth of the osteotomy was limited to the cortical bone. The nal result of this surgical procedure was a bone block formed by 2 vertical and 1 horizontal corticotomies while maintaining the continuity of medullary bone (Fig 1, A). After the perisegmental corticotomy, a cross-shaped orthodontic C-palatal miniplate (KLS Martin, Tuttlingen, Germany; Jin Biomed Co., Bucheon, Korea) was placed at the junction of the midpalatal suture and an imaginary line connecting the distal points of the right and left maxillary rst molars.15,26 This miniplate established the framework for absolute anchorage against which the orthopedic retraction force was applied. A custom-made C-palatal retractor was then bonded to the palatal surface of the maxillary 6 anterior teeth to consolidate them as a single unit. Nickeltitanium closed-coil springs were then used to connect the C-palatal miniplate to the C-palatal retractor for the en-masse orthopedic retraction of the corticotomized maxillary segment (Fig 2).15,27-29 The force applied on each side of the palatal retractor was 600 g (1200 g total) on average. In addition to the palatal retractor, a labial spring retractor with C-tube plates (Jin Biomed Co.) was sometimes added for better torque control of the retracted segment when the patients interincisal angle before the en-masse retraction was within normal limits (Fig 3). The torque control of

the retracted teeth was also managed by titrating the length of the retractor arms so that the line of retraction force could be as close as possible to the center of resistance of the retracted segment. On average, it took approximately 3 to 6 months to close two thirds of the premolar extraction spaces by orthopedic retraction (Fig 4). From this point, the retraction pads of the maxillary canines were disconnected from the retractor to subject the canines to the orthodontic force to establish a solid Class I relationship. At the same time, conventional orthodontic brackets and bands were placed on all teeth, and an initial leveling archwire was engaged. This nal stage of speedy surgical orthodontic treatment lasted until the total orthodontic treatment was completed with ideal Class I molar and canine relationships. A series of lateral cephalograms was taken at 3 time points: pretreatment, postbuccal perisegmental corticotomy, and posttreatment. All subjects were positioned in the cephalostat with the midsagittal plane at a right angle to the x-ray path and the Frankfort horizontal plane (FH) parallel to the oor. The patients were instructed to occlude in maximum intercuspation while completely relaxing their lips. The cephalometric landmarks, reference planes, and measurements used in this study are described in Figures 5 through 8. All linear and angular measurements were taken in the 2-dimensional metric system made by 2 primary reference planes: FH plane and Nperp plane (a plane passing through nasion and

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Fig 2. A, Schematic illustrations of C-palatal miniplate; B, anterior segment retraction using C-palatal retractor and C-plate combined mechanics; C, after retraction.

Fig 3. Specially designed labial appliances for anterior torque control during retraction: A and B, spring labial retractor; C and D, high anterior hook appliance.

perpendicular to the FH plane) as the vertical reference plane. The measurements were also divided into 3 categories: hard tissue, soft tissue, and corticotomy. Each patient served as her own control, so that the observed changes at the different time points were calculated by subtracting the pretreatment value from the posttreatment value. A positive value indicated forward or

downward movement, and a negative value indicated backward or upward movement.

Statistical analysis

Statistical data were generated and interpreted by using SPSS software for Windows (version 12.0; SPSS, Chicago, Ill). The mean and standard deviation of each

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Fig 4. Intraoral photographs and lateral cephalograms of anterior segment retraction using C-palatal retractor after perisegmental corticotomy in a 25-year-old woman: A-C, 1 week after retraction; D-F, 3 months after retraction.

variable at each time point were calculated as well as the value change between pretreatment and posttreatment. A paired t test was used to evaluate the treatment outcomes by comparing pretreatment and posttreatment, and the Pearson correlation analysis was used to identify relationships between the hard-tissue and soft-tissue changes, and the corticotomy variables. All lateral cephalograms were traced and measured by 1 investigator (H.H.A.). To quantify intrarater reliability, 8 of the 24 lateral cephalograms were randomly selected 2 weeks after the rst examination and measured by the same investigator. There were high correlation coefcients of 0.84 to 0.97 (P \0.01) when tested with the Pearson correlation analysis.
RESULTS

