Periodontal considerations for orthodontic treatment

Periodontal Considerations for
Orthodontic Treatment
www.indiandentalacademy.com

Outline
Introduction
From the literature:
Orthodontics for prevention and alleviation of periodontal
problems
 Intraarch and Interarch relationships of anterior teeth
 Mandibular anterior crowding
Orthodontics in patients with periodontal problems
Orthodontics in Periodontic/Prosthodontic Therapy
Case: 54 year old female

Introduction
Periodontal problems are rarely a concern for
children and adolescents in orthodontic treatment
Adult patients are more likely to have periodontal
concerns and may be a reason adult patients seek
orthodontic care
Direct correlation between age and periodontal
pocketing which peaks in the late 30’s
Presence of mucogingival problems peaks in the 20’s
Important to identify high risk patients and high risk
sites

Prevalence of Periodontal pockets and
inadequate attached gingiva as a function of
age
Proffit, William R.. Contemporary Orthodontics, 4th Edition. Mosby,
122006 www.indiandentalacademy.com

Introduction
There is no contraindication to treating adult
patients who have had periodontal disease and bone
loss, as long as the disease is under control.
Consideration of periodontal status is of utmost
importance in treating adult patients.

Introduction
Effects of reduced periodontal support
Loss of alveolar bone
Decreased PDL area
Force placed on a crown of a periodontally
compromised tooth produces greater pressure on the
PDL
Center of resistance is apically displaced
Need lighter forces and relatively larger moments

Introduction
Patients with minimal periodontal involvement
Labial movement of incisors in some patients can be
followed by gingival recession and loss of attachment
Risk is greatest when irregular teeth are aligned by
expanding the dental arch
Gingival recession occurs secondarily to a bone
dehiscence
Best to prevent gingival recession than try to correct it
later

Introduction
Patients with moderate periodontal involvement
Preliminary periodontal therapy may include all
aspects of periodontal treatment except osseous
surgery.
Osseous recontouring or repositioned flaps to
compensate for areas of gingival recession are best
deferred until final occlusal relationships have been
established.
Bonded appliances are preferred over bands to facilitate
in periodontal maintenance
Self-ligating brackets or steel ligatures are preferred as
elastomeric ligatures have higher levels of
microorganisms in gingival plaque.

Introduction
Patients with severe periodontal involvement
More frequent periodontal maintenance
Modified treatment goals and mechanics to minimize
orthodontic forces
Temporary retention of a hopeless tooth for supporting
the orthodontic appliance that will save other teeth
Improvement in bone height after space closure is
possible but unpredictable

Introduction
Gingival esthetic problems (two categories):
Created by excessive and/or uneven display of gingiva
 Missing lateral incisors and canine substitution
 Elongating worn teeth, creating a gummy smile
Created by gingival recession after periodontal bone
loss
 Black triangles
 If crowns are bulbous, interproximal reduction and space
closure is a successful treatment approach

Orthodontics for prevention and
alleviation of periodontal problems
Intraarch and Interarch Relationships of the Anterior
Teeth and Periodontal Conditions
Mandibular Anterior Crowding and Periodontal
Disease

Intraarch and Interarch Relationships of the
Anterior Teeth and Periodontal Conditions
Objective
To investigate the association between orthodontic anomalies:
 Displacement of contact point
 Crowding
 Spacing
 Overjet
 Open bite
 Crossbite
 Overbite
And periodontal conditions:
 Hygiene
 Inflammation
 Disease severity
 Treatment need

Materials/Methods:
101 young adults (age 20-35) with no history of orthodontic
treatment
Inclusion criteria: six natural anterior teeth in maxillary and
mandibular arches, manual tooth brushing at least twice
daily, right handed, thorough knowledge of useful oral
hygiene methods
Noninclusion criteria: smoking, pregnancy, mouth
breathing, diabetes, professional plaque removal and scaling
within 5 months
Oral hygiene, gingival inflammation, and disease severity
assessed
Intraarch and interarch relationship parameters were
assessed

Results and Conclusions
Relationship between crowded dentition and difficulty in plaque
removal and gingival inflammation (especially in mandibular
dentition)
Open bite is more liable to induce morbidity in the periodontium
Crossbite correlates significantly with gingival recession
Overbite was significantly correlated with clinical attachment loss
Overjet was weakly but significantly correlated with plaque index
Weak but significant correlation was found between certain
parameters of intraarch and interarch relationship and some
indices of periodontal conditions
Orthodontic treatment is useful in preservation of the periodontal
condition

Mandibular Anterior Crowding and
Periodontal Disease
Objective
To evaluate the role of mandibular crowding in the etiology
of inflammatory periodontal diseases
Hypotheses:
 The plaque index of the crowded group is greater than that of the
normal group.
 The gingival index of the crowded group is greater than that of the
normal group.

