Surgically Facilitated Orthodontic Therapy, PAOO, and Periodontal Phenotype with Dr. George Mandelaris

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Hey, welcome to Dental Digest. This is a podcast with a mission of enabling you to stay on the cutting edge of evidence-based dentistry.

I'm your host, Dr. Melissa Seibert. In this episode, we're diving into surgical-associated orthodontic therapy or SFOT. This powerful interdisciplinary approach combines periodontal surgery with orthodontics to accelerate tooth movement, expand treatment possibilities, and support long-term stability in complex adult cases.

If you've ever felt limited by conventional ortho or restorative constraints, this episode will challenge and expand your clinical framework.

My guest is Dr. George Mandelaris. He's a board-certified periodontist, co-author of the textbook Surgical-Facilitated Orthodontic Therapy, and a global thought leader in interdisciplinary care.

Dr. Mandelaris serves as a clinical assistant professor at the University of Illinois at Chicago and as an adjunct clinical assistant professor at the University of Michigan. He's also a fellow in both the American and International College of Dentists and a respected educator whose work is shaping the future of collaborative dentistry.

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And I want to thank you personally for listening. Okay, let's jump in.

Dr. Melissa Seibert: So you are one of the premier authorities, in fact, the authority on surgically facilitated ortho. Can you first explain what this is?

Dr. George Mandelaris: I don't know that I've introduced myself like that. I would say I am a very enthusiastic periodontist. I love perio. I have ever since dental school, and I'm really passionate about interdisciplinary dentistry.

I love the relationships I make with the patients, the dentists especially. I just love the whole team concept. I am all about that. I've kind of fallen into this as a result of my journey in the profession. I've had a lot of mentors, and it's kind of like a patchwork quilt of learning from a lot of different people and mentors and different specialties, and then bringing it into my vision and how I see patients and how the profession has evolved.

Dr. Melissa Seibert: Would you please explain then, what is SFOT?

Dr. George Mandelaris: At its bare bones, SFOT is an acronym for surgically facilitated orthodontic therapy. That was actually a term coined by Rick Robley. He coined that term because the Wilcko brothers, who really brought this into modern popularity, had trademarks and copyrights on their terms PAOO, AOO, periodontally accelerated osteogenic orthodontics, and accelerated osteogenic orthodontics.

You couldn't really use those words and terms in marketing or anything else without their permission. So Rick basically created this term. We've all learned on the shoulders of the Wilcko brothers, who really did not invent it, but definitely popularized it. They also shed light on the biology and brought out the truth of the biology of what's happening.

It's been the evolution of the specialty. When you start to combine imaging data, which wasn't around in the 80s and 90s for this, and then you combine airway management and craniofacial considerations, people become much more aware of it.

They're more aware of patients with small oral cavity volumes, patients with airway problems, patients that can have issues and have premolars taken out. So from a bigger healthcare issue, this is where a lot of this fits in.

By and large, when you talk about SFOT, you're really talking about a surgical procedure to accelerate orthodontic tooth movement. That happens because you're creating a surgical insult around the teeth, called corticotomies and dental alveolar decortication.

That creates a regional acceleratory phenomenon, which scientifically is a demineralized bone matrix around the teeth. The dental alveolar bone becomes demineralized for this three- or four-month period of time, which is called the RAP phenomenon, regional acceleratory phenomenon.

That was discovered in Detroit by an orthopedic surgeon named Dr. Frost. Henry Frost was studying fracture healing. He noticed that when you fracture bone, you have this demineralized bone matrix that occurs as part of fracture healing. You have this inflammatory cascade of events that happens.

That is at the core of what is happening. The Wilkos brought out that it is not pressure-tension mechanics or bony block movement, but really this surgical event occurs around the teeth.

It actually occurs even when you open a flap up. It's just not pervasive enough to move the teeth. So you get this demineralized bone matrix, and we do this all the time. We do periodontal regeneration. We do guided bone regeneration.

Even though we're doing it for different purposes and doing it differently, basically we're creating injury. We're creating quasi-fracture healing in the bone to provide access into the marrow and allow blood vessels from within the marrow to come out and vascularize a bone graft.

