2. Orthodontic treatment simultaneous to
or after periodontal cause related
treatment in
periodontally susceptible patients.
Journal of Clinical Periodontology
First published: 11 December 2017
Authors - Eglė Zasčiurinskienė, Nomeda Basevičienė, Rune Lindsten, Christer Slotte, Henrik Jansson, Krister
Bjerklin
PRESENTATION BY – DR. MD ABDUL HALEEM
Guided By – Dr. MM. Dayakar
2
4. Introduction
• Periodontitis is described as a result of an imbalance
of the oral microbiota in the dento-gingival area, and
the host response leading to inflammation and
destruction of the periodontium in susceptible
individuals.
• In order to reduce microorganisms, both non-surgical
and surgical therapies have been successfully
performed.
(Flemmig 1999, Berglundh & Donati 2005)
(Badersten et al. 1981, Badersten et al. 1984, Isidor & Karring 1986, Ramfjord et al. 1987,Kaldahl et al. 1988, Becker et al.
2001, Sanz et al. 2012, Deas et al. 2016) 4
5. • As a consequence of plaque-induced periodontitis, patients with increased
numbers of teeth showing attachment loss also have pathological migration
of anterior teeth, decreased posterior bite height and worsened smile
aesthetics.
• The latter is the most common reason for patients seeking orthodontic
treatment.
(Johal & Ide 1999, Brunsvold 2005) 5
6. • The use of orthodontic tooth movement after
conventional periodontal therapy in
periodontally involved patients has been
described in a number of case reports in the
past years.
• However, the effect of orthodontic treatment
on periodontal tissues, the risks and benefits of
orthodontic tooth movement in the patients
with periodontal pathology is controversial and
lacking sufficient scientific evidence.
• Therefore, it is not clear if it could be used as a
routine treatment protocol in periodontally
involved dentitions.
(Fukunaga et al. 2006, Janson et al. 2011, Pinho et al. 2012, Nakamura et al. 2013, Agarwal et al. 2014) 6
7. • Tooth movement in reduced, but healthy periodontium may improve
attachment level and conversely, in active periodontal cases
orthodontic treatment may cause further progression of periodontal
destruction.
• Thus these studies led to the knowledge that periodontal treatment
should be performed first.
(Ericsson et al. 1977, Wennstrom et al. 1987, Melsen et al. 1988 Melsen 2001) 7
8. 1. The aim of the present randomised clinical trial was to compare
two treatment strategies regarding the effect of orthodontic
tooth movement on periodontal status in patients with plaque-
induced periodontitis.
2. The secondary aim was to evaluate differences in treatment
duration.
Aim
8
9. Materials and methods
Subjects:
• This trial was performed according to the Declaration of Helsinki
guidelines.
• Approval by the Regional Ethical Review Board in Kaunas, Lithuania, and
informed consent from the patients were obtained.
• All patients were given oral and written information about the study design
and their right to withdraw from the study at any time without negative
effect on their future treatment.
9
11. Randomisation and allocation concealment
• The patients who consented to undergo orthodontic treatment were
randomly assigned (computer-generated randomization) into either
the intervention test group (periodontal treatment simultaneous to
orthodontic treatment) or the control group (periodontal treatment
before orthodontic treatment).
Trial design - This was a randomised, controlled, parallel, open label
clinical trial.
11
13. • All trial patients received oral hygiene
instructions (OHI) and professional
oral hygiene (POH).
13
14. Test group:
• Twenty five patients started orthodontic treatment with
conventional straight-wire mechanics directly after POH.
• Non-surgical therapy and subsequent periodontal surgery
in sites showing probing depth (PD) ≥ 6mm that bled on
probing was performed after orthodontic alignment and
levelling phases had been finished.
Control group:
• Twenty five patients received cause-related non-surgical
therapy with subsequent periodontal surgery in sites
showing PD ≥ 6mm that bled on probing, before
orthodontic treatment. Orthodontic treatment was
applied as in the test group.
• Changes in periodontal status were compared between
the groups.
14
15. Periodontal treatment (PT)
Professional oral hygiene
• POH treatment including the removal of supra- and
subgingival calculus by ultrasonic instrumentation
supplemented with hand instruments was performed for
every study patient following baseline examination.