The average total treatment time was 20 months (range, 11-42 months). On average, it took 3 to 6 months to complete the orthopedic retraction. At posttreatment, all changes of hard-tissue variables were statistically signicant, although the linear and angular changes of Point A did not show clinically signicant differences (Table I). More specically, the position of the maxillary central incisor moved signicantly backward by 9.19 6 0.31 mm with a downward movement of 1.17 6 0.36 mm (P \0.01). The decreases in the SNA

and maxillary alveolar ridge angles were also statistically signicant, measured at 1.00 6 0.13 and 13.97 6 1.04 (P \0.001), respectively. In parallel, the angle FH-U1 decreased between pretreatment and posttreatment by 19.73 6 1.17 . The movement of Point A was statistically signicant in the backward (1.12 6 0.13 mm) and downward (0.43 6 0.11 mm) directions. Soft tissue landmarks were also changed at posttreatment. Labrale superius moved signicantly backward (4.60 6 0.29 mm) and downward (1.68 6 0.30 mm) (P \0.001). The nasolabial angle increased signicantly (16.12 6 1.31 ). Subnasale, however, showed neither statistical nor clinical signicant positional changes in the vertical and horizontal directions. When the relationships between hard-tissue and soft-tissue changes were examined by using the Pearson correlation analysis, both the backward movement of the maxillary central incisor tip, (P \0.01) and the bending movement of the maxillary anterior alveolar ridge (P \0.001) showed statistically signicant correlations with upper lip retraction (Nperp-Ls) (Table II). At the same time, the increase in upper lip length (FH-Ls) closely correlated with the maxillary central incisor tips downward movement (linear FH-U1) (P \0.001) as well as backward movement (angular FH-U1) (P\0.05). Despite a statistically and clinically signicant

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Fig 5. Cephalometric landmarks of hard-tissue and softtissue points and associated reference planes: S, Sella; Na, nasion; Or, orbitale; Po, porion; ANS, anterior nasal spine; PNS, posterior nasal spine; A, subspinale; U1, maxillary central incisor; Sn, subnasale; Ls, labrale superius.

change of the nasolabial angle between pretreatment and posttreatment, no hard-tissue variable changes reected statistically signicant correlations with the nasolabial angle. The linear and angular changes of Point A also failed to show statistically signicant correlations with any soft-tissue variable changes. There were correlations between the corticotomy measurements and the hard-tissue and soft-tissue changes (Tables III, Fig 8). The buccal corticotomy width and palatal corticotomy width correlated positively with the change of angular FH-U1. In addition, buccal corticotomy width positively correlated with the maxillary alveolar ridge angle change. Buccal corticotomy width, however, negatively correlated with the value changes of linear FHU1, Nperp-A, SNA, and FH-Ls. The retained cancellous length correlated positively with the changes of NperpA and SNA and negatively with the changes of angular FH-U1, Nperp-U1, and maxillary alveolar ridge angle.
DISCUSSION

Fig 6. Hard-tissue measurements: :FH to U1, Angle between the axis of the maxillary central incisor and the FH plane; FH to U1, distance from the maxillary central incisor to the FH plane; Nperp to U1, distance from maxillary central incisor tip to nasion perpendicular; FH to A, distance from A-point to the FH plane; Nperp to A, distance from A-point to nasion perpendicular; SNA, S-N plane to N-A line; UARA, upper alveolar ridge angle, the angle between the upper alveolar ridge line and the FH plane; U1, maxillary central incisor.

orthodontic adjustments after the orthopedic retraction varied signicantly depending on the patients situation. One patient became pregnant and suspended the speedy surgical orthodontic therapy for more than 1.5 years, whereas 2 other patients suspended the treatment in their nal stage of speedy surgical orthodontic therapy to study abroad for an extended time. Among the different variations of the surgically assisted orthodontics, speedy surgical orthodontics is distinguished by the following 2 characteristics.
Buccal and palatal perisegmental corticotomies

All patients were completely compliant with the orthopedic en-masse retraction protocol after the perisegmental corticotomy. The duration of the nal

The surgical plan of speedy surgical orthodontic therapy includes buccal and palatal perisegmental corticotomies to designate the maxillary 6 anterior teeth as the retracted unit, and the horizontal perisegmental corticotomy site serves as the fulcrum for bone bending of the retracted unit. Comparatively, the surgical design of corticotomy-facilitated orthodontics uses a perisegmantal corticotomy around 1 tooth to create block bone movement to facilitate individual tooth movement.