Even though you're creating this demineralized bone matrix around the teeth, generally you are also doing bone augmentation around the teeth as well, because so many of these teeth are going to be expanded. Dental alveolar bone boundary conditions are generally thin, and orthodontists have a very difficult job in trying to keep the teeth within this trough so they do not exceed the boundary conditions and create iatrogenic periodontal problems.

That could not be underlined more because of how difficult high-level orthodontics really is. Having the phenotype or the bone envelope improved creates enhanced boundary conditions for the orthodontist, but it also improves the periodontal phenotype as well.

When we graft bone around the teeth, you've got this demineralized bone matrix. The teeth are moving without the pressure-tension resistance, so they're moving much more efficiently, 50% faster. Because the patient has had a surgical procedure, they're also moving without the rubber band effect. Now the relapse potential is less.

Because the teeth are moving in this demineralized bone matrix, a lot of the heavy lifting in the orthodontic decompensation phase can be done in a shorter window of time to a greater expense and with a better outcome, so not as much compromise.

At the end of the day, instead of having a periodontal annuity for a patient, you can have a very robust periodontium, which is our goal. Not everybody is a patient, not everybody is a candidate for it, and not everybody needs it. But there are a number of conditions and circumstances where patients can really benefit from this short and long term.

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One of the things that you highlighted, the benefit of this, is that this can help to speed up orthodontics. But I was at a meeting with several periodontists, and one of the things that was discussed there is that speed is not necessarily the prompt. Would you agree that that's not necessarily the number one indication for doing SFOT, that it's sort of the other benefits?

Dr. George Mandelaris: Yeah, I've done a lot of these. I'm well over 500, maybe 600 by now. I've almost never had a patient come in and ask me to do this. On one hand, I could count how many patients have come in and said, “I want you to do this surgery for me so I can get in and out of braces 50% faster.” It just is not a primary goal.

Some patients it is, but it's a benefit that comes along with the procedure. Generally, it's not something that is high on the priority list for the orthodontist, even for the periodontist, and sometimes even the patient. But most of the time, the patient does appreciate getting through the treatment more expeditiously than in two years.

Here's something to think about too. So many of our patients have airway problems. A lot of these patients have severe underlying dentofacial disharmonies that need orthognathic surgery. They need to see a talented oral maxillofacial surgeon to put the bones in the right spot.

If somebody is suffering from OSA, getting them to that life-altering orthognathic surgery is important. It's not just important so they feel better. It's important medically so that they systemically can have an improvement in their heart rate and so many other variables.

There is value in accelerating the process and the decompensation phase so that they can get to orthognathic surgery sooner rather than later. On one hand, I agree with those periodontists. But on the other hand, if you have a patient that you're going to do orthodontics on, there is something to be said about doing this not just for the periodontal benefits, but also so they can move through this and get to that orthognathic procedure that is going to change their lives and hopefully extend their lives.

Dr. Melissa Seibert: I do have to say, now that it's no secret, you're going to be the periodontist doing my SFOT. I'm undergoing MARPE. I have a beautiful diastema the size of my pinky finger.

The original plan with the orthodontist was that we were going to do SFOT on the mandibular arch, and it was thrown out there, “Would you also like to do it on the maxillary arch?” The transverse expansion has been accomplished by the MARPE, but I said yes, let's do it, because this diastema, I'm ready to have this closed.

So I might be one of those few patients that you can count on one hand that is willing to go through it to help expedite treatment.

Let me ask you this as well. You mentioned that there's demineralization as a result of SFOT. Is it fair to say that this is a result of the insult, and then this can be one of the forces that's expediting tooth movement?

Dr. George Mandelaris: Yeah, exactly. Because of the corticotomies, or the quasi-fracture interdental fractures, and the dental alveolar decortication, it has to get close to the ligament of the tooth.

You have to get it so it's at least within a millimeter or millimeter and a half of the ligament. You can't have a mile of bone and just do a little chicken scratch and expect the teeth are going to move faster. You have to get in there and create that injury.

The bone actually does remineralize as well. A lot of the science has shown that it remineralizes to the same level, if not a little bit more in terms of mineral bone density from baseline. So yes, that demineralization phase occurs as a direct result of the injury.

