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Application of Enamel Matrix Derivative and

Intrusive Orthodontic Movement in the
Treatment of Vertical Bony Defects:
A Case Report
Insan Jang, DDS, PhD1/Jae-Kwan Lee, DDS, MSD, PhD2 Spacing caused by pathologic mi-
Geun-Su Song, DDS, MSD3 gration of anterior teeth is a common
Dong-Soon Choi, DDS, MSD, PhD1 chief complaint in adult patients with
Joseph H. Yozgatian, DDS, MMSc, PhD4 periodontitis. Clinically, patients
Bong-Kuen Cha, DDS, MSD, Dr Med Dent1 may present an increased over-
jet and flaring of the anterior teeth
This case report presents treatment of a severe localized horizontal bone resulting from poor alveolar bone
loss combined with infrabony defects adjacent to pathologically migrated support or periodontal attachment
teeth by orthodontic intrusion following a graft of enamel matrix derivative loss. It is essential to control peri-
(EMD) without root surface conditioning. The patient was diagnosed with
odontal inflammation before align-
Angle Class II malocclusion, anterior spacing, and pathologically migrated
incisors. Graft of EMD mixed with bone materials was applied for periodontal ing the migrated teeth to prevent
regeneration before orthodontic treatment, and periapical radiographs were additional loss of connective tissue
taken every 3 months for radiographic evaluation. After closure of anterior attachment.1 Several reports have
spaces by orthodontic treatment, infrabony defects improved dramatically, shown that pathologically migrated
with a favorable alveolar bone level and periodontal pocket depth. Int J incisors with vertical bone defects
Periodontics Restorative Dent 2019;39:73–81. doi: 10.11607/prd.3432
were aligned, with no deterioration
of clinical attachment level and peri-
odontal pocket depth, by a combi-
nation of periodontal treatment and
orthodontic intrusion.2–6 However,
the wedge-shaped radiolucent area
of the infrabony defect in these
studies was not completely filled
by new bone, though a decrease of
Department of Orthodontics, College of Dentistry, Gangneung-Wonju National University,
1 the infrabony defect was observed
Gangneung, South Korea; Research Institute for Dental Engineering, Gangneung-Wonju on the radiograph.2,4 Moreover, it is
National University, Gangneung, South Korea.
2Department of Periodontics, College of Dentistry, Gangneung-Wonju National University,
uncertain whether histologic regen-
Gangneung, South Korea; Research Institute for Dental Engineering, Gangneung-Wonju eration of periodontal attachment
National University, Gangneung, South Korea. could be gained after orthodontic
3Department of Orthodontics, College of Dentistry, Gangneung-Wonju National University,
intrusion7 or if the root surface was
Gangneung, South Korea.
4Department of Oral Health Policy and Epidemiology, Harvard School of Dental Medicine,
covered by the epithelium without
Boston, Massachusetts, USA. new connective tissue attachment.8
Polson et al8 reported that distinct
Correspondence to: Dr Insan Jang, Department of Orthodontics, College of Dentistry, narrowing of the angular bony de-
Gangneung-Wonju National University 120, Gangneung Daehangno,
Gangneung City 25457, Korea. Fax: +82-33-640-3057.
fect had occurred on the pressure
Email: insan@gwnu.ac.kr side after orthodontic movement,
 Submitted April 22, 2017; accepted May 30, 2017. but with no evidence of new con-
 ©2019 by Quintessence Publishing Co Inc. nective tissue attachment.

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74

a b c

d e f
Fig 1  Initial intraoral photographs.

