periodontics and orthodontics by almuzian

University of Glasgow

Orthodontics and periodontics

Mohammed Almuzian

2013

Contents

Introduction...........................................................................................................1

Abbreviated version of the 1999 classification of periodontal diseases and

conditions:.............................................................................................................1

Etiology of periodontal diseases...........................................................................2

Risk factors in periodontitis..................................................................................3

1. Bacterial risk factors................................................................................3

2. Race..........................................................................................................4

3. Gender......................................................................................................4

4. Age...........................................................................................................4

5. Socio-economic status..............................................................................4

6. Smoking...................................................................................................4

7. Systemic disease.......................................................................................4

8. Genetics....................................................................................................5

9. Orthodontic treatment and appliances......................................................5

Diagnosis of periodontal diseases.........................................................................5

1. CPITN......................................................................................................5

Code......................................................................................................................6

2. Radiographs..............................................................................................6

Treatment of periodontal diseases........................................................................6

A) Initial periodontal therapy /non-surgical therapy /Cause Related Therapy

(CRT) includes......................................................................................................6

B) Monitoring response to therapy.......................................................................7

Other periodontal surgery.....................................................................................8

Mohammed Almuzian, University of Glasgow, 2013 Page 1

The relationship of orthodontics and periodontics...............................................8

1. Does malocclusion cause periodontal disease?........................................8

A. Crowding..................................................................................................8

B. Increased Overjet.....................................................................................8

C. Deep Overbite..........................................................................................8

D. Other occlusal considerations..................................................................9

2. Does periodontal disease cause malocclusion?........................................9

3. Periodontally compromised patient having an orthodontic treatment.....9

4. Iatrogenic influence of orthodontic treatment on periodontium............11

Types...................................................................................................................11

Incidence.............................................................................................................11

Gingival recession..............................................................................................12

5. Periodontal surgery as an adjunctive procedures to orthodontic

treatment.............................................................................................................12

6. Role of orthodontics in treatment of periodontal problems...................14


Orthodontics and periodontics

Introduction

Periodontitis is a common disease affecting up to 40% of the adult population

over the age of 40 in the UK.

Gingivitis precedes periodontitis but not all gingivitis progresses to periodontitis

Abbreviated version of the 1999 classification of periodontal diseases and

conditions:

I. Gingival Diseases

A. Dental plaque-induced gingival diseases

B. Non-plaque-induced gingival lesions (Viral, bacterial, fungal)

II. Chronic Periodontitis

Slight: 1-2 mm;

Moderate: 3-4 mm;

Severe: > 5 mm

A. Localized

B. B. Generalized (> 30% of sites are involved)

III. Aggressive Periodontitis

Slight: 1-2 mm CAL;

Moderate: 3-4 mm CAL;

Severe: > 5 mm CAL

A. Localized

B. Generalized (> 30% of sites are involved)

IV. Periodontitis as a Manifestation of Systemic Diseases


A. Associated with genetic disorders

B. Associated with hematological disorders

C. Associated with endocrine disorders

D. Not otherwise specified

V. Necrotizing Periodontal Diseases

A. Necrotizing ulcerative gingivitis

B. Necrotizing ulcerative periodontitis

VI. Abscesses of the Periodontium

A. Gingival abscess

B. Periodontal abscess

VII. Periodontitis Associated With Endodontic Lesions

Combined periodontic-endodontic lesions

VIII. Developmental or Acquired Deformities and Conditions

A. Localized tooth-related factors that modify or predispose to plaque-

induced gingival diseases/periodontitis

B. Mucogingival deformities and conditions around teeth or edentulous

ridges

C. Occlusal trauma

Etiology of periodontal diseases

1. Plaque is the principal aetiology

2. The main bacteria involved are:

o For gingivitis: gram-negative anaerobic bacilli, cocci and spirochetes.


o For deep destructive periodontal lesions: P. gingivalis, P. intermedia and

Actinobacillus actinomycetemcomitans.

3. Tissue destruction in periodontal disease is mainly due to the host's

response to the presence of bacteria by complement activation. So that,

Antigenic substances released by plaque organisms elicit both cell-mediated and

humoral responses, while designed to be protective, also cause localized tissue

damage.

4. The damage is caused by one or all of the major endogenous mediators of

inflammation: histamine, protease, prostaglandins and leukotrienes, lysosomal

acid hydrolases, free radicals, complement and cytokines.

