Perio-Ortho interrelationships - Dr.Malvika
- 1. PERIO - ORTHO INTERRELATIONSHIPS GUIDED BY: DR.RUPINDER KAUR DR.DIVYA JAGGI PRESENTED BY: DR.MALVIKA THAKUR PG II YEAR
- 2. CONTENTS 1. Introduction 2. Periodontal responses to orthodontic force application 3. Benefits of Orthodontic Therapy for a periodontal patient 4. Pre-orthodontic osseous surgery 5. Orthodontic treatment of osseous defects 6. Orthodontic treatment of gingival discrepencies 7. Minor surgery associated with orthodontic therapy 8. Conclusion 9. References 1/39
- 3. INTRODUCTION • The interrelationship between orthodontics and periodontics often resembles symbiosis. • The main objective of periodontal therapy - restore & maintain the health & integrity of the attachment apparatus of teeth. • Loss of periodontal support - pathological tooth migration • Orthodontic treatment - often correct these problems, or at least prevent them from progressing, but it also holds some potential for harm to the periodontal tissues. “TWO-EDGE SWORD” 2/39
- 4. Various studies have shown that - Alveolar bone height reduced in areas of increased over jet Gingivitis is generally associated with crowding Level of bacteria is higher in areas of crowding compared with normal areas in same patient 3/39
- 5. EXTRUSION Least hazardous kind of tooth movement as far as periodontium is considered. Extrusion followed by equilibration of the clinical crown has been shown to reduce infrabony defects and pockets.(Ingber JS, J Periodontol 1974) Periodontal response to various kinds of tooth movement INTRUSION Most authors – Intrusion results in deepening of infrabony pockets, root resorption, bone defects – (Birte Melsen AJODO 1989. Vol.96) Inadequate oral hygiene - shift supragingival plaque into a subgingival position - periodontal destruction (Ericsson et al. 1977, 1978).4/39
- 6. UNCONTROLLED TIPPING in all cases causes heavy forces at the alveolar crest resulting in severe destruction of the epithelial attachment and crestal bone loss. CONTROLLED TIPPING also produces high forces in the periodontal ligament as the fulcrum shifts more and more apically with increasing amounts of bone loss. Infact cases have been documented where a gingival lesion has been converted into a periodontal lesion by the injudicious use of tipping movements. TIPPING 5/39
- 7. BODILY MOVEMENT Moving a tooth bodily into a periodontal defect has been believed to ‘carry the bone’ along with the tooth resulting in improvement of the defect. However recent studies have shown that this is only an illusion because it causes only an improved connective tissue attachment and worsens the bony defect. Hence until new evidence surfaces, this is contraindicated. 6/39
- 8. Anand k patil, JISP,2013 Sequence of events after application of mechanical force 7/39
- 9. DELETERIOUS EFFECTS OF ORTHODONTIC FORCE GINGIVAL PROBLEMS • The gingiva rotates to the same degree and in the same direction of the tooth. • Extensive rotational movement - rotational gingiva to be compressed in the interdental area at the direction of rotation. • Possible consequences of excessive labial tooth movement, especially that of incisors - irreversible gingival recession. • Various authors have reported its occurrence from 1.3% to 10%. 8/39
- 10. • The development of gingival inflammation during orthodontic mechanotherapy is associated with specific bacterial types. • Huser et al studied microbial flora in plaque of patients undergoing orthodontic treatment and found a definite increase in plaque scores and PD when compared with controls. • The bacterial plaque was composed mainly of spirochetes and motile rods. • Other authors reported increased levels of bacteroids and streptococcus species after orthodontic banding. 9/39
- 11. Microbiology around orthodontic bands • Increase in Lactobacillus (Bloom & Brown 1964) • Increase in motile organisms (Leggott et al. 1984) • Increase in Prevotella intermedia (Diamanti- Kipioti et al. 1987, Huser et al. 1990) 10/39 Gingival enlargement • Can be either edematous or fibrotic
- 12. ROOT RESORPTION • Normally, cementum does not undergo appreciable resorption. • Orthodontic force application can sometimes evoke excessive resorption of root cementum, proceeding into the dentin, eventually shortening the root length—a process called root resorption. • Ottolengui and Ketcham (1927) were the first to report severe root resorption associated with orthodontic tooth movement. 11/39 • Of the various orthodontic tooth movements, intrusion and torquing make a tooth root more prone to resorption.
