|Year : 2015 | Volume
| Issue : 1 | Page : 16-22
Effects of laser-aided circumferential supracrestal fiberotomy on relapse of orthodontically treated teeth: A pilot study
Shami Ajit Gokhale, Girish Byakod, Gaurav Gupta, Sangeeta Muglikar, Sharadha Gupta
Department of Periodontolory and Implantology, M.A. Rangoonwala College of Dental Sciences and Research Center, Pune, India
|Date of Web Publication||22-May-2015|
Shami Ajit Gokhale
Plot No. 8, SWOJAS, Shantiban Society, Kothrud, Pune - 411 038
Source of Support: None, Conflict of Interest: None
A significant cause of relapse of orthodontically treated teeth is thought to be the gingival and transseptal fibers of the periodontium, which are stretched and twisted as the tooth is rotated. To relieve the rotated tooth from forces exerted by the stretched fibers, circumferential supracrestal fiberotomy (CSF) was introduced. In simple CSF using a scalpel blade, intergingival, transgingival, transseptal, and semicircular fibers are transected. CSF helps the tissue remodelling and decreases relapse of orthodontically treated teeth. Laser offers numerous advantages compared with surgery. Laser CSF is expected to prevent relapse of orthodontically treated teeth. This study was conducted to evaluate the effectiveness and periodontal side effects of laser CSF on orthodontically rotated tooth. The aims were to compare the: amount of relapse and sulcus depth.The study involves 10 patients between age group of 14- 30 years. Patients with extraction site closure were included with the teeth adjacent to the extracted tooth involved in the study. A split mouth design was made with the maxillary right side as control whereas laser CSF was performed only on the maxillary left side. Laser diode of 980nm wavelength will be used. Evaluation after CSF was done after 4 weeks.
Keywords: Circumferential supracrestal fiberotomy, laser diode, relapse
|How to cite this article:|
Gokhale SA, Byakod G, Gupta G, Muglikar S, Gupta S. Effects of laser-aided circumferential supracrestal fiberotomy on relapse of orthodontically treated teeth: A pilot study. J Dent Lasers 2015;9:16-22
|How to cite this URL:|
Gokhale SA, Byakod G, Gupta G, Muglikar S, Gupta S. Effects of laser-aided circumferential supracrestal fiberotomy on relapse of orthodontically treated teeth: A pilot study. J Dent Lasers [serial online] 2015 [cited 2019 May 22];9:16-22. Available from: http://www.jdentlasers.org/text.asp?2015/9/1/16/157593
| Introduction|| |
Orthodontic treatment involves complex issues like skeletal, dental, and occlusal rehabilitation. Any discrepancy in these issues could possibly lead to relapse.
Relapse is the loss of any correction achieved by orthodontic treatment. When teeth are moved orthodontically, stretching of the periodontal ligament (PDL) and gingival fibers encircling the tooth occur. Postorthodontic treatment, the fibers contract, and relapse occurs. Sometimes relapse may occur due to continued growth pattern after orthodontic treatment. Teeth moved recently are surrounded by the newly formed osteoid bone. As this calcified bone provides no adequate stabilization to the teeth, it contributes to the relapse. In some instances, when the etiology of malocclusion is not eliminated the relapse is bound to occur. Of these, the PDL traction is considered as the most important causative factor for relapse .
Most experts agree that a significant cause of relapse in orthodontically treated teeth is thought to be the gingival fibers and periodontal fibers especially the transeptal and periodontal fibers which are stretched and twisted as the tooth is rotated. ,
There are two soft tissue entities that may influence the stability of teeth following orthodontic movement: Supraalveolar group and principal fibers of PDL. The method by which soft tissues might apply a force capable of moving teeth is not clear since these tissues are composed primarily of nonelastic collagenous fibers. There may be some elastic fibers in supracrestal tissue, but these are sparse. 
One possible explanation to the relapse is that the length of reconstituted collagen fiber can be altered by adjusting the ion concentration of its surrounding medium. Thus, a mechanism is proposed by which the contractile collagen could "recoil" following orthodontic tooth movement. ,
Another histologic explaination of relapse force may relate to elastic-like oxytalan fibers that apparently increase in concentration in supracrestal tissues during rotational movement of teeth. ,,,,,,
Thus, in summary, there is no substantial evidence at present to explain the mechanism by which gingival soft tissues may apply a force capable of moving the teeth.