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through conventional orthodontic forces and biomechanics. This orthodontic phase typically occurs in the regional acceleratory phenomenons effective time frame, enabling the facilitated tooth movement. Recently, Lee et al31 investigated the pattern of accelerated tooth movement in 3 orthodontic therapy protocols in animal models: orthodontic tooth movement with no surgical intervention, treatment combined with a perisegmental linear corticotomy, and treatment combined with an anterior segmental osteotomy. They reported that the regional acceleratory phenomenon was observed only in the corticotomy-treated group, and a distraction osteogenesis effect was observed in the anterior segmental osteotomy-treated group.
Heavy orthopedic retraction against a palatal miniplate anchorage

Fig 7. Soft tissue measurements: FH to Ls, Distance from Ls to the FH plane; Nperp to Ls, distance from Ls to nasion perpendicular; FH to Sn, distance from Sn to the FH plane; Nperp to Sn, distance from Sn to nasion perpendicular; NLA, nasolabial angle, the angle formed by the labial surface of the upper lip at the midline and the inferior border of the nose.

The surgical plan of accelerated osteogenic orthodontics uses numerous perforation corticotomies around each tooth to produce Frosts regional acceleratory phenomenon effect,24,25 which is in turn used to facilitate individual tooth movement (described by Sebaoun et al,30 presenting the systemic and histologic evidence that tooth movement is facilitated after multiple corticotomies around the tooth, attributed to a demineralization and remineralization phenomenon rather than a bony block movement). The perisegmental corticotomy of Chungs speedy surgical orthodontic is used to produce the bone-bending effect of a multiple toothembedding bony block.11,17 A perisegmental linear corticotomy site can provide a focal force-loading zone for heavy orthopedic force by breaking the stress distribution over the cortical bone.20 Frosts regional acceleratory phenomenon effect is, of course, also applied to corticotomy-facilitated orthodontics and speedy surgical orthodontics.13-18,27,28 More specically, after the speedy surgical orthodontics 3 to 6 months of the orthopedic retraction phase, the nal phase of treatment is geared toward detailing the occlusion

Speedy surgical orthodontic uses a heavy orthopedic force to retract the maxillary anterior segment.15,16 The application of heavy forces in maxillary retraction was studied in an animal model with monkeys by Kawakami et al19 and Yoshikawa20 in Japan. They reported that a corticotomized maxillary segment could be effectively retracted using a heavy force of 400 g per side without damage to the intraoral or extraoral soft tissues, inferring that the orthopedic force after a perisegmental corticotomy could clinically apply to humans. In speedy surgical orthodontics maxillary anterior retraction, no tooth-borne anchorage was used. This was to eliminate the possibility of unwanted mesial movement of the maxillary posterior teeth in the treatment of maxillary protrusion. Instead, the constant heavy force was generated against a palatal miniplate providing the absolute intraoral anchorage and transmitted to the perisegmental corticotomy site through a rigid C-palatal retractor bonded to the palatal surface of the 6 maxillary anterior teeth.15 As shown in a recent 3-dimensional nite element analysis study, the stress generated by the heavy orthopedic force is concentrated more on the corticotomized site with relatively even distribution over the retracted segment during the speedy surgical orthodontic maxillary retraction.32 Although the surgical design and the orthodontic biomechanical setup of speedy surgical orthodontics were introduced by Lee et al13 in 1999, our study is the rst to quantify the treatment outcomes of speedy surgical orthodontics by using statistical analyses. The fact that all subjects in our study were women was unintentional. It was simply because most patients who elected speedy surgical orthodontic therapy were women, and we could obtain a sufcient number of subjects from that group. Since the time required for

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Fig 8. A, Corticotomy measurements from lateral cephalograms; B, schematic illustration. BCW, Buccal corticocotomized width (mm); PCW, palatal corticotomized width (mm); RCL, residual cancellous length, the distance between the deepest point of the buccal corticotomy and the deepest point of the palatal corticotomy (mm).