• The result was assessed after 2 weeks.
• In cases with BoP > 30% POH was repeated.
Cause-related periodontal treatment
• Non-surgical therapy was performed under local
anaesthesia at four weekly visits.
• Patients had to rinse with a 0.12% chlorhexidine solution
twice daily during this phase.
15
16. Periodontal surgery
• Modified Widman flap surgery was scheduled and
performed in sites showing PD ≥ 6mm that bled on
probing, following SRP at the 3-month follow-up visit.
• All patients were prescribed mouth rinsing with a 0.12%
chlorhexidine solution twice daily during the surgical
phase and for two weeks following surgery.
• No antibiotics were prescribed for the additional effect
of periodontal treatment.
• The application of active orthodontic forces for the test
group was postponed 2-4 weeks after periodontal
surgery.
16
17. Supportive periodontal
treatment
• OHI (including
interproximal brushing) was
performed continuously
throughout all treatments
for both groups.
• POH was continuously
maintained at 3-6 month
intervals by a dental
hygienist during OT.
17
18. Orthodontic treatment (OT)
• Orthodontic treatment with straight wire appliance was performed.
• Good oral hygiene with a full-mouth plaque score <25% was assured
before the start of OT.
18
19. • Self-ligating brackets with MBT (McLaughlin,
Bennett, Trevisi), prescription (3M Unitek
Orthodontic Products; Monrovia, CA, USA) and
0.022-inch slot were used.
• Aesthetic brackets (Clarity™ SL) were used for
maxillary anterior segment to fulfil the aesthetic
requirements of the trial patients according to
individual needs.
19
20. • Initial levelling and alignment were performed
using round, nitinol heat-activated archwires (3M
Unitek Orthodontic Products; Monrovia, CA, USA).
• The interdental enamel reduction technique was
used in crowded cases where needed.
• Space closure was performed using rectangular or
round stainless steel wires.
• Anchorage, where needed, was ensured with
micro-screws or temporary crowns on implants.
20
21. • Following active OT the fixed appliances were removed and a fixed
(multi-strand wire) orthodontic retainer for maxillary and mandibular
anterior teeth was applied for all patients and Hawley or vacuum-
pressured retainers were provided for the night time for unlimited
period of time.
21
22. Clinical examination
• Standardised clinical measurements at all time points for
every trial patient were performed by the same investigator
(EZ).
• The measurements were performed at all sites around each
tooth with a manual periodontal probe (Hu- Friedy PCP-UNC
15, Chicago, IL, USA).
• Only the deepest measurement was recorded for each of
the four sites: mesial (M), buccal (B), distal (D) and lingual
(L).
• Periodontal assessments before and after OT were
performed only for teeth that were orthodontically moved.
22
23. • T0: Baseline examination. All participants were given a
baseline examination including the following
measurements:
1. Visible plaque index (VPI): counted by the presence of visible
dental plaque along the gingival margin at four sites (M-B-D-L) of
each tooth and expressed as a percentage of examined sites
within each subject.
2. Bleeding on probing (BoP): measured after probing to the base of
the pocket.
3. Pocket depth (PD): measured from the gingival margin to the
bottom of the pocket at four sites (M-B-D-L) and recorded to the
nearest millimetre.
4. Gingival recession (REC): measured as a distance from the
cemento-enamel junction (CEJ) to the gingival margin at four
sites (M-B-D-L) and recorded to the nearest millimetre.
5. Clinical attachment level (CAL): measured as a distance from the
bottom of the pocket to cement-enamel junction and recorded in
millimetres at four sites (M-B-D-L).
23
24. • T1: Pre-orthodontic examination. All patients were examined before OT
start with all and the same measurements: VPI, BoP, PD, REC and CAL.
• T2: Post-orthodontic examination (study end point). All patients were
examined the day of bracket debond: VPI, BoP, PD, REC and CAL.
• Changes in periodontal status were compared between time points T0, T1,
T2 in both groups.
• Examination during OT - Every 3 to 6 months: BoP, PD.
24
25. Radiographic examination
• The enrolled study patients were examined with panoramic
radiographs before PT for diagnostic purpose – evaluation of alveolar
bone status.
25
26. Adverse events:
• One maxillary central incisor developed severe
apical root resorption more than 1/3 of the root.