Risk factors in periodontitis

A. Bacterial risk factors

B. Race

C. Gender

D. Age

E. Socio-economic status

F. Smoking

G. Systemic disease

H. Genetics

I. Orthodontic treatment and appliances


1. Bacterial risk factors

Although specific bacteria have been considered potential periodontal

pathogens, it has become apparent that they are necessary but not sufficient for

disease activity to occur.

The progression of the disease is related to host based risk factors

2. Race

It was more prevalent in individuals of Afro-Caribbean origin.

3. Gender

It has also indicated that destructive periodontitis was consistently more

prevalent in males than females

4. Age

Periodontal disease prevalence increases with age.

5. Socio-economic status

Data has indicated that periodontal disease is more severe in individuals

of lower socio-economic status.

6. Smoking

Smokers are 5-7 times more likely to developed destructive disease than

non-smokers.

They suffer more severe disease than non-smokers with deeper pockets

and greater clinical attachment loss.


They also respond less well to all types of therapy and are more likely to

suffer recurrent disease.

7. Systemic disease

There is positive evidence linking diabetes mellitus to increased risk for

the inflammatory periodontal diseases.

Conditions with depressed neutrophil numbers and function, such as

neutropenia, Down's syndromes and Papillon-Lefèvre syndrome have been

reported with severe periodontitis.

8. Genetics

Recently much attention has focused on genetic polymorphisms

associated with genes involved in cytokine production that have been linked to

an increased risk of adult periodontitis

9. Orthodontic treatment and appliances

Band ledges

Elastomeric modules

Excessive proclination/expansion of teeth

Bracket placement changes subgingival flora

Diagnosis of periodontal diseases

1. CPITN

The Basic Periodontal Examination BPE, requires that the periodontal

tissues should be examined with a standardised periodontal probe using light


pressure (15gm) to examine the tissues for plaque, bleeding, retentive factors

and pocket depths.

The dentition is divided into sextants and each tooth is probed

circumferentially.

Only the highest score is recorded in each sextant. The score codes are as

follows;

Code

0 No bleeding or pocketing detected

1 Bleeding on probing - no pockets greater than 3.5mm

2 Plaque retentive factors present - no pockets greater than 3.5mm

3 Pockets greater than 3.5mm but less than 5.5mm in depth

4 Pockets greater than 5.5mm in depth

When a BPE score of 3 or 4 is recorded then the orthodontist should refer

the patient back to their GDP or to a periodontologist for appropriate care

Only when the GDP or periodontologist has deemed that periodontal

disease is not active should orthodontic treatment be undertaken but 6 months

later on.

2. Radiographs

Panoramic radiographs are often taken as a baseline record for orthodontic

screening. The Royal college of England in 2004 recommended:

Horizontal bitewings for lesser pockets

Vertical bitewings or periapicals for deeper pockets.


Treatment of periodontal diseases

A) Initial periodontal therapy /non-surgical therapy /Cause Related

Therapy (CRT) includes

1. Patient motivation through:

Explanation of the causes and the risks.

Demonstration of oral hygiene techniques

Monitor compliance by plaque index.

2. Supragingival scaling.

3. Removal of plaque retention factors.

4. Subgingival scaling with root surface debridement.

5. Chemotherapeutic adjuncts may be appropriate - chlorhexidine gluconate

0.2 per cent

6. Occlusal adjustment if appropriate.

7. Smoking cessation advice

B) Monitoring response to therapy

Response to therapy should be monitored through:

Patient compliance (plaque and calculus index)

Bleeding

Pocket depth (Following subgingival instrumentation a period of six to

eight weeks should elapse before any probing is performed. Indeed healing is

not complete for six months).


Mobility.

Three scenarios might be identified:

1. Patients demonstrating good response treatment with adequate OH and

absence of evidence of pocket activity will require a maintenance regime to

conserve the improvement achieved.

2. Patients with inadequate response related to poor compliance will not

benefit from surgical intervention but may show health gain from regular

professional dental prophylaxis.

3. Patients with adequate levels of oral hygiene but with residual active

periodontal pockets may benefit from more complex therapy including

periodontal surgery or the use of local antimicrobial therapy as an adjunct to

further non-surgical debridement.