Table I. Changes of hard-tissue and soft-tissue measurements

T1 Mean 6 SD Hard-tissue measurements FH-U1 ( ) FH-U1 (mm) Nperp-U1 (mm) FH-A (mm) Nperp-A (mm) SNA ( ) UARA ( ) Soft-tissue measurements FH-Sn (mm) Nperp-Sn (mm) FH-Ls (mm) Nperp-Ls (mm) NLA ( ) 120.73 6 6.83 62.45 6 3.86 8.79 6 3.89 35.77 6 2.87 0.00 6 2.82 80.77 6 2.27 116.12 6 6.71 33.60 6 2.84 12.94 6 3.18 51.50 6 4.24 19.37 6 3.71 89.90 6 10.97 T3 Mean 6 SD 101.00 6 6.88 63.62 6 3.44 0.39 6 4.21 36.21 6 2.89 1.12 6 3.05 79.77 6 2.21 102.14 6 7.93 33.70 6 2.89 12.84 6 3.28 53.18 6 3.87 14.77 6 4.22 106.03 6 10.25 T3T1 Mean 6 SD 19.73 6 1.17 1.17 6 0.36 9.19 6 0.31 0.43 6 0.11 1.12 6 0.13 1.00 6 0.13 13.97 6 1.04 0.10 6 0.07 0.10 6 0.06 1.68 6 0.30 4.60 6 0.29 16.12 6 1.31 P value 0.000* 0.003y 0.000* 0.001y 0.000* 0.000* 0.000* 0.175 0.125 0.000* 0.000* 0.000*

T1, Pretreatment; T3, posttreatment. Statistically signicant differences between groups by paired t tests: *P \0.001; yP \0.01.

the en-masse orthopedic retraction ranged from only 3 to 6 months with minimal variations, we dened posttreatment as the time point when the orthopedic retraction was completed, rather than the time point when the total orthodontic treatment was completed, to more accurately assess the soft-tissue and hard-tissue changes by speedy surgical orthodontic therapy. Each patients personal and social situation often extended the total treatment time. The mean total treatment time for the subjects in this study was 20 months with a range of 11 to 42 months, which did not show signicant differences compared with conventional orthodontic therapy with 4 premolar extractions. However, the primary goal of speedy surgical orthodontics is not to shorten the total treatment time; rather, it is to present a novel alternative to the conventional orthognathic surgery-based orthodontic therapy under general anesthesia. Speedy surgical orthodontic therapy

corrects the adults severe maxillary protrusion with gradual bending of the retracted maxillary bony segment after decreasing the cortical bones resistance to the heavy retraction force. A block bone movement embedding multiple teeth might contribute to reducing the periodontal complications related to the extensive retraction of the maxillary teeth because signicant retractions of the maxillary incisors in speedy surgical orthodontics are achieved by bone bending without changing the preexisting periodontal environment of the retracted teeth. In our patient population, there were no self-reported medical complications such as loss of tooth vitality, severe root resorption, or periodontal damage during or after the complete orthodontic treatment. However, we recognize the importance of periodontal stability before and after speedy surgical orthodontic therapy and intend to include periodic periodontal assessments as part of the

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Table II. Correlation coefcients between hard-tissue and soft-tissue changes (T3-T1)
Hard tissue Soft tissue DFH-Sn (mm) DNperp-Sn (mm) DFH-Ls (mm) DNperp-Ls (mm) DNLA ( ) DFH-U1 ( ) 0.352 0.037 0.491* 0.242 0.210


DFH-U1 (mm) 0.428* 0.281 0.651z 0.064 0.042

DNperp-U1 (mm) 0.277 0.143 0.301 0.542y 0.323

DFH-A (mm) 0.300 0.611y 0.030 0.352 0.212

DNperp-A (mm) 0.256 0.040 0.247 0.062 0.087

DSNA ( ) 0.217 0.006 0.221 0.074 0.122

DUARA ( ) 0.414* 0.240 0.357 0.641z 0.307

*P \0.05; yP \0.01; zP \0.001.