- 13. Brezniak and Wasserstein classified root resorption according to its severity : (1) Cemental, or surface resorption - where only the outer layers are resorbed, to be fully regenerated or remodeled later. (2) Dentinal resorption with repair, where the cementum and the outer layers of dentin are resorbed, and are repaired along with morphological alterations. (3) Circumferential root resorption, where full resorption of the hard tissue components of the root apex occurs, resulting in root shortening. 12/39
- 14. PULPAL REACTIONS • Various experiments have demonstrated an initial decrease in blood flow, lasting approximately 32 minutes, followed by an increase in blood flow (lasting 48 hours). • Mostafa et al reported congested and dilated blood vessels, and edema of pulpal tissue in their histologic observations. • Derringer et al identified the specific angiogenic growth factors released in response to orthodontic force application - VEGF, FGF-2, PDGF, and TGF-beta. • Perinetti et al demonstrated that an enzyme, Aspartate Aminotransferase (which is released extracellularly upon cell death), is significantly elevated after orthodontic force application. 13/39
- 15. 1. Aligning crowded or malposed teeth permits the adult patient better access to clean all surfaces of their teeth adequately. 2. Orthodontic therapy also benefits the patient with a severe fracture of a maxillary anterior tooth that requires forced eruption to permit adequate restoration of the root. 3. Vertical orthodontic tooth repositioning can improve certain types of osseous defects in periodontal patients. Often the tooth movement eliminates the need for resective osseous surgery BENEFITS OF ORTHODONTICS FOR A PERIODONTAL PATIENT 14/39 4. Orthodontic treatment can improve the esthetic relationship of the maxillary gingival margin levels before restorative dentistry. 5. Orthodontic treatment allows open gingival embrasures to be corrected to regain lost papilla. If located in the maxillary anterior region they can be unaesthetic. 6. Orthodontic treatment could improve adjacent tooth position before implant placement or tooth replacement. This is especially true for the patient who has been missing teeth for several years and has drifting and tipping of the adjacent dentition.
- 16. OSSEOUS CRATERS • Interproximal, two-wall defect that does not improve with orthodontic treatment. • Some shallow craters (4- to 5-mm pocket) may be maintainable nonsurgically during orthodontic treatment. • If surgical correction is needed this type of osseous lesion can be eliminated by reshaping the defect & ↓ PD. • This in turn enhances the ability to maintain these interproximal areas during orthodontic treatment. PREORTHODONTIC OSSEOUS SURGERY 15/39
- 17. • Three-wall defects are amenable to pocket reduction with regenerative periodontal therapy. • Bone grafts using either autogenous bone or allografts along with the use of resorbable membranes have been successful in filling three-wall defects. • If the result of periodontal therapy is stable 3 to 6 months after periodontal surgery , orthodontic treatment may be initiated. THREE WALL INTRABONY DEFECT 16/39
- 18. • Hemiseptal defects are one- or two-wall osseous defects that often are found around mesially tipped teeth or teeth that have supererupted . • Usually, these defects can be eliminated with the appropriate orthodontic treatment. • In the case of the tipped tooth, uprighting and eruption of the tooth levels the bony defect. • If the tooth is supererupted, intrusion and levelling of the adjacent cementoenamel junctions can help level the osseous defect. HEMISEPTAL DEFECTS ORTHODONTIC TREATMENT OF OSSEOUS DEFECTS 17/39
- 19. • In a patient with advanced horizontal bone loss, the bone level may have receded several mm from the CEJ - the crown-to- root ratio becomes less favorable. • Aligning the crowns - may perpetuate tooth mobility & significant bone discrepancies. • In these situations, the crowns of the teeth may require considerable equilibration. • GOAL of equilibration and creative bracket placement is to provide a more favorable bony architecture, as well as a more favorable crown to root ratio. ADVANCED HORIZONTAL BONE LOSS 18/39
- 20. FURCATION DEFECTS 19/39 • Furcation lesions require special consideration – The most difficult lesions to maintain Can worsen during orthodontic therapy. • The molars require bands with tubes and other attachments that impede the patient’s access to the buccal furcation for home care and instrumentation at the time of recall. • If a patient with a class III furcation defect will be undergoing orthodontic treatment, a possible method for treating the furcation is to eliminate it by hemisecting the crown and root of the tooth
- 21. • Several missing teeth in the mandibular left posterior quadrant. • Third molar had short roots …extracted • Implants placed 20/39
- 22. ROOT PROXIMITY Roots of posterior teeth in close proximity Compromised periodontal health Compromised accessibility for restoration of adjacent teeth. 21/39 Orthodontic therapy Roots can be moved apart Bone will be formed b/w the adjacent roots Opens Embrasure beneath the tooth contact Additional bone support Enhances pt's access to interproximal region. Improves the periodontal health of this area.