Materials and Methods
Two groups
 30 males (no ortho treatment) with Angle Class I malocclusion and
mandibular anterior crowding
 30 males (no ortho treatment) with normal occlusion and no
mandibular anterior crowding
Degree of crowding determined by measuring casts
Supragingival and subgingival scaling and curettage
Subjects instructed not to change oral hygiene habits
Scoring of plaque and gingival indices measured four times
 Prior to treatment
 One week posttreatment
 Two weeks posttreatment
 Four weeks posttreatment
Periodontal Disease

Results and Discussion
Crowding in the anterior region of the mandibular arch
is a predisposing factor for the initiation and
progression of periodontal pathosis
 Possibly due to difficulty of oral hygiene (resulting in
inflammation) or improper proximal contacts (narrowing of
embrasures and disruption of col)
Gingival index is higher in the presence of crowding
Plaque index tends to return to its original
pretreatment value much faster in a crowded lower
anterior segment
Periodontal Disease

Managing Treatment for the Orthodontic
Patient with Periodontal Problems
Objectives:
To describe the responsibilities of orthodontists for
diagnosing periodontal problems
To discuss interdisciplinary management of several
periodontal problems requiring orthodontic
intervention

Periodontal Examination by the
Orthodontist
For each adult patient
Cursory 5 minute periodontal screening examination
Probing key indicator teeth
Upper molar interproximal regions
Buccal furcations
Lower canine/lateral incisor area, especially where there is
crowding
Evaluating attached gingiva
Studying appropriate radiographs
Vertical bitewings show crestal bone more clearly
Parafunction
Screen for bruxing or clenching

Preorthodontic Periodontal
Therapy
Home care/oral hygiene
Root planing and subgingival debridement
Antibiotic therapy if necessary
Possible need for perio surgery before initiation of
orthodontic treatment

Preorthodontic Gingival
Surgery
Gingival grafting
Teeth with less than 2 mm of attached gingiva
Areas likely to become inflamed which may be at greater risk
for attachment loss
Teeth that will be proclined and have a greater risk of
recession
Teeth with prominent roots
Gingival Recession and Root Coverage
Connective tissue grafts
Placed based on esthetics, tooth sensitivity, depth of erosion
in the root, presence of composite gingival restorations,
patient’s wishes concerning esthetic outcome

Preorthodontic Osseous Surgery
Osseous Craters
Interproximal two wall defect that will not improve with
orthodontic treatment
Repaired by reshaping the defect
Three Wall Intrabony defects
Bone grafts and regenerative therapy
Hemiseptal Defects
One to two wall osseous defects
Often around mesially tipped or supraerupted teeth
May often be eliminated with appropriate orthodontic
treatment

Furcation Defects
Class I—amenable to osseous surgical correction with good
prognosis
Class II—treated with grafting and regenerative therapy with
barrier membranes
Class III—difficult to treat; grafting and membranes not as
predictable
Class II and III sometimes treated with root amputation or
hemisection
Root Proximity
May be corrected with orthodontic treatment
Treated surgically with root amputation
Preorthodontic Osseous Surgery

Orthodontic Treatment of
Periodontal Defects
Advanced horizontal bone loss
Important to appropriately place bands and brackets
according to bone height with possible equilibration of
teeth
Hemiseptal defect
If bone level is flat between adjacent teeth which have
marginal ridge discrepancy, correction of the marginal
ridge discrepancy will create a hemiseptal defect in the
bone
Occlusal equilibration is necessary instead of leveling
the marginal ridges

Furcation defects
Orthodontic treatment prior to hemisection of the
tooth
After orthodontic treatment, endo therapy on both
roots, perio surgery to divide the tooth, recontouring of
bone around each root, crowns placed after tissue heals
OR
Roots of molar with furcation defect may need to be
divergent for bridge abutment, in which case, tooth
would be hemisected prior to orthodontic treatment
Periodontal Defects