Table III. Correlation coefcients between changes and corticotomy measurements

Hard-tissue changes Soft-tissue changes Corticotomy measurement DFH-U1 DFH-U1 DNperp-U1 DFH-A DNperp-A DSNA DUARA DFH-Sn DNperp-Sn DFH-Ls DNperp-Ls DNLA (mm) (mm) (mm) (mm) ( ) ( ) (mm) (mm) (mm) (mm) ( ) (mean 6 SD, mm) ( ) BCW (3.23 6 0.79) 0.421* 0.552y 0.319 0.263 0.486* 0.557y 0.495* 0.213 0.283 0.494* 0.062 0.195 PCW (3.37 6 0.97) 0.447* 0.329 0.387 0.053 0.022 0.068 0.354 0.342 0.189 0.316 0.317 0.202 0.339 0.406* 0.116 0.685z 0.651z 0.432* 0.291 0.302 0.229 0.119 0.072 RCL (7.30 6 2.48) 0.634z

*P \0.05; yP \0.01; zP \0.001.

speedy surgical orthodontic protocol to monitor the patients periodontal health. An incomplete cortical bone cut can make it difcult to move the targeted segment, increase the risk of root resorption, and result in uncontrolled tipping of the anterior teeth during retraction. Special attention is required on the palatal rugae area, since the cortical bone is thicker there than in any other palatal area. The perisegmental corticotomy procedure must be meticulously performed by an experienced surgeon to ensure the success of the orthopedic and orthodontic therapy. Some surgeons elect to do both buccal and palatal perisegmental corticotomies at the same time as a 1-stage procedure.16 A 1-stage perisegmental corticotomy uses a blind tunneling approach via small incisions on the maxillary buccal vestibule to reach the palatal side. A 2-stage perisegmental corticotomy often gives the surgeon a better view and the patient more time to heal. Therefore, a 2-stage approach can be less technique sensitive with lower risks of tissue damage and more predictable outcomes. The surgical procedure of speedy surgical orthodontics always includes luxation of the retracted segment immediately after the perisegmental corticotomy. The method of luxation, however, is quite different from that of accelerated osteogenic orthodontics. Whereas accelerated osteogenic orthodontics applies an aggressive luxation force to facilitate tooth movement every 2 weeks after the multiple cortical perforation around each tooth, speedy surgical orthodontics luxation can

be described as a gentle but rm pressure on the corticotomized bony segment, 1 time immediately after the last perisegmental corticotomy (often, the buccal corticotomy). Especially in a 2-stage perisegmental corticotomy method, the luxation helps to disrupt the unwanted callus formation at the rst corticotomized site (palatal side). The orthodontist should be able to feel the bending of the corticotomized bony segment at this time. Patients were also instructed to gently push the corticotomized segment 3 to 5 times a day in the buccolingual direction. The patient was monitored by the orthodontist every 3 weeks to maintain the optimal orthopedic force level. Patients should immediately return to the clinic for adjustments if any retractor pad loosens, because retraction occurs rapidly and any tooth not connected by the retractor will be left behind with a large gap. The changes of the hard-tissue and soft-tissue variables are dramatic in speedy surgical orthodontic therapy. The angle between the FH reference plane and the axis of the maxillary central incisor decreased by 19.7 on average. The maxillary alveolar ridge angle decreased by 14.0 , and the protrusion of the maxillary central incisor decreased by 9.2 mm with a minimal extrusion of 1.2 mm. The upper lip protrusion also decreased by 4.6 mm with the increased upper lip length by 1.7 mm. The nasolabial angle increased on average by 16.1 . These results reect that the dramatic angular change of the axis of the maxillary central incisor was mostly due to the dramatic maxillary alveolar ridge angle reduction by the bone-bending effect.