Enamel matrix derivative (EMD)
is a commercially available bio-
material known to enhance the
proliferation and differentiation of
osteoblasts,9,10 stimulate prolifera-
tion of periodontal ligament cells,11
and promote cementogenesis,12,13
although the mechanisms are not yet
clearly determined. Grafts of EMD
mixed with bone materials have
been performed on periodontally
affected root surfaces in an effort
to achieve periodontal regenera-
tion.14–16 However, only a few reports
exist on the pathologic migration
of anterior teeth with infrabony de-
fects treated by a combination of
orthodontic movement and the
application of EMD.17,18 These ear-
lier investigators17,18 performed root
surface conditioning by ethylene-
diaminetetraacetic acid (EDTA) be-
fore the application of EMD on the
periodontal defects. Although root
surface conditioning with demin-
eralizing agents has been used to
decontaminate the root surface, re-
move the smear layer, and expose
the collagenous matrix,19 there is still
some controversy regarding its clini-
cal and radiographic effects.20,21
This case report presents an
orthodontic treatment of pathologi-
cally migrated teeth with infrabony
defects following application of
EMDs without root surface condi-
tioning with EDTA. We also evalu-
ated the clinical and radiographic
stability 1 year after treatment.
Diagnosis and Treatment
Plan
A 55-year-old woman was referred
from a prosthodontist to move the
supraerupted maxillary left central
incisor to the level of the occlusal
plane for prosthodontic rehabilita-
tion. Her chief complaints were the
protruded left central incisor and
diastemata of the maxillary anterior
teeth. The maxillary left central in-
cisor was distinctly extruded, and
spaces between the maxillary and
mandibular anterior teeth were
observed (Fig 1). Radiographic ex-
amination revealed generalized alve-
olar bone loss. Vertical bony defects
were evident on the mesial sides
of the maxillary right lateral incisor
and the maxillary left central incisor
(Fig 2), and periodontal examina-
tion confirmed the presence of deep
periodontal pockets (Table 1).
The treatment plan involved
control of periodontitis, extraction
of the supraerupted maxillary left
first molar, endodontic treatment of
the maxillary right second premolar,
and alignment of the maxillary left
central incisor with partial bonding
of a fixed orthodontic appliance
for prosthetic rehabilitation on the
maxillary anterior teeth. Implants

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 75

were scheduled to be placed for

the missing maxillary and mandibu-
lar left first molars after orthodontic
treatment. However, after 6 months
of orthodontic treatment, the pa-
tient wanted the spaces closed by
orthodontic tooth movement on the
maxillary and mandibular anterior
teeth rather than by prosthodontic
a
rehabilitations. Therefore, the ini-
tial treatment plan was changed to
comprehensive orthodontic treat-
ment for space closure in the maxil-
lary and mandibular incisors.

Treatment Progress

At 1 month after the initial periodon- b c d

tal treatment, which included scal- Fig 2  Initial (a) panoramic, (b, c) periapical, and (d) cephalometric radiographs. Vertical
ing and root planing, a button was bony defects (arrows) on the mesial sides of the maxillary right lateral incisor and left
bonded on the lingual surface of central incisor were observed on the periapical radiographs.

the maxillary left central incisor and

a miniscrew was placed on the pal-
ate as an anchorage for intrusion.
Periodontal surgery for application
of EMD with synthetic bone was
performed under local anesthesia as
shown in Fig 3. Crevicular incisions
were made around the incisors, and
semilunar incisions were made on
the palatal sides of the interdental
papilla area for primary closure and
regeneration in the vertical defect
area. After complete removal of the
granulation tissue and debridement
with ultrasonic scaler and hand in-
struments, the root surfaces were
rinsed with a sterile saline solution.
The mixture of EMD (Emdogain,
Straumann) and synthetic bone
(BoneCeramic, Straumann) was ap-
plied on the mesial surfaces of the
right lateral incisor and left central in-
cisor. The mucoperiosteal flaps were
replaced and sutured to achieve
complete closure with 5-0 nonre-
sorbable nylon sutures (Happylon).
Postoperatively, the patient received
antibiotics (Augmentin) 3 times a day
for 5 days, along with 0.1% chlorhex-
idine mouthrinse. The patient was
instructed to refrain from brushing
or irritating the surgical area, and the
sutures were removed 2 weeks after
surgery. The postoperative healing
was uneventful, and no complica-
tions were observed.
At 1 month after periodontal
surgery, intrusion of the maxillary
left central incisor was initiated by
means of an elastic chain fixed to
the miniscrew. However, the max-
illary left central incisor showed
lingual inclination with occlusal in-
terference with the lower incisors.
Therefore, the fixed orthodontic
appliance (0.022-inch Victory MBT
bracket, 3M/Unitek) and 0.017 ×
0.022-inch stainless-steel wire were
placed on the maxillary teeth, and a
0.012-inch nickel-titanium wire was
overlaid for intrusion of the maxillary
left central incisor at the next visit
(Fig 4). At 7 months after the begin-
ning of orthodontic treatment, fixed
orthodontic appliances were placed
on the mandibular teeth (Fig 5). All
the spaces between the maxillary
and mandibular incisors were closed
by elastic chains. The patient re-
ceived periodic checkups with the
periodontist every 3 months, and

