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A simple presentation of some of the benefits of orthodontics on periodontal health.

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  1. 1. ObjectivesDiscuss the diagnostic tools which arepertinent for orthodonticsDiscuss the importance of orthodontics andperiodontal therapy
  2. 2. (Dr L. Andrews, AJO-DO 1972)A cornerstone article on optimum static occlusion
  3. 3. Super class I molar: Optimum occlusion• The distal surface of the permanent upper firstmolar should be in contact with the mesial surface ofthe lower second permanent molar– This gives the best interdigitation of the premolars– Class I canine– Adequate overbite and overjet1
  4. 4. Angulation (tip)• The part of the toothgingival to the crown isdistal to the part which isincisal or occlusal to thegingival margin• This concept is veryimportant in estheticdentistry2
  5. 5. This angulation is incorporated in mostbonded brackets
  6. 6. Improvement in the angulation of theupper incisors
  7. 7. Proper angulation of the tooth…..…..influences– The emergence of theteeth– The position of thecontact points– The creation of blacktriangles– Gingival contours– The closure ofdiastemas
  8. 8. …. At the smile level
  9. 9. Each tooth has it’s owninclination (torque)…. torque influences– Lip support– Gingival contours– The size of the arches– The shape of the arches– Emergence profile of theteeth– The smile line3
  10. 10. 2006: Gingival recession, dentist sends for a gingival graftPeriodontal response to occlusaltrauma and poor inclination
  11. 11. 2011: recall visitPatient refused comprehensiveorthodontics
  12. 12. Pre-ortho Impacted canines upper archPeriodontal response (adult)
  13. 13. Some lingual root torque and betterhygiene. Still needs a graft
  14. 14. Torque and periodontics• 28 year old patient with‘’hopeless’’ lowerincisors.• 36 months of agressiveortho for correction ofCl III relationship• « Nothing to lose »2007
  15. 15. Torquing roots back into bone
  16. 16. Finished case post perio-orthoTooth mobility 1 to 2 but periodontistconfident we can keep the teeth2011 after gingival graftsplaced on 41 31 only
  17. 17. In this case we also improved theincisor coupling
  18. 18. Other occlusal considerations:Comments?
  19. 19. Optimal Interdigiation• Maximal interdigitation ,a functionalocclusion with cuspid guidance , respectingthe dictates of the temporo-mandibular joints,are imporant goals in all orthodontictreatments• Form follows function: a well balancedfunctional occlusion usually results in betterperiodontal health.
  20. 20. Contact points marginal Ridges• Points or surface contacts have a great influence onthe morphology of the gingiva. An example iscomprimised interproximal papillae
  21. 21. The gingival line
  22. 22. Teeth are aligned respecting thegingival line(especiallly in patients who have a gummy smile)
  23. 23. It is important to maximize the esthetics byaligning the gingival margins
  24. 24. To enhance periodontal health
  25. 25. OrthodonticsPeriodonticsRestorativeDentistryPatient needingrehabilitationInterdisciplinary Treatment
  26. 26. Single tooth restorations
  27. 27. Factors to consider in the preservation of atoothPossible role of orthodonticsIt’s importance as part of the occlusionRestorabilityPeriodonticsEndodontics
  28. 28. Here is the case:The patient was a 50 year old maleGood general healthHe had # 11,21,22 restored six month previouslyHe was concerned about the deepbite ,The dentist reassured him thatthe occlusion would improve by itself…. now #21 was fractured…..
  29. 29. Sequence of treatment is veryimportant!Normally, we begin by establishing posterior supportImplantsplaced but notrestored
  30. 30. Diagnosis• #21 fractured at gingivalmargin• Occlusal trauma on anteriorteeth• Loss of posterior support• Violation of the biologicwidth
  31. 31. Initial investigation: Temporisation ofcrowns at #11,21,22
  32. 32. It was decided to extrude #21 to re-establish biologic width
  33. 33. The gingival line became unevenOrthodontic extrusion results in an uneven gingival line. Some times fibrotomies canbe performed to decrease the extent of the lowering of the gingival crestOne of the advantages of orthodontic extrusion is that it significantlyreduces the amount of lengthening of the crown preparation
  34. 34. Lengthening of the clinical crown waslimited to t eth #12,22
  35. 35. Healing phase with excellenttemporary crowns
  36. 36. Multiple restorations
  37. 37. Orthodontic treatment and multiplerestorations• 40 year old mother• Consults because shebreaks her loweranterior teeth• Second opinion:• Patient refusedorthognathic surgery
  38. 38. Observations• Cl II malocclusion –Bimaxillary retrusion• Overbite: 80% -100%• Retrusive upper and lower incisors• Heavily restored dentition• Severe curve of Spee• 36 absent, 37 decayed
  39. 39. Treatment Objectives• Open the bite• Correct curve of Spee• Improve Class II relationship (compensation)• Optimum positioning of crowns and roots forfuture rehabilitation• Replace bridge.