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Another interesting nding was that the maxillary central incisors were retracted over 9 mm, with an average extrusion of 1.2 mm. Since the average distance between the horizontal corticotomy line and the tip of the maxillary central incisor was at least 30 mm and the average change of FH-U1 was 19 , pure rotation of the corticotomized segment with the corticotomy site as the fulcrum point would have caused at least 1.64 mm of downward movement of the maxillary central incisor tip. The effect of less extrusion can be explained by the speedy surgical orthodontics intraoral en-masse retraction setup in 3 dimensions. As described in detail in the Material and methods section (Fig 1), the C-palatal miniplate is often positioned much higher than the palatal retractor. Therefore, this setup has an innate intrusion vector of the retraction force. In reality, however, the palatal retraction arms are often adjusted to adapt to the contour of the anterior palate for the patients comfort; this reduces the vertical discrepancy between the C-palatal miniplate and the point of retraction force application, decreasing the magnitude of intrusion. Therefore, the length of the retraction arms plays a critical role in determining the vector and the moment of the retraction force for the retracted segment. The line of retraction force of speedy surgical orthodontic biomechanics can be easily adjusted to approximate as closely as possible to the center of resistance of the retracted segment, minimizing the vertical positional change of the central incisors during retraction. Although 1.2 mm of extrusion on average might indicate that the line of retraction force was still lower than the center of resistance, it seems that the amount of average extrusion would have been greater without the inherent intrusion component of the speedy surgical orthodontic biomechanical setup for retraction. An unexpected nding was that the positional and angular values of Point A did not show clinically significant changes, even though the value changes were statistically signicant. This nding can be explained by the fact that the horizontal portion of the buccal perisegmental corticotomy was quite often at or near Point A, and the anterior alveolar bone bending might have accrued around it with Point A as the fulcrum. In addition, the use of a labial spring retractor to better control the anterior torque of the retracted segment could have suppressed the signicant positional and angular changes of Point A. As expected, subnasale was the only landmark that did not show statistically and clinically signicant positional changes by speedy surgical orthodontic therapy. Although a conventional LeFort I osteotomy occurs above the level of the anterior nasal spine and signicantly affects the position of the nasal base after surgery,

the surgical level of the perisegmental corticotomy is much lower than the anterior nasal spine level. Therefore, subnasale, the soft-tissue counterpart of anterior nasal spine, must have had the least inuence from the speedy surgical orthodontic therapy. The correlation coefcient results of soft-tissue and hard-tissue changes identied 2 variables most closely correlated with the upper lip retraction. The rst was the retraction of the maxillary central incisors, and the second was the bending of the corticotomized alveolar ridge. In addition, upper lip length was shown to have a positive correlation with extrusion of the maxillary central incisor and a negative correlation with retroclination of the maxillary central incisors. These results are partly in agreement of other studies reporting correlations between incisor movement and their overlying soft-tissue changes.32-34 For example, Talass et al34 reported that maxillary incisor retraction has a signicantly positive effect on upper lip retraction, lower lip lengthening, and nasolabial angle. The results of the Pearson correlation coefcient test indicated that all linear soft-tissue changes had some statistically signicant correlations with the hard-tissue changes. However, the nasolabial anble change (the only angular soft-tissue change) showed no statistically signicant correlation with any hard-tissue changes, although the nasolabial angle showed clinically dramatic changes by speedy surgical orthodontic therapy. This was an unexpected result; however, when we expanded the correlation analysis to include soft-tissue changes, the nasolabial angle change showed a statistically significant correlation with another linear soft-tissue change (Nperp-Ls angle; coefcient, 0.66298; P 5 0.0004). This result showed that a favorable nasolabial angle change was primarily related to the upper lip change. This correlation analysis also identied that the 2 most critical changes of hard-tissue variables that must have inuenced the signicant upper lip retraction were retraction of the maxillary central incisors and bending of the maxillary anterior alveolar ridge. Of note, these hard-tissue changes did not necessarily correlate with the nasolabial angle change, but a visible association trend could be detected. This area of investigation could be explored by including additional test variables. To investigate the relationships between the regional specications of maxillary corticotomy and the changes of soft-tissue and hard-tissue variables, a lateral cephalogram was taken for each patient immediately after the corticotomy (Fig 8). Table III clearly illustrates that a wider buccal corticotomy achieves more retroclination of the maxillary central incisors as well as that of the maxillary anterior alveolar ridge. On the other hand, a wider buccal corticotomy results in less retraction of