Root proximity
Careful bracket placement
2-3 mm of root separation will provide adequate bone
and embrasure space to improve periodontal health
Possible need for occlusal adjustment
Hopeless teeth
Used for orthodontic anchorage
Inflammation should be controlled
Periodontal Defects

Postorthodontic Periodontal
treatment
3 month periodontal maintenance
It takes 6 mo after band removal for adequate remodeling,
cessation of mobility, and narrowing of the PDLs
New set of periapical radiographs and periodontal re-
examination after 6 months
Borderline pocket depth areas that were maintained
during orthodontic treatment are potential candidates for
osseous correction
Tissue grafting of borderline attached gingiva
Occlusal adjustments to fine-tune occlusion
Nightguard (maxillary nightguard may serve as retainer)
Restorative treatment after periodontal stability is
achieved

Conclusions
Especially regarding adults in orthodontic treatment,
periodontal considerations are of utmost importance.
The key to treating these types of patients is
communication and proper diagnosis before
orthodontic therapy as well as continued dialogue
during orthodontic treatment.

The Orthodontist’s Role in 21st
Century
Periodontic-Prosthodontic Therapy
Objective
To explain through case studies what the orthodontist
can provide and where the orthodontist is an integral
part of the periodontic-prosthodontic treatment

Facilitative Orthodontics
The position of the teeth in their spatial relation to the
alveolar process can affect the shape and location of the
periodontium
Mesial tipping is the first link in a pathologic causal chain and
is a risk factor for periodontal disease.
Mesial periodontal defects may be reduced by uprighting
mesially inclined molars

Orthodontic elimination of gingival
pockets caused by dental crowding
All periodontal patients
scheduled for osseous
resection should be given the
option to undergo some
orthodontic care to obviate
the chance of unnecessary
alveolar bone removal.
If orthodontic uprighting is
not done as shown in the
bottom image, then excessive
amounts of bone must be
removed during osseous
surgery

Forced Eruption
Method of treating one and two
walled osseous defects
Method of enhancing clinical
crown lengthening for
prosthetics
Extrusion followed by repeated
gingival fiberotomies which
prevent coronal displacement of
the gingiva and attachment
apparatus with the tooth during
extrusion
Repeated gingival fiberotomies
eliminate creation of iatrogenic
gingival pockets distally as
mesial pockets are eliminated by
uprighting

Leveling of gingiva by extrusion of
lateral incisors

Case 1: Orthodontics as an aid in
minimizing surgical morbidity
Vertical osseous defect on mesial
aspect of maxillary left lateral incisor
Orthodontic extrusion to bring bone
on the mesial defect to normal level
of adjacent teeth
Repeated fiberotomies only on the
distal aspect to prevent gingival
attachment from moving incisallywww.indiandentalacademy.com

correcting biologic width violations
 Patient’s complaint was gingival
inflammation and recession on left
maxillary central and lateral incisors
 Periodontists recommended surgical
crown lengthening to correct biologic
width impingement
 Extrusion with fiberotomies to correct
biologic width impingement
 Further extrusion to level gingival
margins

improving implant sites
External and internal
resorption on the labial
of mandibular left
lateral incisor
Tooth was extruded 7
mm to create adequate
hard and soft tissue for
implant placement

Case 4: Recognition of crowding as
a periodontal concern
Widened interproximal space and healthier bone by distally driving
the second molar with facilitative orthodontics
Widening of interproximal bone by orthodontic alignment of the
dental arch can greatly enhance local host resistance and prognosis of
an infected dentition
Arch length deficiency is the most significant component of
malocclusion from a periodontic perspective

Case 5: The use of implant supported
anchorage with selective decortication
Patient presented with anterior open
bite and pathological flaring of
maxillary teeth
Endosseous implants in molar
regions were used as anchorage to
retract the maxillary teeth
Anterior distorted alveolar
architecture can be reengineered
with periodontically accelerated
osteogenic orthodontic
augmentation (PAOO) surgery to
produce regional acceleratory
phenomenon (RAP)
Results in a vast increase in
osteoblast and osteoclast activity and
a “softening” of the healing alveolus
bone