- 23. Occasionally, children and adolescents may fall and injure their anterior teeth. # may extend beneath the level of the GM & terminate at the level of the alveolar ridge. Restoration of the # crown is impossible because the tooth preparation would extend to the level of the bone. overextension of the crown margin - invasion of the BW of the tooth - persistent inflammation of the marginal gingiva. It may be beneficial to erupt the # root out of the bone & move the # margin coronally so that it can be properly restored. if the # extends too far apically, it may be better to extract the tooth and replace it with an implant or bridge. FRACTURED TEETH/FORCED ERUPTION
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- 25. • 6 criteria determine whether the tooth should be forcibly erupted or extracted. 1. Root length 2. Root form 3. Level of fracture 4. Relative importance of tooth 5. Esthetics 6. Endodontic/periodontic prognosis • The orthodontic mechanics necessary to erupt the tooth can vary from elastic traction to orthodontic banding and bracketing. 24/39
- 26. HOPELESS TEETH MAINTAINED FOR ORTHODONTIC ANCHORAGE • Patients with advanced periodontal disease may have specific teeth diagnosed as hopeless, which would be extracted before orthodontics. • However, these teeth can be useful for orthodontic anchorage if the periodontal inflammation can be controlled. 25/39
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- 28. UNEVEN GINGIVAL MARGINS • The relationship of the gingival margins of the six maxillary anterior teeth plays an important role in the esthetic appearance of the crowns. ORTHODONTIC TREATMENT OF GINGIVAL DISCREPANCIES 27/39 1. The gingival margins of the two central incisors should be at the same level. 2. The gingival margins of the central incisors should be positioned more apically than the lateral incisors & at the same level as the canines. 3. The contour of the labial gingival margins should mimic the CEJs of the teeth. 4. A papilla should exist b/w each tooth, & the height of the tip of the papilla is usually halfway b/w the incisal edge & the labial gingival height of contour over the center of each anterior tooth. FACTORS CONTRIBUTE TO IDEAL GINGIVAL FORM.
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- 30. SIGNIFICANT ABRASION AND OVERERUPTION • Occasionally, patients have destructive dental habits such as a protrusive bruxing habit that could result in significant wear of the maxillary and mandibular incisors and compensatory overeruption of these teeth. • Two options are available. i) Crown lengthening ii) Orthodontically intrude the teeth and move the gingival margins apically 29/39
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- 32. OPEN GINGIVAL EMBRASURES • The presence of a papilla between the maxillary central incisors is a key esthetic factor in any individual. • This open space is usually due to one of three causes: Tooth Shape, Root Angulation, Or Periodontal Bone Loss. • The interproximal contact b/w the maxillary central incisors consists of 2 parts- tooth contact, the papilla. • Ratio of papilla to contact is 1:1. 31/39
- 33. 32/39 Another possibility is to erupt adjacent teeth when the interproximal bone level is positioned apically. This type of movement may help create a more esthetic papilla between two teeth despite alveolar bone loss. By closing open contacts, the interproximal gingiva can be squeezed and moved incisally. In some situations, a deficient papilla can be improved with orthodontic treatment. Papilla is the problem, the cause is lack of bone support due to an underlying periodontal problem. If the patient has an open embrasure, evaluate - caused by the papilla or the tooth contact.