• Due to reduced bone level and extensive apical root
resorption, this tooth was deemed for extraction
after OT.
• One maxillary central incisor developed severe
external root resorption with extension to the pulp.
• This tooth was vital, resulted in CAL gain with PD <
4mm and was left for follow up.
26
27. Outcomes
• Gain in CAL was chosen as the primary response variable to judge the effectiveness of
the treatment.
• Secondary outcomes included:
(i) PD reduction
(ii) REC development
(iii) Treatment duration.
Data management:
• Measurement analysis included sites that had CAL ≥4mm and expressed as median value
within each subject in test and control groups at time points corresponding to T0 and T2.
• Sites were classified as follows: < 4mm, 4-6mm and > 6mm. Sites, that had changed CAL
and PD class during treatment phases T0-T1, T1-T2 and T0-T2 were analysed.
27
28. • Analysis was performed at tooth level for PD change from T0 to T2
and only sites with PD ≥ 4mm were included.
• PD change was measured for every tooth number according to FDI
World Dental Federation system.
• PD change T0-T2 was grouped (<2 and ≥ 2 mm).
• Teeth were also grouped as anterior (central incisors, lateral incisors,
canines) and posterior (premolars, molars).
• Two age groups (≤35 and >35 years) were also created.
28
29. Statistical analysis:
Sample size:
• The CAL difference of 1.0 mm was considered to be of clinical importance
between the test and control groups.
• To be able to detect a clinically meaningful difference in mean CAL of 1.0
mm between groups, standard deviation of 1.0 mm, with a power of 90%
and an alpha-level at 0.05, 22 patients were needed in each group.
• To compensate for dropouts, twenty-five patients were recruited in each
group.
29
30. Baseline data
• There were no significant differences between the test and control
treatment groups.
• One patient in each group smoked ≤ 5 cigarettes per day. Both of them
stopped smoking during the treatment.
• Majority of included patients showed reduced posterior height of the
occlusion with proclined anterior teeth (80%).
• Most of them had spacing in the upper and/or lower teeth and/or
overeruption of incisors.
Results:
30
32. CAL change after periodontal-orthodontic treatment (T0-T2)
• No difference in CAL change was found between test and control
patients.
• 22 patients (88%) in every group resulted in CAL gain.
32
34. T0-T1: Pre-orthodontic treatment phase
• No difference in the median % of CAL change was found between test
and control groups.
• There was a significant difference in mean duration of the initial (pre-
orthodontic) treatment phase between the test and control groups.
34
38. T1-T2: Orthodontic treatment phase
• Mean OT time did not differ between the groups (Table 5).
• No difference in CAL change was observed between the test and control
groups after OT.
T0-T2: Whole periodontal-orthodontic treatment
• Total periodontal-orthodontic treatment duration was significantly longer
for the control group with mean time difference found 4.05 ±1.59 months.
• A significant difference between the groups was found in median % of sites
that changed to the lower disease group of PD.
38
40. • PD - pocket depth;
• Control group n=25;
• Test group n=25;
• T0-baseline;
• T2-after total
treatment;
The difference
observed in sites with
baseline PD of 4-6 mm,
which after combined
treatment became
<4mm.
40
41. • Tooth level analysis of PD change T0-T2 showed no significant
difference between different teeth and was mean 2.72 mm.
• As no difference in CAL change after combined periodontal-
orthodontic treatment was found between test and control patients,
the null hypothesis was accepted.
41
42. • The present trial shows the overall favourable results of periodontal –
orthodontic treatment of patients with plaque-induced periodontitis.
• To the best of knowledge, the present study is the first RCT, which is
designed to analyse two different timings of PT in combination with
OT in patients with plaque-induced periodontitis.
• Previously published clinical studies (Melsen et al. 1989, Melsen
2001, Cardaropoli et al. 2001, Corrente et al. 2003, Re et al. 2004)
evaluated OT effect on attachment apparatus, when surgical PT was
completed 1-2 weeks before OT.
42
43. Main findings:
• The main clinical finding of the present trial was CAL gain observed in both
groups, in spite of the timing of the PT (Table 3 and 4).
• CAL gain was also reported in a study by Corrente et al. (2003), where
intrusion was used to reposition migrated maxillary incisors.