However, from a practical point of view, supraalveolar soft tissues do seemingly contribute to the relapse of orthodontically treated teeth specifically orthodontically rotated teeth. ,,,,,,
No orthodontic treatment should be done when long standing results cannot be achieved. Retention is the holding of teeth in an ideal esthetic and functional position at the end of orthodontic treatment.
The gingival and periodontal tissues are affected by orthodontic tooth movement and require time for reorganization when the appliances are removed. The teeth may be in an inherently unstable position after treatment so that soft tissue pressure constantly produces a relapse tendency. Furthermore, the changes produced by growth may alter the orthodontic treatment results. All these things make retention necessary.
Three types of retainers are used: Removable retention, fixed retention, and active retention. Various types of removable appliances are Hawley's retainer, wrap around or clip-on retainer, Essix retainer, Damon splint and modifications of these appliances. Fixed retainers are used in cases where stability is questionable and prolonged retention is planned. The four main indications are maintaining lower incisor position, holding diastema closed, implant or pontic space maintenance, and retaining closed extraction spaces. Active retainers are removable appliances that correct irregularities and maintain as a retainer. These are: Spring retainer, used to realign malpositioned incisors and modified functional appliance (activator or bionator) that manages the relapse potential in Class II or Class III cases.
In 1970, Edwards reported a simple and apparently efficacious surgical technique to alleviate the influence that the supracrestal periodontal fibers presumably have on rotational relapse.  Campbell Moore and Mathews named the procedure as "circumferential supracrestal fibrotomy." 
In the simple cerebrospinal fluid (CSF) using a scalpel blade, intergingival, transgingival, transseptal, and semicircular fibers are transected. 
However, conventional CSF has some clinical drawbacks like poor patient acceptability, invasiveness and the fact that it is feasible only on teeth with healthy periodontium. Hence, alternative procedures like the use of lasers, cautery or caustic agents need to be considered. 
Frick and Rankin demonstrated that electrocautery is as effective as a conventional procedure for CSF with added benefits of less bleeding and lesser chance of infection. 
Lasers offer numerous advantages compared with conventional surgery. It also offers biostimulatory effects, coagulates blood vessels, seals lymphatics, and sterilizes wound during ablation while maintaining a clear, clean surgical field. ,
Other beneficial effects with the use of lasers include stimulation of wound healing, collagen synthesis, and acceleration of bone remodeling during tooth movements. ,
Kunal Dhingra et al. (2012) studied the root surface morphologic changes after 980 nm diode laser aided CSF on fluorosed and nonfluorosed teeth.
Ji-Won Lee et al. (2010) compared the effects of laser CSF using diode, CO 2 and Er: YAG lasers on the morphology and chemical composition of root surfaces.
These two studies did not attempt to check the relapse following CSF on orthodontically treated teeth but concluded that the use of lasers in CSF was safe with respect to root surface morphology.
In 2009 Kim et al. investigated the effectiveness and periodontal side effects of laser CSF and low-level laser therapy on orthodontically rotated teeth in beagles. They concluded that laser CSF is an effective procedure to reduce relapse after tooth rotation causing no apparent damage to the supporting periodontal structures.
The current study was conducted to evaluate the effectiveness of laser CSF using diode laser on orthodontically treated teeth and to estimate the periodontal side effects.
The aims of this study were to evaluate the effectiveness of CSF using diode laser in terms of the rate of relapse and to evaluate the periodontal side effects.
The study plans to evaluate the effectiveness of CSF on relapse of teeth by measuring the mid-bracket distance (MSD) and the distance between the cusp tips of the selected teeth and measuring the sulcus depth before and after the CSF procedure.
| Materials and Methods|| |
For the present pilot study, 5 patients between age group of 14 and 25 years undergoing orthodontic treatment at MARDC were selected.
The study was approved by the Institution's Ethics Committee, and an informed consent was obtained from either the patient or parent as applicable.
