Research Article, Dent Health Curr Res Vol: 7 Issue: 3

To Assess Variation in Buccal Bone Thickness and Height of the Alveolar Bone as a Result of Transverse Dimensional Changes in Maxillary Arch in Patients Undergoing Orthodontic Treatment with Passive Self-ligating Bracket System using Cone Beam Computed Tomographic Images

Vandana S^*

Department of Orthodontics, AECS Maaruti College of Dental Sciences & Research Center, Bengaluru, India

*Corresponding Author:

Vandana S
Department of Orthodontics, AECS Maaruti College of Dental Sciences & Research Center, Bengaluru (560076), India
Tel: 91855340994
E-mail: vandanasriram92@gmail.com

Received Date: January 10, 2020; Accepted Date: March 09, 2021; Published Date: March 16, 2021

Citation: Vandana S (2021) To Assess Variation in Buccal Bone Thickness and Height of the Alveolar Bone as a Result of Transverse Dimensional Changes in Maxillary Arch in Patients Undergoing Orthodontic Treatment with Passive Self-ligating Bracket System using Cone Beam Computed Tomographic Images.. Dent Health Curr Res 7:3.

Copyright: © All articles published in Dental Health: Current Research are the property of SciTechnol, and is protected by copyright laws. “Copyright © 2021, SciTechnol, All Rights Reserved.

Abstract

Keywords:

CBCT, Buccal bone thickness, Buccal bone height, Self-ligating brackets.

Introduction

Orthodontic specialty wouldn’t have existed if human dentition were not to have periodontium, which help us in providing good smile.

Though the thickness of periodontal ligament is just 0.25 mm it is a highly effective structure that holds the teeth firmly. Its reparative function takes up the responsibility of remodeling the alveolar bone.

To achieve successful and stable treatment outcome, both the limitations and possibility of orthodontic tooth movement must be understood and respected in order to prevent iatrogenic effects to the periodontium such as gingival recession, dehiscence and bone fenestrations [1]. During anterior-posterior movement of anterior and transverse movement of the posteriors special care has to be taken to prevent such effects (Tables 1-3).

Research has shown evidence of better tissue response of bone to light continuous forces. These biologically consistent forces not only aid in more predictable tooth movements [2] but also decrease abusive effect on periodontium there by aid in maintaining better bone integrity from pre to post treatment phases [2-4].

Realistically speaking light forces can be effective only if the factor of friction is taken out of the picture and self-ligating brackets claims to do so. Even though self-ligating brackets have been in use since 1933 [5-12]. It was in 1998. Dr Dwight Damon who proposed that when we use self-ligating bracket the friction is at its lowest [4-11, 13-43].

While using Damon system in crowding cases, space is gained for DE crowding by transverse changes in premolar region [12] which is often termed as ‘‘Transverse arch development’’ by Damon practitioners. To date there have been not much studies looking at the effects of Damon system on the alveolar bone health while achieving transverse arch development.

Tacco et al. [13] measured the maxillary changes on the dental casts after 12 months of treatment at the end of leveling and aligning phase of treatment) with Damon and conventional pre-adjusted brackets. Similar increase in transverse measurements was found in both the groups.

Vajaria et al. [14] compared the transverse changes produced by Damon and Conventional bracket system by using scanned dental casts. They reported the change in maxillary intermolar width in Damon was significantly greater than in conventional.

Pandis et al. [15] conducted similar study focusing only on mandibular measurements.

Basciftci et al. [16] by using digital dental casts found the Damon appliance was able to produce significant expansion of both dental arches that remained stable in the long term.

Transverse response of the dental arch treated with self-ligating has been studied, especially the dent alveolar response on the dental casts. However little is known regarding CBCT scans used to assess the alveolar bone on the posterior region were buccal bone can be detected and quantified.

Before the introduction of computed tomography it was not possible to visualize the buccal bone due to superimposition that occurred in 2D radiographs [17,18].

Timock et al. [19] investigated the accuracy and reproducibility of measurements of alveolar bone height and thickness by means of CBCT imaging. They found good precision and accuracy for both measurements.

The stability for every orthodontic treatment and its posttreatment retention lies on the health of the alveolar bone. During the course of the treatment using low force and low friction system seems to be a better option in preserving bone health while achieving transverse dimensional changes.

In literature there are not many studies conducted on adults to determine the effects of transverse changes on thickness and height of the alveolar bone.