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Point A. In addition, it seems that the increase of upper lip length and the extrusion of the maxillary central incisors are less severe if the buccal corticotomy is wider. These results might be because the orthopedic retraction force is generated against the miniplate on the roof of the mouth, causing the line of retraction force to be lower than the center of resistance of the retracted segment. Consequently, a wider buccal corticotomy accommodates more room into which the maxillary anterior segment can move after the intrusive retraction force. Although the width of the palatal corticotomy had a statistically signicant positive correlation with the amount of retroclination of the maxillary central incisors, it did not show a statistically signicant correlation with any other hard-tissue or soft-tissue changes. This might be because the dimensions of the palatal corticotomy were, in general, less consistent than those of the buccal corticotomy caused by the difculty of visualization during surgery. As expected, the greater the amount of retained medullary bone after the buccal and palatal corticotomies, the less bending of the retracted segment was observed. In addition, the amount of retraction of the maxillary central incisor was shown to be less with greater amounts of retained medullary bone. An unexpected nding was a statistically signicant positive correlation between the retained medullary bone and the change of Point A, suggesting that a greater Point A retraction can be expected when the medullary bone is retained more. This result could indicate that the bone-bending effect is more positively correlated with the width of the corticotomy on each side of the buccal or palatal bones rather than the thickness of the residual medullary bone (Fig 8). With the limitations of conventional 2-dimensional radiographic analysis of a 3-dimensional object, it will be meaningful to investigate this relationship by using 3-dimensional data analysis in the future. The fact that all subjects of the current study were somen was unintentional. It was simply because most patients who elected speedy surgical orthodontic therapy were female, and we could obtain enough subjects from this population. Further studies are needed to compare the differences in treatment effects between male and female patients as related to bone differences and hormonal differences in bone reorganization.
CONCLUSIONS

orthopedic retraction force for a bone-bending effect of the corticotomized maxillary anterior segment. Therefore, speedy surgical orthodontics can serve as an alternative treatment modality to conventional orthognathic surgery or anterior segmental osteotomy-based orthodontic treatment for an adults maxillary or bimaxillary protrusion.
REFERENCES 1. Miyajima K, Nagahara K, Lizuka T. Orthodontic treatment for a patient after menopause. Angle Orthod 1996;66:173-80. 2. Handelman CS. The anterior alveolus: its importance in limiting orthodontic treatment and its inuence on the occurrence of iatrogenic sequelae. Angle Orthod 1996;66:95-109. 3. Park JU, Hwang YS. Evaluation of the soft and hard tissue changes after anterior segmental osteotomy on the maxilla and mandible. J Oral Maxillofac Surg 2008;66:98-103. 4. Steinhuser EW. Historical development of orthognathic surgery. J a Craniomaxillofac Surg 1996;24:195-204. 5. Wassmund J. Lehrbuch der praktischen chirurgie de mundes und der keifer, Volume 1. Leipzig, Germany: Barth; 1935:p. 260-82. 6. Cupar I. Surgical treatment of alterations in form and position of the maxilla. Osterr Z Stomatol 1954;51:565-77. 7. Wunderer S. Surgical correction of extreme prognathism. Dtsch Z Mund Kiefer Gesichtschir 1989;13:98-100. 8. Scheideman GB, Kawamura H, Finn RA, Bell WH. Wound healing after anterior and posterior subapical osteotomy. J Oral Maxillofac Surg 1985;43:408-16. 9. Laigan DT, Hey JH, West HA. Aseptic necrosis following maxillary osteotomies: report of 36 cases. J Oral Maxillofac Surg 1990;48: 142-56. 10. Kle H. Surgical operations on the alveolar ridge to correct occlusal o abnormalities. Oral Surg Oral Med Oral Pathol 1959;12:515-29. 11. Suya H. Corticotomy in orthodontics. In: Hosl E, Baldauf A, editors. Mechanical and biological basics in orthodontic therapy. Heidelberg, Germany: Huthig Buch Verlag; 1991. p. 207-26. 12. Wilcko WM, Wilcko T, Bouquot JE, Ferguson DJ. Rapid orthodontics with alveolar reshaping: two case reports of decrowding. Int J Periodontics Restorative Dent 2001;21:9-19. 13. Lee BS, Hwang HW, Chung KR. Clinical use of corticotomies in adult orthodontics. J Korean Soc Maxillofacial Plast Surg 1999; 21:303-11. 14. Chung KR, Oh MY, Ko SJ. Corticotomy-assisted orthodontics. J Clin Orthod 2001;35:331-9. 15. Chung KR, Kim SH, Lee BS. Speedy surgical orthodontic treatment using temporary anchorage devices as an alternative to orthognathic surgery. Am J Orthod Dentofacial Orthop 2009;135:787-98. 16. Chung KR, Mitsugi M, Lee BS, Kanno T, Lee W, Kim SH. Speedy surgical orthodontic treatment with skeletal anchorage in adults sagittal correction and open bite correction. J Oral Maxillofac Surg 2009;67:2130-48. 17. Chung KR. Text book of speedy orthodontics. 1st ed. Seoul, Korea: Jeesung; 2001. 18. Kanno T, Mitsugi M, Furuki Y, Kozato S, Ayasaka N, Mori H. Corticotomy and compression osteogenesis in the posterior maxilla for treating severe anterior open bite. Int J Oral Maxillofac Surg 2007; 36:354-7. 19. Kawakami T, Nishimoto M, Matsuda Y, Deguchi T, Eda S. Histologic suture changes following retraction of the maxillary anterior bone segment after corticotomy. Endod Dent Traumatol 1996;12: 38-43.