Patients who were willing to participate in the study and had undergone the extraction of maxillary first premolars during the course of orthodontic treatment were selected.
The sites chosen for CSF were the teeth adjacent to the extraction site, that is, the maxillary canine and maxillary second premolar.
The procedure was planned 5 weeks before debonding was to be done.
A split-mouth design was planned with laser CSF performed only on maxillary left side and maxillary right side acted as control side (where no CSF was performed).
The following clinical parameters were measured for both the test and control teeth.
Laser fibrotomy procedure
- Sulcus depth along Mesio buccal, Disto buccal, and Facial line angles
- MSD, that is, the distance between the brackets of the canine and second premolar [Figure 1]
- Distance between cusp tips (DCT) of the maxillary canine and second premolar [Figure 2].
About 2% lidocaine with 1:1,00,000 epinephrine was administered to provide local anesthesia during the procedure. A diode laser of 980 nm wavelength was used (Sunny™ diode laser).
The maximum depth of insertion of the laser tip was determined to be the sum of sulcus depth and biologic width (1.2 mm) [Figure 3].
The laser tip of 0.4 mm was inserted into the gingival sulcus to the level of alveolar bone crest and incision was extended around tooth circumference with the system configured to a continuous wave (1.2 W) with the movement of the laser tip in an up and down stroking movement [Figure 4].
The laser tip was moved in a circumferential manner taking care that all the fibers were lysed. Postoperative analgesic (diclomol tablet: Diclofenac sodium 50 mg + paracetamol 500 mg) was given only in one out of five treated patients on account of slight pain followed by the procedure. Patients were recalled 4 weeks after the procedure, and all clinical measurements were checked again.
| Results|| |
The results of the study were compared using nonparametric counterpart to the paired samples t-test which is the Wilcoxon signed-rank test for paired samples.
It can be inferred from [Table 1] that the MSD as measured between the bracket on 23 and 25 preoperatively 9.0 ± 0.35 on the control side and 9.10 ± 1.02 on the test side before treatment and changed to 9.7 ± 0.45 and 9.0 ± 0.94 on control and test side respectively.
|Table 1: Measurements of mid-bracket distance, distance between cusp tips and probing sulcus depths on test and control side pre and posttreatment |
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The DCT as measured between the tips of 23 and 25 on the control side were 8.4 ± 0.65 and 9.2 ± 0.27 before and after treatment, and the value was statistically significant (P = 0.046). The treated side showed no significant increase or decrease in the cusp tips of the measured teeth. The probing depth at the 3 measured surfaces of canine and premolar showed statistically significant increase in the values as compared to before and after treatment. The probing depth of mesiobuccal line angle of canine increased to a mean value of 2.032 (P = 0.042*) that at the facial line angle increased to a mean value of 2.032 (P = 0.038*) and that of the distobuccal line angle increased to 2.07 (P = 0.039*) for the second premolar the probing depth at the mesiobuccal line angle increased to a mean value of 2.60 (P = 0.039*) and at the facial line angle, increased to 2.04 (P = 0.041*), and that of the distobuccal line angle increased to 2.03 (P = 0.042*). The probing depth values of control side (right side) increased slightly but were not statistically significant.
| Discussion|| |
The objective of the retention phase of orthodontic treatment is to maintain teeth in their corrected positions after active tooth movement.
Retention is achieved by placing appliances, called retainers (e.g. Hawley's retainer or Essix retainer) on the teeth, by undertaking additional or adjunctive procedures or by a combination of these techniques.
The biggest disadvantage of a bonded retainer is that they make it difficult for the patient to brush and floss. If the person does not have the skills or motivation to perform effective oral hygiene practices, it is likely that such areas will become areas of plaque accumulation. Especially, when long-term use is considered, debris can put the person at a greater risk for periodontal disease.
Removable retainers are usually of two types: Hawley's and Essix retainer. Essix retainers have disadvantages that they are relatively fragile and can develop cracks, breaks or holes especially if the patient has a tooth grinding habit. It is nonadjustable and can interfere with speech and can also not be used to make further alignment, refinement or correction. Hawley's retainer consists of wires and clasps embedded in a relatively thick plastic body covering the palate or may lie along the lingual surface of the lowers. The visibility of the labial bow is of esthetic concern. This retainer can also interfere with the speech, the biggest disadvantage is that since it is removable, it is of no use if not used by the patient and also causes excessive salivation.