- 34. PERICISION- Circumferential Supracrestal Fiberotomy (Edwards, 1970). Relapse of severely rotated teeth due to rebound of elastic fibres in the supracrestal tissues can be reduced by pericision. Inserting a surgical blade into the gingival sulcus and severing the epithelial attachment surrounding the involved teeth. The blade also transects the transseptal fibers by interdentally entering the periodontal ligament space. Periodontal Surgery for the Orthodontic Patient 33/39
- 35. FRENECTOMY / FRENOTOMY • Bergstrom et al (1973) stated that the probability for diastema in the long run is the same whether or not frenectomy is preformed. Earlier frenectomy extending into palatal surface was advocated. But this leads to loss of inter dental papilla between upper central incisors. • So, the frenotomy by Edwards (1977) was introduced, which represents a more gentle operation, with only partial removal of frenum and with the purpose of relocating the attachment in an apical direction. 33/39
- 36. REMOVAL OF GINGIVAL INVAGINATION (CLEFTS) • Incomplete adaptation of supporting structures during orthodontic closure of extraction spaces - infolding or invagination of the gingiva. • The clinical appearance of such invagination : a minor one surface crease to deep clefts that extend across the interdental papilla. 34/39
- 37. • There is general trend toward some resolution of these defects with time, but many invaginations persist for 5 years, or more after completion of orthodontic therapy . • Edward (1971) suggested that simple removal of only the excess gingiva in the buccal and lingual area of approximated teeth would be sufficient to alleviate the tendency for the teeth to separate after orthodontic movement. 35/39
- 38. GINGIVECTOMY • If a gingival margin discrepancy is present, but the patients lip does not moves upward to expose the discrepancy upon smiling, it does not require correction. • If the gingival discrepancy is apparent, however, one of four different techniques may be used. • Gingivectomy • Intrusion and incisal restoration or porcelain laminate veneer • Extrusion + fiberotomy + porcelain crown • Surgical crown lengthening, by flap procedure and ostectomy/osteoplasty of bone (Bragger et al 1992) 36/39
- 39. PERIODONTALLY ACCELERATED OSTEOGENIC ORTHODONTICS • Wilcko et al 2001 reported a revised corticotomy-facilitated technique - (PAOO) is a combination of a selective decortication facilitated orthodontic technique and alveolar augmentation. • With this technique, one teeth can be moved 2-3 times further in one third or one fourth of the time required for traditional orthodontic therapy . 37/39
- 40. • Wilcko and coworkers reported that in a surface computed tomographic (CT) scan evaluation of selectively decorticated patients was that the rapid tooth movement was not the result of bony block movement • But rather a transient localized demineralization-remineralization phenomenon in the bony alveolar housing consistent with the wound healing pattern of the Regional Acceleratory Phenomenon (RAP). 38/39
- 41. A MAGNIFICIENT ORTHODONTIC TREATMENT CAN BE DESTROYED BY POOR PERIODONTAL SUPPORT. HENCE , EVALUATION AND MAINTENANCE OF PERIODONTAL HEALTH BEFORE , DURING AND AFTER TREATMENT IS VERY IMPORTANT !! CONCLUSION 39/39
- 42. REFERENCES 1. Clinical Periodontology , Carranza 10th edition 2. An update on Periodontic-orthodontic interrelationships, Aous Dannan , J Indian Soc Periodontol. 2010 Jan -Mar; 14(1): 66–71. 3. Sapna singla, Influence of orthodontic therapy on periodontal health: a review. indian journal of dental sciences. (June 2013 Issue:2, Vol.:5) 4. Patil AK, Shetty AS, Setty S, Thakur S. Understanding the advances in biology of orthodontic tooth movement for improved ortho-perio interdisciplinary approach. J Indian Soc Periodontol 2013;17:309-18.
Editor's Notes
- #10: It is widely accepted that at least 2 mm of keratinized gingiva should be present to withstand orthodontic force and prevent recession.
- #17: Concavities in the crest of the interdental boneconfined within the facial and lingual walls. Figure 51-1 This patient had a 6-mm probing defect distal to the maxillary right first molar (A). When this area was flapped (B), a cratering defect was apparent. Osseous surgery was used to alter the bony architecture on the buccal and lingual surfaces to eliminate the defect (C and D). After 6 weeks, the probing pocket defect had been reduced to 3 mm and orthodontic appliances were placed on the teeth (E). By eliminating the crater before orthodontic therapy, the patient could maintain the area during and after orthodontic treatment (F).
- #18: This patient had a significant periodontal pocket distal to the mandibular right first molar. Periapical radiograph confirmed the osseous defect. A flap was elevated revealing a deep, three-wall osseous defect. Freeze-dried bone was placed in the defect. Six months after the bone graft, orthodontic treatment was initiated. The final periapical radiograph shows that the preorthodontic bone graft helped regenerate bone and eliminate the defect distal to the molar
- #19: (A).This patient was missing the mandibular left second premolar, and the first molar had tipped mesially. (B) Pretreatment periapical radiograph revealed a significant hemiseptal osseous defect on the mesial side of the molar. (C). To eliminate the defect, the molar was erupted, and the occlusal surface was equilibrated (D). The eruption was stopped when the bone defect was leveled (E) The posttreatment intraoral photograph and (F) periapical radiograph show that the periodontal health had been improved by correcting the hemiseptal defect orthodontically.
- #20: MOST IMPORTANT FACTOR IN TREATMENT IS LOCATION OF THE BANDS 1 : 1.5 normal crown to root ratio Before orthodontic treatment, this patient had a significant class III malocclusion. The maxillary central incisors had overerupted relative to the occlusal plane. Pretreatment periapical radiograph showed that significant horizontal bone loss had occurred. To avoid creating a vertical periodontal defect by intruding the central incisors, the brackets were placed to maintain the bone height The incisal edges of the centrals were equilibrated , and the orthodontic treatment was completed without intruding the incisors
- #21: A & B This patient had a class III furcation defect before orthodontic treatment C. Orthodontic treatment was performed D. and the furcation defect was maintained by the periodontist on 2-month recalls until after orthodontic treatment. D. After appliance removal, the tooth was hemisected and the roots were restored and splinted together The final periapical radiograph shows that the furcation defect has been eliminated by hemisecting and restoring the two root fragments.