• The change of sites with PD ≥ 4 mm was observed in both groups in every
treatment phase (Table 4).
• At the end (T0-T2), there was more sites that changed PD class (healed) in the
control than in the test group (Table 4 and 6).
43
44. • Classified PD analysis showed that this difference was mainly in sites with initial
PD of 4-6mm (Table 6).
• This could probably be explained by more sites with PD 4-6 mm at T0 in the
control group.
• The method we used to classify pockets could also influence the result that PD of
4-6 mm remained in the same class.
• The pockets that initially were 6mm could heal to 4 mm, but we couldn’t see that
as they remained in the limits of the same class.
• However, deep periodontal pockets (>6mm) at T0 showed similar improvement in
both groups (Table 6).
• Nearly half of them healed to the “healthy” status (<4mm). 44
45. • The multivariate binary logistic regression analysis showed greater
chance for PD improvement by ≥2mm in anterior teeth and teeth in
male patients.
• 80% of patients in the study had baseline proclination of anterior
teeth.
• So, anterior teeth were intruded and retruded and this could
influence difference in soft tissue response.
45
47. • Gingival recession is a common consequence of periodontal and orthodontic
treatment.
• In the present trial, more sites resulted in REC in the control group at T0-T1, and part
of them improved during OT (Table 4).
• This could happen due to orthodontic movements, as shown in earlier studies
(Melsen et al. 1989, Melsen 2001, Cardaropoli et al. 2001, Re et al. 2004).
• For the test group, fewer sites developed REC during the initial PT.
• But the changes went in the opposite direction during OT with an increase of sites
with recession development.
• This could be related to the PT being performed simultaneous to OT for this group.
• After T0-T2 there was no significant difference in median % of sites with REC
development between the groups (Table 4).
47
48. • Mean OT duration was similar for both groups and is in agreement with
the findings of a recent review article, where the average comprehensive
OT time was 20 months (Tsichlaki et al. 2016).
• Based on the results of the present trial, total treatment time was
significantly longer for the control group patients (Table 5).
• This difference for the control group was due to the longer PT phase
before OT.
• If the treatment duration is important for the patient, based on the
findings of this trial, final PT may be performed simultaneously during OT.
• Due to the absence of studies with comprehensive OT in patients with
plaque-induced periodontitis, especially RCTs, it was not able to compare
the present study findings. 48
49. Conclusions:
• Both groups showed gain of clinical attachment level (CAL) and reduction of
sites with probing depth (PD) ≥4mm.
• No difference in REC development between the two groups was observed.
• Total periodontal–orthodontic treatment time was significantly longer for the
control group, where the final periodontal treatment was performed before
the orthodontic treatment.
• Based on the results of this trial it can be concluded that orthodontic
treatment, simultaneously to the periodontal treatment, could be used in the
routine treatment of patients with plaque-induced periodontitis.
49
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50
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51
Stages in fixed orthodontic therapy
Leveling and alignment
Over bite reduction : It should precede overjet reduction in order to have a smooth movement of teeth in the horizontal plane. Deep over bite are corrected by instruction of the anteriors or by extrusion of the posterior teeth.
Overjet reduction and space closure : There are two types of mechanisms used for anterior retraction. Friction or sliding mechanics Frictionless or loop mechanics
Final tooth positioning : During this phase of treatment smaller diameter wires such as .016 inches stainless steel or rectangular beta titanium are used as they are more flexible and allow precise finishing.
According to Raymond Begg, the major stages of comprehensive orthodontic treatment are ; alignment and leveling, correction of molar relationship and space closure, finishing. Tooth leveling and aligning is normally the first orthodontic objective during the initial stage of treatment
The work of McLaughlin, Bennett, and Trevisi between 1993 and 1997 • Third-generation bracket system MBT used ideally for sliding mechanics • Laser numbering for brackets • Replaced the rectangular shape to rhomboidal form • Reduce anterior tip specifications
EZ - Eglė Zasčiurinskienė
NULL HYPOTHESIS simply means “ NO DIFFERENCE” The hypothesis says that OBSERVED DIFFERENCE IS ENTIRELY DUE TO SAMPLING ERROR i.e. it occurred purely by chance. It is denoted by Ho.