Managing treatment for the orthodontic patient with periodontal problems by David P. Mathews and Vincent g. Kokich ppt

1. Literature review

2. Type of study Review
Authors David P. Mathews and Vincent g. Kokich
Date of publication 1997
Name of Journal Seminars in Orthodontics

3. Introduction
Most orthodontic patients are children and adolescents (8-16 years).
Many of them have underlying periodontal problems that could become worse during
orthodontic therapy.
 Periodontal problems should be identified before orthodontic treatment.

4. Aim
 To describe the responsibilities of orthodontists for diagnosing periodontal problems
and discuss the interdisciplinary management of several periodontal problems requiring
orthodontic intervention.

5. Periodontal Examination By The Orthodontist
 The etiologic factors including plaque, subgingival calculus, and occlusal trauma
 It takes a 5 minute periodontal examination during the initial consultation with the
patient.
 This is a simple screening examination, if problems are discovered, then referral to a
periodontist for a further diagnosis.

6. Periodontal Examination By The Orthodontist
 The screening examination involves:
 Periodontal Probing.
 Evaluating attached gingiva.
 Studying appropriate radiographs.

7. Periodontal Examination By The Orthodontist
 Periodontal Probing ( Periodontal Screening and Recording):
 Rapid and effective
 Common areas for periodontal disease in adults are found in the upper molar
interproximal regions, buccal furcations, and in the lower canine/lateral area,
especially in patients with crowding.

8. Periodontal Examination By The Orthodontist

9. Periodontal Examination By The Orthodontist
 Attached Gingiva:
 The width of gingiva can be measured with a probe.
 Areas with less than 2 mm of gingiva will require further evaluation by a periodontist.
 Light finger touch in the vestibule and ruffle the mucosal tissue.

10. Periodontal Examination By The Orthodontist
 Attached Gingiva:

11. Periodontal Examination By The Orthodontist
 Radiographs:
 Panoramic radiographs are not as diagnostic as a vertical bitewing radiograph for the
evaluation of periodontal osseous lesions.
 A vertical bitewing is more diagnostic and will show the crestal bone more clearly.

12. Periodontal Examination By The Orthodontist
 Parafunction:
 A cursory evaluation of advanced mobility is imperative.
 Clenchers and bruxers can cause extensive osseous breakdown during orthodontic
therapy. These patients may need a biteplate appliance (nightguard).

13. Pre-orthodontic Periodontal Therapy
 Initial phase of periodontal treatment involved the following:
 Home-care program (automatic toothbrush)
 Root planing and subgingival debridement
 Antibiotic, then evaluation can be done a few months (3 months ) after initial
debridement

14. Pre-orthodontic Periodontal Therapy
Pre-orthodontic
Gingival Surgery
Pre-orthodontic
Osseous Surgery
Gingiva
Grafting
Gingival
Recession and
Root Coverage
Osseous
Craters
Hemiseptal
Defects
Three-Wall
Infrabony
Defects
Furcation
Defects
Root
Proximity

15. Pre-orthodontic Gingival Surgery
Gingiva
Grafting
 Teeth with less than 2 mm of gingiva may require grafting
 Some factors that need to be considered in making this decision:
 Teeth that will be proclined orthodontically have a greater risk of
recession.
 Teeth with prominent roots have a higher incidence of recession.
Pre-orthodontic
Gingival Surgery

16. My patient

17. Pre-orthodontic Gingival Surgery
Gingival
Recession and
Root Coverage
 Gingival Grafting were the traditional methods for root coverage.
 Connective tissue graft has become the treatment of choice to cover
denuded roots.
Greater degree of root coverage, more esthetic and less traumatic
The decision to perform a root coverage procedure is based on esthetics,
tooth sensitivity and the patient's wishes
Pre-orthodontic
Gingival Surgery

18. Pre-orthodontic Gingival Surgery
Gingival
Recession and
Root Coverage
 The decision to perform a root coverage procedure is based on esthetics,
tooth sensitivity and the patient's wishes
Pre-orthodontic
Gingival Surgery
For cosmetic reasons  after orthodontic treatment
Recession and inadequate gingiva  before or during orthodontic treatment

20. Pre-orthodontic Osseous Surgery
Pre-orthodontic
Osseous Surgery
Osseous
Craters
An interproximal two-wall defect .
Will not improve with orthodontic treatment.
Can easily be eliminated by reshaping the defect and reducing the
pocket depth.