- #22: two implants were placed in the mandibular left posterior quadrant The implants were used as anchors to facilitate orthodontic treatment help reestablish the left posterior occlusion
- #23: However, for the patient undergoing orthodontic therapy, the roots can be moved apart and bone will form b/w the adjacent roots. Before orthodontic treatment, this patient had significant mesial tipping of the maxillary right first and second molars, causing marginal ridge discrepancies. The tipping produced root proximity between the molars. To eliminate the root proximity, the brackets were placed perpendicular to the long axis of the teeth. This method of bracket placement FACILITATED ROOT ALIGNMENT and ELIMINATION OF THE ROOT PROXIMITY, as well as LEVELING OF THE MARGINAL RIDGE discrepancies
- #25: This patient had a severe fracture of the maxillary right central incisor that extended apical to the level of the alveolar crest on the lingual side To restore the tooth adequately and avoid impinging on the periodontium, the fractured root was extruded 4 mm. As the tooth erupted, the gingival margin followed the tooth. Gingival surgery was required to lengthen the crown of the central incisor so that the final restoration had sufficient ferrule for resistance and retention and the appropriate gingival margin relationship with the adjacent central incisor`
- #26: If all these factors are favorable, then forced eruption of the fractured root is indicated.
- #28: This patient had an impacted mandibular right second molar (A). The mandibular right first molar was periodontally hopeless because of an advanced class III furcation defect. The impacted second molar was extracted, but the FIRST MOLAR WAS MAINTAINED AS AN ANCHOR to help upright the third molar orthodontically (B to D). After orthodontic uprighting of the third molar, the first molar was extracted and a bridge was placed to restore the edentulous space (E and F).
- #29: Four factors contribute to ideal gingival form.
- #30: This patient - protrusive bruxing habit that had resulted in abrasion and overeruption of the maxillary right central incisor . The objective was to level the GM during orthodontic therapy. Although gingival surgery was a possibility, the labial sulculas was only 1 mm, and the CEJ of the maxillary right central incisor was located at the bottom of the sulcus. Therefore the best solution involved positioning the orthodontic brackets to facilitate intrusion of the right central incisor (B to D). This permitted the restorative dentist to restore the portion of the tooth that the patient had abraded (E), resulting in the correct gingival margin levels and crown lengths at the end of treatment (F).
- #32: This patient had a PROTRUSIVE BRUXING HABIT that had caused severe abrasion of the maxillary anterior teeth , resulting in the loss of over half of the crown length of the incisors (A and B). Two possible options existed for gaining crown length to restore the incisors. One possibility was an apically positioned flap with osseous recontouring, which would expose the roots of the teeth. The less destructive option was to intrude the four incisors orthodontically, level the gingival margins (C and D), and allow the dentist to restore the abraded incisal edges (E and F). The orthodontic option was clearly successful and desirable in this patient.
- #33: Half of the space is occupied by papilla, and half is formed by the tooth contact.
- #34: Figure 51-14 This patient initially had overlapped maxillary central incisors (A), and after initial orthodontic alignment of the teeth, an open gingival embrasure appeared between the centrals (B). Radiograph showed that the open embrasure was caused by divergence of the central incisor roots (C). To correct the problem, the central incisor brackets were repositioned (D), and the roots were moved together. This required restoration of the incisal edges after orthodontic therapy (E) because these teeth had worn unevenly before therapy. As the roots were paralleled (F), the tooth contact moved gingivally and the papilla moved incisally, resulting in the elimination of the open gingival embrasure.
- #35: Methods to reduce the occurrence of rotational relapse may include (1) complete correction, or overcorrection, of rotated teeth, (2) long-term retention with bonded lingual retainers,and (3) the use of fiberotomy. A fiberotomy or pericision is an orthodontic surgical procedure designed to sever the gingival fibers around a tooth. It usually reduces the tendency to relapse of tooth rotations corrected by dental braces or other treatments
- #40: (PAOO) is a clinical procedure that combines selective alveolar corticotomy, particulate bone grafting, and the application of orthodontic forces. In 2001, Wilcko et al reported a revised corticotomy-facilitated technique that included periodontal alveolar augmentation, called Periodontally Accelerated Osteogenic Orthodontics.