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76

Table 1  Periodontal Measurements (mm) Before and After Periodontal Surgery and Orthodontic Treatment
Maxillary right lateral incisor Maxillary
Distobuccal Midbuccal Mesiobuccal Distolingual Midlingual Mesiolingual Distobuccal Midbuccal
Probing depth
Before treatment 3 3 6 4 3 5 4 2
After treatment 3 3 3 3 3 3 3 3
Recession
Before treatment 0 0 2 0 0 2 0 0
After treatment 0 0 0 0 0 0 0 0
Clinical attachment level
Before treatment 3 3 8 4 3 7 4 2
After treatment 3 3 3 3 3 3 3 2

Fig 3  Surgical procedure. (a–c) Enamel

matrix derivative (EMD) with synthetic bone
graft was applied on the infrabony defects
of the maxillary right lateral and left central
incisors. Both teeth had combination
defects of two walls on the cervical area
and three walls on the apical area. (d)
Mucoperiosteal flaps were replaced and
sutured to achieve complete closure with
a b 5-0 nonresorbable nylon sutures.

c d

the alveolar bone level was evalu-
ated on the periapical radiographs
(Fig 6). The patient showed excellent
compliance with periodontal main-
tenance and a high level of plaque
control. The fixed orthodontic ap-
pliances were removed after 18
months of orthodontic treatment,
and the fixed retainers were bond-
ed to the lingual surfaces of the
anterior teeth to prevent relapse of
anterior spacing and to decrease
tooth mobility (Fig 7).
Treatment Results
Spaces between the maxillary and
mandibular anterior teeth were suc-
cessfully closed after orthodontic
treatment (Fig 7). Normal overjet
and overbite and esthetic interdental
papillae on the anterior teeth were
gained after space closure (Fig 7).
The periodontal examination follow-
ing 18 months of orthodontic treat-
ment showed a reduction in probing
depth by 2 mm around the maxillary
left central incisor and 3 mm around
the right lateral incisor. Gain of clinical

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 77

right central incisor Maxillary left central incisor

Mesiobuccal Distolingual Midlingual Mesiolingual Mesiobuccal Midbuccal Distobuccal Mesiolingual Midlingual Distolingual

3 3 3 3 5 2 3 4 4 3
3 3 3 3 3 3 3 3 3 3

0 0 0 0 1 0 0 1 0 0
0 0 0 0 0 0 0 0 0 0

3 3 3 3 6 2 3 5 4 3
3 3 3 3 3 3 3 3 3 3

a b c

d e f
Fig 4  Intraoral photographs 1 month after orthodontic treatment.

attachment on these teeth was
3 mm and 5 mm, respectively (Table
1). Much of the improvement was
thought to be the result of orthodon-
tic intrusion, which was reflected in
the radiographs (Fig 6). The periapi-
cal radiographs demonstrated that
the cone-shaped vertical defects
were filled with radiopaque mate-
rial after periodontal regeneration
surgery (Fig 6a), and the defect area
gradually became smaller with intru-
sion and closure of the space by orth-
odontic treatment (Figs 6b to 6g).
The infrabony defects of the maxillary
incisors were dramatically improved,
with slight apical root resorption on
the periapical radiographs (Fig 6h).
The superimposition of lateral cepha-
lometric tracings showed intrusion
and bodily movement of the maxil-
lary incisors and lingual inclination of
the mandibular incisors after space
closure (Fig 8). The periodontal pock-
et depths on the maxillary anterior
teeth were all < 3 mm with no gingi-
val recession after orthodontic treat-
ment and were maintained at the
1-year checkup with favorable teeth
alignment (Fig 9).