The adjunctive procedures include interproximal stripping or CSF, which are applied to the teeth/surrounding periodontium to aid the retention process.
In the present study, the MSD increased to an average of 0.7 mm on the control side, whereas it increased very minimally (0.1 mm) on the treated side.
Furthermore, the DCT on the untreated (control) side, showed a considerable increase (statistically significant). The treated side showed no significant increase in the measurement of DCT. These two findings are suggestive of a relapse occurring on the untreated side whereas CSF treated site showed nearly no relapse.
The probing depth measurements in the sulcus of the canines and second premolars on the treated side increased to an average of 1-2 mm as opposed to a negligible change in the measurements on the control side.
In the current study, the relapse on the control side was considered to be the effect of orthodontically stretched gingival collagen fibers, which pull the tooth toward the pretreatment position.
Many theories have been proposed to explain relapse for orthodontic treatment. Using standard error of mean, Redlich et al. reported that the stretched gingival fibers were torn, ripped, disorganized, and laterally spaced; and increased number of elastic fibers was also seen near the torn collagen fibers. This study suggests that relapse may not be due to the stretched collagen fibers but rather it originates in changed elastic properties.
The approximate 1-2 mm increase in probing pocket depth (PPD) at week 4 could have been caused by temporary hyperplastic gingivitis.
There was no sign of gingival recession but increased PPD by about 0.67 mm.  Thus, CSF seems to be a procedure of choice for counteracting this.
A shortwave laser (500-1000 nm) is absorbed by pigmented tissue/blood elements, but less absorbed by water or HO. As light energy from diode laser (980 nm) is highly absorbed by soft tissue and poorly by teeth and bone, hard tissue damage is avoided. 
This study confirms the safety of laser CSF as no particular injury to teeth or bone was seen.
By stimulating thrombocyte activation and blood vessel concealment, there is less blood loss during and after surgery and hence more patient acceptance. Use of lasers can also decrease swelling by sealing the lymphatic vessels. 
Surgical lasers have a central zone of carbonization surrounded by a zone of vaporization, coagulation and protein denaturation, and a stimulating zone. This may be one reason for improved healing with laser surgery compared with traditional scalpel surgery.
Laser also offers bactericidal properties transferred by the laser within the pocket and can thus reduce the risk of infection. 
As the laser beam is irradiated from the end of a 0.4 mm diameter tip cannot be used for transection, and thus an up and down stroking movement was initially required.
To find a more plausible explanation of the effect of lasers on relapse tendency, a study with a larger sample size and longer follow-up period is recommended. Further study with histologic evaluation and effects of use of different lasers for CSF at the molecular level should be carried out. The use of the conventional technique of CSF using a scalpel as a control would give a better explanation on the relapse following orthodontic treatment.
| Conclusion|| |
Laser CSF is an effective procedure to decrease the relapse following tooth rotation causing no apparent damage to supporting periodontal structures.
Laser CSF for orthodontically rotated teeth without retainers appears to decrease relapse tendency.
| References|| |
Wiser GM. Resection of the supra-alveolar fibers and the retention of orthodontically rotated teeth. Am J Orthod 1996;52:855.
Edwards JG. A surgical procedure to eliminate rotational relapse. Am J Orthod 1970;57:35-46.
Gianelly AA. Goldman HM. Biologic Basis of Orthodontics. Philadelphia: Lea and Febiger; 1971. p. 35-61.
Sherebrin MH, Oplatka A. Contraction-relaxation of collagen fibers in LiBr-water-acetone solutions. Biopolymers 1968;6:1169-75.
Edwards JG. A study of the periodontium during orthodontic rotation of teeth. Am J Orthod 1968;54:441-61.
Edwards JG. The diastema, the frenum, the frenectomy: A clinical study. Am J Orthod 1977;71:489-508.