This study is carried out to assess the changes in the alveolar bone around the teeth when transverse changes are brought about using Damon self-ligating brackets.

This assessment is done by treating patients with passive selfligating bracket system (Damon) and transverse dimensional changes were measured on the study models which were taken at (Table 1) i.e. prior the onset of treatment and again at (Table 2) which is taken after 10 months into treatment. CBCT scans were taken at (Table 1) and (Table 2) to assess any changes in the alveolar bone height, buccal bone thickness and transverse dimension using Galileo’s software (Tables 4 & 5).

Table 1: Mean Distribution of the Subjects Based on Pre and Post Scores of Buccal Bone Thickness at 3 Mm.

Table 2: Comparison of the Groups (Pre And Post) Using Paired Sample T Test of Buccal Bone Thickness at 3 Mm.

Table 3: Mean Distribution of the Subjects Based On Pre and Post Scores of Buccal Bone Thickness at 6 Mm.

Table 4: Comparison of The Groups (Pre And Post) Using Paired Sample T Test of Buccal Bone Thickness at 6 Mm.

Table 5: Percentage Reduction or Increase in Each Tooth at 3 And 6 Mm (Buccal Bone Thickness).

Aim

To assess variation in buccal bone thickness and height of the alveolar bone as a result of transverse dimensional changes in maxillary arch in patients undergoing orthodontic treatment with passive self-ligating bracket system using Cone Beam Computed Tomographic Images.

Objectives

• To evaluate the amount of transverse dimensional changes in maxillary arch.

• *To evaluate the changes in terms of buccal bone thickness and height.

Materials and Methods

This study was approved by ethical committee of AECS Maaruti College of Dental Science. This is an in vivo study conducted in our college in the department of orthodontics. Based on the preliminary sample size estimation, fourteen patients were randomly selected from the Out Patient Department.

All the fourteen patients involved in the study were explained about the study and written consent to undergo the CBCT radiographic examinations and to participate in this investigation was obtained from all the patients and from their parents or guardians. CBCT scans were taken following the approved protocol.

Patients presenting with moderate crowding (3 mm-7mm), presence of all the permanent teeth except 3rd molar, absence of spacing, Angles class 1 malocclusion, straight profile were considered the inclusion criteria.

Patients who were periodontal compromised patients who had undergone orthodontic treatment earlier, patients with systemic diseases or craniofacial syndromes and those determined to need corrective jaw surgery were excluded from the study.

All the patients satisfying inclusion criteria were treated without any extractions.

Intra oral impressions of teeth and adjacent soft tissue were taken prior the onset of treatment using algitex and poured with orthocal to make study models. The transverse distance between left and right 1^st and 2^nd premolars and 1^st molars were measured at the occlusal level on the dental casts using a digital caliper of 0.001 mm accuracy to record the pre-treatment transverse dimensions. Irregularity index was recorded on pretreatment model (Figures 1-6). CBCT Scans were taken prior the onset of treatment, to assess the current status of buccal bone. The following acquisition parameters were used:

Figure 1: Vernier caliper with 0.01 mm.

Figure 2: Pre-treatment study model.

Figure 3: Measuring inter-premolar width at Table1 in study model.

Figure 4: Measuring inter-premolar width at Table 2 in study model.

Figure 5: Alginate impression material used to record intraoral structures.

Figure 6: Orthoca.

Tube current of 6 Ma,

Tube voltage of 85 kv,

Field of view of 8*8 cm,

Radiation time 14180 ms which generates a voxel thickness of 0.15 mm. All the patients involved in the study were bonded with Damon Passive self-ligating brackets using ormco’senlite adhesive and primer, Damon cunitiarch wires treatment protocol was followed according to Damon Work book .

After 10 months into treatment when patients were on 18*25 cuniti at (Table 1) impressions were taken to make the study models, CBCT scans were repeated for all the patients involved in the study with the identical scanning protocol that was used at T0 for scans at (Table 1). All the measurements done prior the onset of treatment at (Table 1) the transverse dimension, buccal bone height and thickness were repeated at (Table 1, Figures 7 & 8).

Figure 7: KALDENT

Figure 8: Damon Bracket Kit.

3D Image Processing and Measurements

Each CBCT scan was imported into XG3D software (version 1.4) using the DICOM file format.