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78

a b c

d e f
Fig 5  Intraoral photographs 7 months after orthodontic treatment. Fixed orthodontic appliances were also placed on the mandibular teeth.

Discussion

The present case report has shown

that pathologically migrated an-
terior teeth could be treated suc-
cessfully by orthodontic treatment
a b c d
and application of EMD with syn-
thetic bone on the vertical bony
defects. Pocket depth, clinical
attachment level on clinical ex-
amination, and bone level on the
radiographic images had evidently
improved, suggesting that appli-
e f g h cation of EMD with synthetic bone
Fig 6  Periapical radiographs taken (a) 2 weeks after periodontal and orthodontic tooth movement
surgery, (b) before orthodontic treatment, (c) at 2 months, to the vertical defect sides led to
(d) 6 months, (e) 9 months, (f) 12 months, (g) 15 months, and
the synergistic effects. The patient
(h) 18 months after orthodontic treatment. (i) Radiograph showing
1-year retention. had thick gingival biotype, which
might have contributed to the fa-
vorable and esthetic interdental pa-
i pilla observed posttreatment.22–24 It
remains uncertain whether new at-
tachment of periodontal ligaments
with new cementum was gained,
because histologic analysis could
not be performed.

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 79

a b c

d e f
Fig 7  Intraoral photographs after 18 months of orthodontic treatment.

In addition to EMD, synthetic

bone was grafted with the expecta-
tion of new bone formation in the
infrabony defect. EMD is expected
to be osteopromotive, which means
EMD by itself does not provide the
space or the inductive factors nec-
essary for bone formation.25 On
the other hand, bone substitutes
a
commonly used in periodontal sur-
gery may fill bone defects, enhance
bone formation, and provide me-
chanical support,26 while allowing
EMD to enhance periodontal re-
generation. Gurinsky et al27 com-
pared the clinical results of EMD
alone with a combination of EMD
and bone materials in periodontal
defects. They reported that similar
probing depths and clinical attach-
ment levels were found between
groups, but radiographic bone fill
was greater when EMD and bone
b c
materials were applied together. In
Fig 8  (a) Panoramic and (b) cephalometric radiographs and (c) superimposition of
the present case, the decreased size cephalometric tracings after orthodontic treatment. Solid line = before orthodontic
of vertical defects and radiopaque treatment; dotted line = after orthodontic treatment.

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80

a b c

d e f
Fig 9  Intraoral photographs at 1-year retention.

materials that filled in the infrabony of EDTA root conditioning as an ad- Acknowledgments
defect might be attributable to the junct to regenerative surgery with
presence of bone materials grafted EMD. However, without histologic The authors reported no conflicts of interest
with EMD and periodontal regen- evaluation it cannot be ascertained related to this study.

eration. It is not clear whether the
synthetic bone was resorbed and
subsequently replaced by new bone
or whether it remained unchanged
in the grafted site. Sculean et al28
reported that in most histologic
specimens, graft particles were still
present at 9 months with a lack of
osteoclastic activity at the surface
of the bone particles, even though
new bone surrounding the graft ma-
terials was observed.
Root conditioning with 24%
EDTA before EMD application
was not performed in the present
case. However, the clinical and ra-
diographic results were favorable.
The present findings agree with
those from earlier clinical and ra-
diographic studies20,21 that failed to
demonstrate any significant benefit
from the present case report that
omission of root conditioning affect-
ed the regenerative outcomes.
Conclusions
This case demonstrates a successful
treatment modality for vertical bony
defects associated with pathologic
migration of anterior teeth. This was
achieved by grafts of EMDs mixed
with bone materials followed by in-
trusive orthodontic movement. Root
conditioning was not performed in
this case, which may indicate that
biomodification of root surface by
EDTA before application of EMDs
may not be an essential treatment
modality for improving clinical out-
comes.
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