  40. 40. Improvement of Class II
  41. 41. Post orthodontics. Left side needs more prosthodontic work.
  42. 42. Periodontics- Orthodontics
  43. 43. Improvement of the periodontium• Orthodontic treatment could improve acontrolled periodontal condition by:– Re-establishment of adequate contact points andoptimal inter-radicular distances– Alignment of the teeth to allow better oralhygiene– Re-establishment of a stable occlusion– Optimize « anterior coupling »
  44. 44. Be careful!• It is contraindicated tobegin orthodontictreatment (Invisalignincluded) in thepresence of activeperiodontal disease.• A curettage is minimaltreatment
  45. 45. Look for periodontal,endodontic, caries cystic andany other problems
  46. 46. Free gingival graft or not pre-orthodontic therapy?
  47. 47. Orthodontic Preparation DEC 2008Opening space for surgical cut RPE inserted and cemented
  48. 48. MARCH 2009
  49. 49. SEPT 2009
  51. 51. Gingival grafts????
  52. 52. APRIL 2010: IMPROVED OCCLUSION.MUCH IMPROVED PERIODONTALCONDITIONWill need gingival graft on 14 and lower incisors but other teeth are now under control
  53. 53. Orthodontics in collaboration withperiodontics• Improve the oral hygiene• Make contact pointsadequate• Establish functionalocclusion• Optimize the position ofthe teeth to acceptocclusal forces in the longaxes of the teeth• Perform selectiveextrusion –intrusion• Improve esthetics
  54. 54. Post curettage , orthodontic andprosthodontic therapy:Noticeable improvement in gingival margins
  55. 55. Simple orthodontic treatment
  56. 56. Treatment post periodontal treatment(Photos Dr Benhamou)Thirty five year old patient whose complaint was night timebleeding.Dentist told her it was due to her pregnancyHad a consultation with a periodontist on therecommendation of a friend.With only digital pressure!Pus and bleeding….Purple and edematous gingiva
  57. 57. General horizontal bone loss(moderate to severe)
  58. 58. Periodontics was institutedpre-orthodontics• Debridement and curettage to be performed• Reshape the inadequate contours of the crownof #11• Bleeding of gums to be addressed• Gingival grafts to be made where necessary
  59. 59. After debridement
  60. 60. Intrusion and interproximal reductionof incisors
  61. 61. Hhowever, there were still food traps.
  62. 62. Orthodontic treatment:Interproximal reduction (IPR) is essential in this case• The interproximalreduction was limitedto the anteriorsegments.• The posterior segmentsimproved without IPRZachrisson showed greater stabilitypost orthodontics if we could avoid theproclination of the lower incisors
  63. 63. • Ultra light forces• Upper and lowerincisor intrusion2 onceselastics.
  64. 64. • Controlled periodontal condition• Active phase of orthodontics is finished
  65. 65. • Female 17years old• Chief Complaint:– I do not like my smile and my gumsbleed when i brush• Medical Historye:– Good general health– No allergies– No smoking• Dental history:– Poor oral hygiene– Brushes only once a day– No flossing– Noticed upper teeth separatingsincelast yearData Collection
  66. 66. Clinical Evaluation• Extra oral– Gummy smile– Narrow smile• Intra oralClasse I molaire– Overbite 100%– PSR IV maxilla– Gingival redness and swelling– Mobility: 2 on 11, 21 ,24– Exsudât 11 et 24– Diastema 11 and 21: 2.5 mm
  67. 67. • Localized bone loss 11, 24• Generalized horizontal bone loss (10-20%) with 40% between11 and 21• 18, 28, 38, 48 impacted• Low caries rateRadiologic Evaluation
  68. 68. 1. Periodontics• Diagnostic: Aggressive localized periodontitis• Treatment:– Debridement (antibiotics)– Hygiene instructions– Bone grafting 24– Open curettage 11-21– 3 months recall
  69. 69. 2. Orthodontie
  70. 70. Overeruption of the upper incisors
  71. 71. Goals of treatment (limited)• Intrusion of upper incisors• Maintain posterior occlusion• Reshape upper arch• Close anterior diastema• Reposition upper laterals for veneers orcomposite restorations (Bolton discrepancy)
  72. 72. Intrusion arch . Light forcesFavorable gingivalresponse
  73. 73. Creation of a more favorable occlusal plane
  74. 74. Orthodontic Extraction• Limit bone resorption• Better control of bony levels• Atraumatic extraction• Better gingival contour
  75. 75. Extrusion pre-implantImmediate implantAtraumatic extractionaction atraumatique de reste de la racineVery light orthdontic wire ( NiTi) to bring bone with the rootOrthodontic bracketingTemporizeCalcium Hydroxyde (Coronal reduction )