Cross sections of 0.1 mm thickness were made so that the axial slices were perpendicular to the long axis of the tooth in the buccolingual direction for each individual tooth. The cross sections were generated passing through the pulp apex and crossing the center of the root perpendicular to the alveolar contour at the level of the root cervical third. This can be done regardless of the angulation/ rotation of the tooth relative to the alveolar process or the presence of crowding. These cross-section images were imported into the software galileos within which the following variables were assessed:

• *Buccal bone thickness (BBT) at 3 and 6 mm from the cement enamel junction (CEJ).

• Buccal bone height (BBH), defined as the distance from the CEJ to the alveolar crest (Figure 9 & 10)

Figure 9: Broader Damon copper Niti wires.

Figure 10: Measuring BBT and BBH at T0 Using Gallioleos software.

The inter–first premolar, inter–second premolar, and intermolar widths were measured (Figures 11-15)

Figure 11: Measuring BBT and BBH at Table 2 Using Gallioleos software.

Figure 12: Transverse arch development.

Figure 13: Transverse arch development from Table 1 to Table 2.

Figure 14: Colouring of the bone done to signify the Bone covering the roots.

Figure 15: CBCT machine used for the study.

The difference was compared in terms of initial and final change in buccal bone height and buccal bone thickness for the maxillary first molar, maxillary first and second premolars. Initial and final change in intermolar and inter first and second premolar distance were measured.

T tests - Means: Difference between two dependent means (matched pairs).

Input:                      Tail(s)                                        = One                              

                                Effect size dz                              = 0.7114427                               

                                α err prob                                  = 0.05                             

                               Power (1-β err prob)                 = 0.8

Output:                  No centrality parameter δ            = 2.661975                             

                             Critical t                                      = 1.770933                              

                              Df                                               = 13                              

                             Total sample size                         = 14                              

                             Actual power                              = 0.809150

A power analysis was established by G*power, version 3.0.1 (Franz Fauluniversitat, Kiel, Germany). A sample size of 14 subjects would yield 80% power to detect significant differences, with effect size of 0.711 (derived from the article Deolino J ibiapina et al.) and significance level at 0.05.

Discussion

Alleviation of crowding without extractions and proximal reduction of the tooth can be achieved by distal movement of posterior teeth, expansion of the dental arch and incisor proclination [20]. However, sagittal expansion beyond the skeletal base boundaries or root movement through the bone may, according to animal [21, 22] and human [23-26] studies, constitute a risk of developing bony dehiscence and gingival recession. Transverse expansion can be achieved by relieving the muscle matrix [27] using buccal pressure with palatal devices [20] and fixed appliances using broad arch wires has been suggested recently [28,32]. According to three dimensional studies the rapid palatal expansion can cause horizontal and vertical reductions in the buckle alveolar bone of the pre-molars and molars [29,30]. The Damon self-ligating system claims that using low friction and low force are purported to be good for physiologically rebuilding the alveolar bone. They claim that post-treatment computed tomography (CT) images show transverse arch development and normal alveolar bone on lingual and buckle surfaces 31.

The three dimensional capability of cone beam computed tomography (CBCT) technology makes it possible to non-invasively assess alveolar bone changes for posterior teeth [41] where buccal bone defects can be detected and quantified [36]. Various studies [44-47,39] have indicated that CBCT images can be used to obtain accurate linear and angular measurements. Others [48] found a small systematic error, which became statistically significant only when combining several measurements. The accuracy of CBCT images for the detection and quantification of periodontal bone defects in three dimensions has been evaluated. Misch et al. [36] concluded that the three dimensional capabilityof CBCT offered a significant advantage because all defects including buccal and lingual defects could be detected and quantified.

Mol and Balasundaram 41concluded that CBCT images provide better diagnostic and quantitative information on periodontal bone levels in three dimensions than conventional radiography but the accuracy in the anterior aspect of the jaws was limited.

With rapid maxillary expansion, a significant amount of bone loss was reported by Garib et al [29]who found that RME reduced the buccal bone plate thickness of supporting teeth 0.6 to 0.9 mm and induced bone dehiscence’s on the buccal aspect where there was a significant reduction of alveolar crest level of 7.1 ± 4.6 mm at the first premolars and 3.8 ± 4.4 mm at the mesiobuccal area of the first molars. Rungcharas saeng et al [37] found that buccal crown tipping and reduction in thickness of buccal bone and height of the maxillary posterior teeth were the immediate effects of RME. Ballanti et al [46] found a significant reduction in buccal alveolar bone thickness of maxillary molars with the greatest amount of bone resorption being 0.4mm. The combination of self-ligating brackets with heatactivated super elastic arch wires has been reported to produce a lowforce, low-friction environment in which the bone follows the tooth movement. Thus, orthodontic treatment with self-ligating appliances would allow for greater dent alveolar expansion, causes less incisor proclamation, and require fewer extractions than the treatment with conventional appliances [32].