Speedy surgical orthodontic biomechanics enables orthodontists to dramatically relocate the maxillary anterior teeth beyond an average scope of orthodontic tooth movement by establishing a unique intraoral biomechanical setup that can generate a constant heavy

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Choo et al

20. Yoshikawa Y. Effects on corticotomy on maxillary retraction induced by orthopedic force. J Matsumoto Dent Coll Soc 1987;13: 292-320. 21. Moon CH, Lee JS, Lee HS, Choi JH. Non-surgical treatment and retention of open bite in adult patients with orthodontic mini-implants. Korean J Orthod 2009;39:402-19. 22. Lee NK, Choi DS, Jang IS, Cha BK. Factors inuencing primary stability of miniplate anchorage: a three-dimensional nite element analysis. Korean J Orthod 2008;38:304-13. 23. Jeon MS, Kang YG, Mo SS, Lee KH, Kook YA, Kim SH. Effects of surface treatment on the osseointegration potential of orthodontic mini-implant. Korean J Orthod 2008;38:328-36. 24. Frost HM. The biology of fracture healing. Clin Orthop Related Res 1989;248:283-93. 25. Wilcko MT, Wilcko WM, Pulver JJ, Bissada NF, Bouquot JE. Accelerated osteogenic orthodontics technique: a 1-stage surgically facilitated rapid orthodontic technique with alveolar augmentation. J Oral Maxillofac Surg 2009;67:2149-59. 26. Chung KR, Kook YA, Kim SH, Mo SS, Jung JA. Class II malocclusion treated by combining a lingual retractor and a palatal plate. Am J Orthod Dentofacial Orthop 2008;133:112-23. 27. Kim SH, Lee KB, Chung KR, Nelson G, Kim TW. Severe bimaxillary protrusion with adult periodontitis treated by corticotomy and compression osteogenesis. Korean J Orthod 2009;39: 54-65.

28. Kim HS, Lee YJ, Park YG, Chung KR, Kang YG, Chung KR, et al. Histologic assessment of the biological effects after Speedy Surgical Orthodontics in a beagle animal model: a preliminary study. Korean J Orthod 2011;41:361-71. 29. Chung KR, Jeong DM, Park HJ, Kim SH, Nelson G. Severe bidentoalveolar protrusion treated with lingual biocreative therapy using palatal miniplate. Korean J Orthod 2010;40:276-87. 30. Sebaoun JD, Kantarci A, Turner JW, Carvalho RS, Van Dyke TE, Ferguson DJ. Modeling of trabecular bone and lamina dura following selective alveolar decortication in rats. J Periodontol 2008;79:1679-88. 31. Lee W, Karapetyan G, Moats R, Yamashita DD, Moon HB, Ferguson DJ, et al. Corticotomy-/osteotomy-assisted tooth movement microCTs differ. J Dent Res 2008;87:861-7. 32. Chung AJ, Kim US, Lee SH, Kang SS, Choi HI, Jo JH, et al. The pattern of movement and stress distribution during retraction of maxillary incisors using a 3-D nite element method. Korean J Orthod 2007;37:98-113. 33. Lee JK, Chung KR, Baek SH. Treatment outcomes of orthodontic treatment, corticotomy-assisted orthodontic treatment, and anterior segmental osteotomy for bimaxillary dentoalveolar protrusion. Plast Reconstr Surg 2007;120:1027-36. 34. Talass MF, Talass L, Baker RC. Soft-tissue prole changes resulting from retraction of maxillary incisors. Am J Orthod Dentofacial Orthop 1987;91:385-94.

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