Other periodontal surgery

1. Fibreotomy / circumferential supracrestal fibreotomy technique (CSF)

2. Fraenotomy: attachment of the fraenum is severed from the gingiva and

periosteum and is resited apically

3. Removal of gingival invaginations (clefts): Space closure=piling of soft tissue

with deep vertical cleft running apically. If persisting> 5 years excise the cleft

with deep vertical incisions on either side of the cleft, leaving an open wound

and healing by secondary intention

4. Gingivectomy


The relationship of orthodontics and periodontics

1. Does malocclusion cause periodontal disease?

A. Crowding

Ainamo 1972,

Concluded that irregularity of the teeth does not periodontal breakdown

Irregularity does OH ability

Association between irregularity & periodontal disease does become

significant when tooth brushing is average.

Bollen 2008 in her systematic review showed a positive correlation

Addy et al 1988

Conclusion periodontal breakdown not associated with crowding

B. Increased Overjet

Bjornas et al 1994

Helm & Peterson 89 periodontal pocketing & gingivitis + OH is

poorer with OJ

C. Deep Overbite

Class II/2 gingival recession on labial surface of lowers, palatal uppers

D. Other occlusal considerations

Root approximation thin interdental bone

Traumatic occlusion giggling forces

Incompetant lips plaque more difficult to remove

2. Does periodontal disease cause malocclusion?

Profit 1978 equilibrium theory:

1. intrinsic forces by the tongue and lips

2. extrinsic forces: habits ( thumb sucking),orthodontic appliances


3. Forces from dental occlusion

4. Forces from the periodontal membrane

Loss of PD support less able to withstand soft tissues + occlusal forces

tooth movement

3. Periodontally compromised patient having an orthodontic treatment

A. There is no evidence that orthodontic treatment will worsen the PD

condition if the OH and PD condition is stabilized.

B. No treatment should be started unless these features are available

Pockets less than 5mm

Bleeding scores less than 15%

Plaque scores less than 15%

Cleanable teeth and prosthesis

No root caries.

Badersten 1984 says at least 6 months after stabilizing periodontal

treatment

C. Appliance: Orthodontic treatment might act as a retentive factor for

plaque and certain preventive measurement might be indicated:

High standard of oral hygiene

Keep the appliances and mechanics simple.

Avoid hooks, elastics and excessive bonding resin outside the bracket

bases.

Wire ligatures accumulate less plaque

Bonds are preferable to bands.


D. Biomechanics:

Light forced indicated during treatment since there is a change in the

center of resistance

Reinforce anchorage

E. Adjunct to treatment

1. Physical

Oral Hygiene Motivation Method (OHMM)

electric toothbrush

professional prophylactic programmes

2. Chemical

0.12% chlorhexidine gluconate

0.2% chlorhexidine gluconate usually recommended

F. Screening

• BPE probing 3 monthly. Boyd (1989) 3 monthly intervals

• full chart if greater than score 3 in more than one sextant

G. Progress of treatment and PD status monitoring: Warning signs during

treatment need strict action, these includes:

Inadequate OH

Bleeding on probing

Sub-gingival calculus

Radiographic signs of bone loss

Probing depths of greater than 4mm

It is preferable to terminate orthodontic treatment in patients who fail to respond

to instructions for oral hygiene procedures

H. Retention: in PD compromised dentition, the use of semireigid fixed

retainer to allow some functioning of the pd tissue during fixation.


4. Iatrogenic influence of orthodontic treatment on periodontium

Types

• Gingivitis

• Gingival recession

• Gingival hyperplasia

• ANUG

• Periodontitis

• Burns

• Bone loss

Incidence

A. Nearly all FA patients will get gingivitis but with no difference in

periodontal status between postorthodontic and non-orthodontic patients

B. rarely progresses to attachment loss

C. MH: Patients with certain medical conditions are more at risk of

periodontal problems for example poorly controlled diabetics or epileptics

whose anticonvulsants cause gingival hyperplasia

D. Mechanics: Certain treatment mechanics e.g. proclination of lower

incisors in a Class III case prior to surgery can result in gingival defects.

Management in these cases should be coordinated with a periodontologist, who

may recommend improved plaque control alone or a free gingival graft.