A more comprehensive study assessing the changes in buccal bone in both the posterior and anterior regions of the maxilla has not yet been published.

Therefore, the main purpose of this study was to assess the effects of using a passive self-ligating appliance on the maxillary buccal alveolar bone to alleviate crowding, with a non-extraction approach. Fourteen patients from the OPD of AECS Maaruti College Of Dental Science, Bangalore were selected for the study. All the patients met the inclusion criteria of the study. Study models and CBCT scans were recorded. CBCT scans were recorded prior to the treatment marked as T0. The patients were bonded with DAMON passive selfligating brackets and Post 10 months into treatment when patients were on 18*25 cunitii.e. at (Table 2), study models and CBCT scans were repeated. Galileo’s software was used to assess the change in the thickness and height of buccal bone and changes in transverse dimensions of the arch.

Information available from CBCT images provided a noninvasive insight into the dynamics of tooth movement during our study.

Cattaneo et al [12] found 12–23% reduction of buccal bone thickness in relation to second premolar, following non-extraction orthodontic treatment with self-ligating appliances.

In a study carried out by Juliana et al [33] which was the first ever study published measuring the BBT and BBH post aligning at 3mm and 6mm from CEJ, BBT reduced 36% and 45% respectively, and the decrease in BBT was non-significant in 2^nd premolar region. Apical migration of the marginal bone was seen in 75% of central incisors and 59% of mesiobuccal root of 1^st Molars. But the bone reduction at 2^nd Premolar was not significant in their study. In a systematic review by Bollen et al. [49-67], they suggested that orthodontic therapy was associated with small amounts of alveolar bone loss. In our study in contrast to the findings of Cattaneo and coworkers [12], the bone reduction was not significant.

At 3 mm from CEJ, the findings showed increase in the buccal bone thickness of 24, 15, 25, 16 and 26 and out of this increase in 24 and 25 were statistically significant. However, a small amount of bone loss in 14 region was noticed which was not statistically significant. BBT of 1^st premolars at 3 mm from CEJ overall increased by 30.69%, BBT of 2^nd premolars at 3 mm from CEJ increased by 59.07%. and BBT of 1^st molars at 3 mm from CEJ increased by 52.58%.

At 6mm from CEJ the buccal bone thickness is slightly decreased in 16 and 26 out of which the decreased value is statistically significant only in 16 and is not significant for 26. The bone thickness in 14, 24, 15 and 25 showed slight increase and was statistically significant in 24 and 25.

BBT of 1^st premolars at 6 mm from CEJ increased by 62.25%

BBT of 2^nd premolars at 6 mm from CEJ increased by 50.64%

BBT of 16 at 6 mm from CEJ decreased by 47.69%, and of 26 increased by 13.15%, overall of 1^st molars at 6 mm from CEJ decreased by 30.41%.

Buccal bone height when measured from CEJ to alveolar crest showed increase of boneheight in 14, 24, 25, 16 and 26. The increase was statistically significant in 24, 16 and 26 but not significant in 14 and 25. A small amount of decrease of the bone height in 15 and was statistically significant.

BBH of 14 increased by 7.73% and at 24 increased by 45.95%, overall at first premolars BBH was increased by 53.68%.

BBH at 15 decreased by 54.42%, at 25 increased by 7.23% and overall in 2^nd premolars it’s decreased by 30.82%.

BBH at 16 and 26 is increased by 44.09% and 56.32% respectively and the overall the increase in BBH at 1^st molars is 50.2%.

Increase in transverse dimension leading to transverse arch development when measured on CBCT scan at 1^st PM was 3.45mm, at 2^nd PM was 2.83 mm and 1^st molar was 2.44 mm from Tables 6-12.

Table 6: Mean Distribution of the Subjects Based on Pre and Post Scores Of Buccal Bone Height.

Table 7: Comparison of the Groups (Pre and Post) Using Paired Sample T test of Buccal Bone Height.

Table 9: Mean Distribution of the Pre and Post (Transverse) On Cbct.

Table 10: Comparison of Pre and Post (Transverse) Using Paired Sample T Test (Cbct).