Dr. Melissa Seibert: We've talked about this, but in a pretty tangential way. What is really the primary indication for SFOT? Who are the patients that you're doing this on? To me, it seems predominantly, really entirely, ortho patients.

Dr. George Mandelaris: Yeah, it's mainly orthodontic patients that have phenotype compromises. They have vulnerable phenotypes.

In some cases, it may be after the fact. The patients have been decompensated and have very little attached gingiva. They have a very minimal zone or no zone of gingiva. Their bone volume is very thin. They're at very high risk for having recession-based attachment loss problems in the future.

Those are primarily the patients we're managing. More and more orthodontists are recognizing the benefit and the need for this because so many of them are using 3D planning softwares that actually show the foundation.

It's not just moving the crowns of the teeth and the gum tissue miraculously not changing. A lot of the 3D software now is CT-based, and it is transparent from a foundation standpoint. It shows the impact of tooth movement and the planned tooth movement on the dental alveolar complex and the bone around the teeth.

Through that software, you can clearly see that there may be a lot of dental alveolar deficiencies that are either made worse or perhaps made better. You're able to see the foundation and the impact of the tooth movement plan on the dental alveolar complex. Invariably, people are deficient in terms of facial bone.

Dr. Melissa Seibert: You talked about one indication as patients with a vulnerable type of phenotype. Is it safe to also say that this is largely used in ortho patients where we want to do expansion beyond what the existing alveolar bone will tolerate?

Dr. George Mandelaris: Yes, for sure. A very common patient would be patients with crowding. Patients with crowding generally have dental alveolar deficiencies. There isn't quite enough bone around the teeth to align everything. That's partly why they are crowded.

When you identify crowding, generally speaking, unless you're going to take a tooth out, and that may be different, but if you're going to do a non-extraction plan where you're going to expand and not overly camouflage or overly tip the tooth, which is also not great periodontally, then bone augmentation would be quite advantageous.

The lower anterior is super vulnerable. That's the main area where people are highly vulnerable: crowding and minimal attachment.

Ashley Hoders, myself, Kevin Murphy, and Marianne Evans have some papers that are going to be published in the International Journal of Periodontics and Restorative Dentistry on phenotype-driven treatment planning.

That basically evaluates a patient's gingival phenotype. Number one, is the facial tissue thick or thin? If you can see a probe through it, or not, it's a millimeter thick or not. Then, do they have two millimeters of keratinized tissue or not? That's the gingival phenotype.

Then the bone morphotype on CT is the bone at the crest and at the mid-root. Is it thick or thin? Is it a millimeter or more or less?

That would categorize somebody as having an intact, susceptible, or deficient vulnerable periodontal phenotype. Then based on the treatment plan proposed for the patient, either they're going to have a mild, moderate, or severe exacerbation of that phenotype.

In one case, it may be a mild phenotype. It's an intact periodontal phenotype, so maybe there's no treatment needed, or maybe it's just a connective tissue graft.

Or maybe it's a patient who has very thin bone morphotype, very thin gingiva, but two millimeters of keratinized tissue, and the treatment plan is going to severely compromise or stress the phenotype. Maybe bone augmentation might be an option here, or SFOT or PAOO could be an option.

Dr. Melissa Seibert: And the treatment you're referring to, would that be orthodontics?

Dr. George Mandelaris: Yes, generally it's orthodontics. Although in some cases, advanced restorative can create iatrogenic problems too, mainly with attached gingiva.

Dr. Melissa Seibert: Which advanced restorative treatments are you referring to?

Dr. George Mandelaris: Let's say you're going to do a full-mouth reconstruction. You're going to open up somebody's vertical and deal with anterior coupling problems. How are you going to manage these anterior coupling issues?

How about working in a centric relation position? If you're going to put somebody on splint therapy and relax their muscles, and their condyles now get seated and that visceral tissue is removed, what happens? They generally become more Class II. The vertical and the condyle are corrected, and they become more Class II. So they're more open.

How are we going to fix that? Invariably, it does involve some ortho. It would be very unusual to do this post-treatment.