Gingival recession

Miller classification


Etiology

1. Plaque,

2. Position of the tooth,

3. Vigorous tooth brushing,

4. Traumatic occlusion,


5. Prominent fraenum

6. Thin marginal gingivae.

7. Alveolar plate is thin.

8. Orthodontic movement to position the tooth labially

Benefits of orthodontic treatment in relation to gingival recession, Johal

2013

1. Self-maintaining oral hygiene

2. Crown alignment within the dento-alveolar envelope

3. Removal of occlusal trauma

4. Root alignment within the bone

Risk factors, Johal 2013

One could consider the acronym ABEF to help take into account the risk

factors:

A: Anatomy of the alveolar bone and proximity of the root to the cortical plates

B: Biotype

E: Environment (oral hygiene, habits, poor brushing,poor orthodontic

mechanics, active lingual retainers)

F: Functional matrix (smoking)


The mechanics or treatment modalities that could be employed to minimize

the risk of recession

1. Maintain good oral hygiene throughout orthodontic treatment

2. Eliminate potential causes of recession (piercing, smoking, traumatic tooth

brushing)

3. Avoid uncontrolled dento-alveolar expansion and maintain arch form by

extraction or IDS.

4. Customise bonding and mechanics

5. Modify tooth anatomy whenever indicated

6. in lower incisor crowding, consider segment arch mechanics and create space

before using it and use it wisely

7. Consider atypical extractions of severly involved tooth

8. Avoid jiggling because it may cause periodontal problems

9. Treat early (interceptive procedures and treatment in mixed dentition)

10.Gingival grafting before orthodontic treatment

Treatment of gingival recession, Johal 2013

1. Thorough instructions on plaque control should be provided.

2. Free gingival graft

3. EMD

4. Modified coronally advanced tunnel flap approach


5. envelope technique with connective tissue graft

6. The laterally positioned flap with or without connective tissue graft.

7. A frenectomy can also be considered

8. The gingiva is attached to the supracrestal portion of the root so that lingual

movement of the incisor will result in a labial increase in gingival height.

5. Periodontal surgery as an adjunctive procedures to orthodontic

treatment

Fibreotomy (CSF).

Procedure

Developed by Edward 1988

Littlewood 2006 support its advantages

Basically this involves insertion of a scalpel into the gingival sulcus and

incising the circum-gingival fibers surrounding the tooth to a depth of about 3m

below the level of the alveolar crest.

The blade also transects the transseptal fibres by entering the periodontal

ligament space.

Indicated

Improve retention after de-rotation

Contraindication

Poor oral hygiene,

Gingivitis or active periodontal disease.


In cases of treated periodontitis because the crevicular incision may

damage the long junctional epithelium

Thin gingivae

Fraenotomy

Indication

Unaesthetic fraenum

When the fraenum with a fan-like attachment may obstruct closure

Removal of gingival invaginations (clefts)

Indication

During orthodontic closure of extraction sites, the teeth tend to push the

gingivae ahead to create a pile of soft tissue.

The excess gingiva has the appearance of an enlarged papilla with a deep

vertical cleft running apically.

There is some resolution of these defects with time but many persist for 5

years after completion of orthodontic therapy.

Procedure

Excise the cleft with deep vertical incisions on either side of the cleft,

leaving an open wound and healing by secondary intention

Gingivectomy

Indication

Improving aesthetic.


This is particularly so in cases with missing lateral incisors, after

premolar auto transplantation and 'gummy' smiles.

Increase the clinical crown length

Contraindication

Gingivectomy should not be carried if there is a risk of exposing the root

surface.

6. Role of orthodontics in treatment of periodontal problems

Bollen 2008 showed that ortho treatment will not improve perio condition

Some authors prefer to perform orthodontic treatment before stabilizing the pd

condition based on the believe that orthodontic treatment would eliminate bony

defect as teeth moved ad thus reducing pocket depth.

However, Kokich (1996) mentioned that:

A. Gingival margin discrepancies

Gingival margin discrepancies can be addressed by surgical or orthodontic

means. Decision depends on:

1. Level of smile line : if low smile line and the gingivae can not be shown,

then the correction is unnecessary.

2. The depth of the gingival sulci over the teeth in question: If the sulcular

depth is unequal, coronal-lengthening surgery may alleviate the problem. If the

sulci are of equal depth, then orthodontic is indicated by extruding it to move its

gingival margin coronally allowing for correction of the gingival margin

discrepancy and then subsequent reduction to correct the resulting incisal edge

discrepancy.