Table 11: Mean Distribution of the Pre and Post (Transpost) On Cast.

Table 12: Comparison of Pre and Post (Transverse-Post on Cast) Using Paired Sample T Test.

When measured on study models the increase in transverse dimension at 1^st PM was 6.2 mm, at 2^nd PM was 4.7 mm and 1^st molar was 1.52 mm from (Tables 1-2). We found that the maxillary intermolar width increased significantly in premolars and molars from (Tables 1-2). Consistent with this finding, Tecco et al. [13], Lorenzo et al. [34], Lillian et al. [59] found that self-ligating and appliances increased maxillary dent alveolar widths. Megan et al. [65] found significant increase of maxillary dent alveolar widths with lowfriction appliance.

Intra observer reliability was found to be 0.7 (Moderate corelation).

Hence it can be concluded that the treatment with DAMON SLB’s results in significant increase in transverse dimensions which were found to be more at premolar region. Further, an increase in BBT at 3mm from CEJ of premolars and molars except in 14and an increase in 1^st and 2^nd premolars at 6mm from CEJ were noticed but there was a decrease in BBT at molars at 6mm from CEJ. Buccal bone height from CEJ to alveolar crest significantly increased in 24, 16 and 26, whereas BBH significantly decreased in 15.

Scope of the Study

The literature is filled with the advantages of SLB for orthodontic treatment. However, there are no studies that have investigated the buccal bone changes with SLB after the completion of leveling and aligning. Several studies have investigated the buccal bone changes with rapid maxillary expansion and they revealed that there is a buccal bone loss. Several clinical studies indicate that orthodontic treatment can have a mild detrimental effect on the periodontium but there is limited quantitative data for this. There are limited reports that compared the transverse dimension changes and its effects. This study will examine the buccal bone changes, the transverse dimensional changes, from (Tables 1-2) using Damon passive selfligating brackets in maxillary arch.

Limitations

The study had some limitation which includes shorter treatment duration; a large variation in initial BBT, a small amount of expansion, presence of brackets affects the precise measurements at (Table 2).

A higher sample size can help in determining the parameters more effectively. The sample was analyzed after 10months of treatment; a long term follow-up study can help to understand the changes better.

The present study was carried out to assess the amount of transverse dimensional changes in the maxillary arch and its effect on the buccal alveolar bone thickness and height. This was done using Damon Q passive self-ligating brackets on 14 patients with a nonextraction approach.

Statistical analysis

The interpremolar, intermolar distance, buccal bone thickness and height measured on CBCT scan at (Tables 1-2) were collected. The data was statistically analyzed using paired sample t test for the changes in buccal bone thickness and height. Level of Significance:P<0.05

Software Used:SPSS

Statistical Technique Used:Paired t- test was used to assess the changes

From (Table 1 & 2).

Conclusion

• Non-extraction alignment with self-ligating appliances generated significant amount of dental arch expansion. Maximum was found to be at 2^nd premolar region followed by 1^st premolar followed by 1^st molar.

• Significant increase in arch development from (Tables 1 & 2).

• BBT at 3 mm was increased in 15, 24 and 25, 16 and 26, but at14 it was decreased and was not statistically significant.

• BBT of 1^st premolars at 3 mm from CEJ increased by 30.69%

• BBT of 2^nd premolars at 3 mm from CEJ increased by 59.07%

• BBT of 1^st molars at 3 mm from CEJ increased by 52.58%

• BBT at 6 mm increased in premolars but was slightly decreased in 1^st molars.

• BBT of 1^st premolars at 6 mm from CEJ increased by 62.25%

• BBT of 2^nd premolars at 6mm from CEJ increased by 50.64%

• BBT of 16 at 6 mm from CEJ decreased by 47.69%, and of 26 increased by 13.15%, overall of 1^st molars at 6 mm from CEJ decreased by 30.41%.

• BBH was increased in first molars and first premolars; increase was statistically significant in 16, 26 and 24. Whereas, it was decreased in 15, 25 and statistically significant decrease of BBH was noticed in 15.

• BBH of 14 isincreased by 7.7%, at 24 increased by 45.95%, overall in 1^st premolars it was increased by 26.38%.

• BBH at 15 decreased by 54.42%, at 25 increased by 7.23%, overall in 2^nd premolars it was decreased by 30.82%

• BBH at 16 and 26 is increased by 44.09% and 56.32% respectively; overall the increase in BBH at 1st molars is 50.2%.

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