Fullmer HM. The histochemistry of connective tissues. In: Hall DA, editor. International Review of Connective Tissue Research. Orlando, Florida: Academic Press; 1965.
Fullmer HM, Lillie RD. The oxytalan fiber: A previously undescribed connective tissue fiber. J Histochem Cytochem 1958;6:425-30.
Goggins JF. The distribution of oxylatan connective tissue fibers in the periodontal ligaments of deciduous teeth. Periodontics 1966;4:182-6.
Rygh P. Periodontal responses to orthodontic forces. In: McNamara JA, Ribbens KA, editors. Malocclusion and the Periodontium. Monogram 15. Ann Arbor: University of Michigan; 1964.
Sims MR. Reconstitution of the human oxytalan system during orthodontic tooth movement. Am J Orthod 1976;70:38-58.
Fullmer HM, Sheetz JH, Narkates AJ. Oxytalan connective tissue fibers: A review. J Oral Pathol 1974;3:291-316.
Boese LR. Increased stability of orthodontically rotated teeth following gingivectomy in Macaca nemestrina. Am J Orthod 1969;56:273-90.
Brain WE. The effect of surgical transsection of free gingival fibers on the regression of orthodontically rotated teeth in the dog. Am J Orthod 1969;55:50-70.
Crum RE, Andreasen GF. The effect of gingival fiber surgery on the retention of rotated teeth. Am J Orthod 1974;65:626-37.
Erickson BE, Kaplan H, Aisenberg MS. Orthodontics and transseptal fibers. Histologic interpretation of repair phenomena following the removal of first premolars with the retraction of anterior segments. Am J Orthod Oral Surg 1945;31:1-20.
Ewan SJ, Pastemak R. Periodontal surgery - An adjunct to orthodontic therapy. Periodontics 1964;2:162-71.
Thompson HE. Orthodontic relapses analyzed in the study of connective tissue fibers. Am J Orthod 1959;45:93. Wiser GM. Resection of the supra-alveolar fibers and the retention of orthodontically rotated teeth. Am J Orthod 1966;62:855.
Edwards JG. A surgical procedure to eliminate rotational relapse. Am J Orthod 1970;57:35-46.
Campbell PM, Moore JW, Matthews JL. Orthodontically corrected midline diastemas. A histologic study and surgical procedure. Am J Orthod 1975;67:139-58.
Kim SJ, Paek JH, Park KH, Kang SG, Park YG. Laser-aided circumferential supracrestal fiberotomy and low-level laser therapy effects on relapse of rotated teeth in beagles. Angle Orthod 2010;80:385-90.
Fricke LL, Rankine CA. Comparison of electrosurgery with conventional fiberotomies on rotational relapse and gingival tissue in the dog. Am J Orthod Dentofacial Orthop 1990;97:405-12.
Sarver DM, Yanosky M. Principles of cosmetic dentistry in orthodontics: Part 3. Laser treatments for tooth eruption and soft tissue problems. Am J Orthod Dentofacial Orthop 2005;127:262-4.
Hall RR. The healing of tissues incised by a carbon-dioxide laser. Br J Surg 1971;58:222-5.
Youssef M, Ashkar S, Hamade E, Gutknecht N, Lampert F, Mir M. The effect of low-level laser therapy during orthodontic movement: A preliminary study. Lasers Med Sci 2008;23:27-33.
Mester E, Mester AF, Mester A. The biomedical effects of laser application. Lasers Surg Med 1985;5:31-9.
Balboni GC, Brandi ML, Zonefrati L, Repice F. Effect of laser irradiation on collagen production by fibroblasts in vitro. Bull Assoc Anat 1985;69:15-8.
Redlich M, Rahamim E, Gaft A, Shoshan S. The response of supraalveolar gingival collagen to orthodontic rotation movement in dogs. Am J Orthod Dentofacial Orthop 1996;110:247-55.
Kravitz ND, Kusnoto B. Soft-tissue lasers in orthodontics: An overview. Am J Orthod Dentofacial Orthop 2008;133:S110-4.
Lioubavina-Hack N. Lasers in dentistry 5. The use of lasers in periodontology. Ned Tijdschr Tandheelkd 2002;109:286-92.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]