3. Coronal tooth structure: . The overerupted tooth due to attristion or

abrasion should be slowly intruded to allow apical migration of the gingival

margin and then restored back up to the proper height.


B. ‘‘the missing papilla’’

Aetiologies (Zachirsson 2004):

Post treatment interdental contact points that are located too far incisally,

Tarnow et al 1992 analyzed the correlation between the presence of

interdental papillae and the vertical distance between the contact point

and the interproximal bone crest. When the vertical distance from the

contact point to the crest of bone was 5 mm or less, the papilla was

present almost 100% of the time. If the distance was 6 mm, most

commonly only partial papilla fill of the embrasure between the teeth was

found. the distance was 7 mm or more, the papilla was missing most of

the time. These findings indicate that the papilla will extend only a

limited distance from the alveolar bone crest to the interproximal contact.

Since the supracrestal connective tissue attachment zone is normally

approximately 1 mm, the biologic height of the interdental papilla may be

limited to about 4 mm.

Triangular-shaped or divergent crown shape

Loss of periodontal support due to plaque-associated lesions.

Improper (divergent) root angulations,

Contours of prosthetic restorations,

Traumatic oral hygiene procedures may also negatively influence the

outline of the interdental soft tissues

Prevelances

A recent study by Kurth and Kokich 2001 demonstrated that open

gingival embrasures is a common posttreatment finding in adult

orthodontic patients. In their sample of 337 patients with a mean age of

about 32 years, 38% had open spaces between the maxillary central

incisors.


In another study, Burke et al 1994 found a 42% prevalence in adolescent

orthodontic patients with crowded central incisors.

Treatment

1. Accept: Kokich Jr et al 1999 found that orthodontists identified a 2-mm

open space between the maxillary central incisors as unattractive. However,

general dentists and lay people apparently were unable to detect an open

gingival embrasure unless it was 3 mm long. These results indicate that small

open spaces may not be noticeable enough by the average patient to necessitate

their correction.

2. IPS but with consideration to the TSD

3. Tooth movement with simple repositioning of the orthodontic brackets or

by judicious wire bending,

4. Selective cosmetic bonding

C. The ‘‘gummy smile’’

Causes

1. Vertical maxillary excess: it can be treated by orthognathic surgery

2. Gingival hyperplasia or coronal positioned gingivae due to delayed

apical gingival migration in the adolescent. In this situation, gingival surgery

should be performed

3. Short lip: treated by plastic surgery

4. Over eruption of the teeth which treated by absolute incisor intrusion.

However, intrusion of teeth can shift supragingival positioned plaque

subgingivally. Professional subgingival scaling is particularly important during

the phase of active intrusion. Intrusion should generally be undertaken in

patients with an excellent standard of oral hygiene.

5. Combinations

D. Horizontal or AP bone regeneration


1. It has been shown that a tooth with a healthy periodontium maintains this

when it is moved into an area of reduced bone height.

2. It is important to emphasise that the periodontal condition must be

stabilised prior to treatment.

E. Vertical bone regeneration

During the orthodontic extrusion the relationship of the CEJ to the bone crest is

maintained so that the bone follows the tooth. This means that the extrusive

tooth movement repositions the intact connective tissue and the vertical bone

defect is either eliminated or shallowed out.

Indicated

1. Used to shallow out infrabony defects

2. To increase the clinical crown length of a single crown.

F. Management of drifting incisors

Migration and spacing of the upper anterior incisors is often the first indication

to the patient that there may a problem with their teeth.

G. Management of tilted molar teeth (This invariably is the second

molar tooth).

Indications

1. Presence of a functionally disturbed occlusion.

2. Paralleling of abutment prior to prosthetic preparation.

Treatments options


1. Acceptance and monitoring its position

2. Orthodontic uprighting

3. Uprighting followed by space closure.

Advantages

1. Easier abutment preparation enhancing parallelism.

2. Elimination or reduction of mesial periodontal lesions.

Factors must be considered

1. Assess the position of the 3rd molar. If the planned upright position is

impeded by the 3rd molar then it should be removed.

2. The most appropriate tooth movement should be considered. Distal crown

tipping increases the pontic space, while mesial root tipping reduces it.

3. Space closure following uprighting by is complicated if there is a mesial

periodontal defect. When an infrabony defect is present, it is essential to ensure

that that the periodontal condition is stabilised prior to any uprighting.


periodontics and orthodontics by almuzian

Health & Medicine