Periodontically Accelerated Osteogenic
Orthodontic Augmentation
Wilckodontics
Produces regional acceleratory phenomenon (RAP)
Vast increase in osteoblast and osteoclast activity
Clinically manifested as “softening” of the healing alveolus
bone
Tissue engineering of distorted alveolar architecture
Periodontist uses a #2 round bur to place small superficial
holes just barely through the cortical plate on the buccal
and/or lingual sides of the alveolar process
Creating a therapeutic physiology through bone
regeneration
New dimension in dentofacial orthopedics

Case 6: Treatment of an anterior
open bite

Patient presented with occlusal contact on unilateral
second molars and severe generalized gingival and
bony dehiscences
PAOO recommended prior to arch expansion in
patients with dehiscences or fenestrations
Case 6: Treatment of an anterior open
bite

Vertical impaction of posterior dentition with
orthodontic temporary anchorage devices
The dentoalveolar complex allows the alveolus to be
molded as a separate “organ” using the teeth as
“handles” to reshape the alveolar bone.
open bite

PAOO and graft from first molar to first molar which helped to
create a new therapeutic alveolar ontogeny
Soft connective tissue grafting was needed from first molar to first
molar to eliminate gingival recession.
Anterior open bite closed in 7 months with no ancillary
orthognathic surgery
open bite

Case 7: Dental Crossbite
 Generalized gingival recession and bony pockets in
the posterior areas
 Asymmetric Class III skeletal malocclusion
 Right side posterior crossbite
 End to end incisal relationship
 Dental and skeletal midline deviation
 Alveolar process of mandibular incisors extremely thin
on buccal and lingual
 Decortication and grafts in maxillary alveolus for
expansion
 Grafts of bone and dense connective tissue on buccal
and lingual of mandibular anterior
 Alloderm (CT graft) placed from first molar to first
molar on the labial aspects of maxillary and
mandibular teeth and on lingual aspect of mandibular
anterior teeth.
 7 months total treatment time
 Short treatment time ideal from a periodontal
perspective because it minimized a concomitant
bacterial load that becomes increasingly pathogenic
with time

Case 8: Camouflage of Severe
Skeletal Dysplasia Mild Class
II skeletal
relationship
Severe
anterior
overjet
Congenitall
y missing
second
premolars
Flat profile

 Full thickness
mucogingival flaps
reflected
 Selective alveolar
decortication
 Demineralized bone
matrix graft to widen
alveolus in the direction
of desired tooth
movement
 Primary closure
 Little discomfort
Skeletal Dysplasia

Bony dehiscence and fenestrations
Bone grafting changes B point
labially while lending stability
Prevents gingival soft tissue
dehiscences
Alternative to bicuspid extraction
therapy
Primary closure
Case 8: Camouflage of Severe Skeletal
Dysplasia

TAD acts as absolute
anchorage to move molars
distally as coiled spring
moves premolar mesially to
open previous ortho
extraction site to enhance
flattened profile
Final ortho treatment and
preprosthetic treatment
with nearly ideal
overjet/overbite
relationship
Skeletal Dysplasia

Conclusions
Interdisciplinary collaboration often offers the best
treatment for patients
Such sophisticated treatment requires excellent
communication and coordination.
The Orthodontist’s Role in 21st
Century
Periodontic-Prosthodontic Therapy

References
El-Mangoury, Nagwa, et al. Mandibular Anterior Crowding and
Periodontal Disease. Angle Orthodontist, Vol. 57, No. 1, January
1987.
Mathews, David P, and Vincent G. Kokich. Managing
Treatment for the Orthodontic Patient with Periodontal
Problems. Seminars in Orthodontics, Vol. 3, No. 1, March 1997.
Mihram, William L, and Murphy, Neal C. The Orthodontist’s
Role in 21st
Century Periodontic-Prosthodontic Therapy.
Seminars in Orthodontics, Vol. 14, No. 4, December 2008.
Ngom, Papa, et al. Intraarch and Interarch Relationships of the
Anterior Teeth and Periodontal Conditions. Angle Orthodontist,
Vol. 76, No. 2, March 2006.
Proffit, William R.. Contemporary Orthodontics, 4th Edition.
Mosby, 2007

Periodontal considerations for orthodontic treatment

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