22. Pre-orthodontic Osseous Surgery
Pre-orthodontic
Osseous Surgery
Three-Wall
Infrabony
Defects
 They are amenable to pocket reduction with regenerative periodontal
therapy .
 Bone grafts along with the use of membranes (resorbable or non
resorbable have been very successful in filling three-wall defects.
 If the patient remains periodontally stable over the next 3- 6 months, the
orthodontic phase of therapy can be initiated.

23. Pre-orthodontic Osseous Surgery
Pre-orthodontic
Osseous Surgery
Three-Wall
Infrabony
Defects
 Bone grafts:
a) Autograft (autogenous)  same person
b) Allograft  another person
c) Xenograft  animal
d) Alloplast  artificial ( synthetic)

25. Pre-orthodontic Osseous Surgery
Pre-orthodontic
Osseous Surgery
Hemiseptal
Defects
 One to two wall osseous defects.
 Around mesially tipped teeth or teeth that have supererupted.
 Can be eliminated with appropriate orthodontic treatment.
 Intrusion and leveling of the adjacent cementoenamel junctions (CEJs) can help level
the osseous defect.
 Should be stabilized for at least 6 months and reassessed periodontally.

27. Pre-orthodontic Osseous Surgery
Pre-orthodontic
Osseous Surgery
Furcation
Defects
Incipient ( Class I )
Osseous
surgical
correction

28. Pre-orthodontic Osseous Surgery
Pre-orthodontic
Osseous Surgery
Furcation
Defects
Moderate ( Class II )
Grafting and
regenerative
therapy with
barrier membranes

29. Pre-orthodontic Osseous Surgery
Pre-orthodontic
Osseous Surgery
Furcation
Defects
Advanced ( Class III )
 Root amputation.
 The most favorable
root to remove is the
distobuccal root of
an upper molar.
Open-flap-curettage ,
through and through
furcation  for easier
cleaning, hemisection,
or even extraction
Lower arch
Upper arch

30. Pre-orthodontic Osseous Surgery
Pre-orthodontic
Osseous Surgery
Root
Proximity
Root proximity can be exacerbated when a molar supererupts.
Can be corrected by orthodontic treatment without periodontal surgery.
Anterior root proximity Upper posterior teeth
 Easier to maintain due to access and
narrower buccolingual width of alveolus
 Difficult to maintain due to difficult access
for home care and broader buccolingual
width of alveolus.
 These areas more prone to osseous
breakdown

31. Orthodontic treatment of
periodontal defect
The position of the bracket is usually
determined by the bone level .
In a periodontally healthy
individual,
The position of the bracket is usually
determined by the anatomy of the
crown of the tooth.
In a patient with advanced horizontal bone
loss
The bone level may have several millimeters
and the crown to root ratio will become less
favorable.

32. Orthodontic treatment of periodontal defect
If bone level is oriented in the same direction as the
marginal ridge discrepancy
leveling the marginal ridges will level the bone.
If the bone is flat and a marginal ridge discrepancy
Equilibrate the crown of the tooth. the orthodontist
should not level the marginal ridges because it will
produce Hemiseptal bone defect and periodontal
pocket between the 2 teeth.
If discrepancy is between both the marginal ridges and
the bone levels
Level the bone orthodontically and equilibrate any
remaining discrepancies between the marginal ridges.
This will produce the best occlusal result and improve
the periodontal health
Hemiseptal Defects

33. Orthodontic treatment of periodontal defect Furcation Defects
 Patient with a Class III furcation defect requiring hemisection
If the roots of the teeth will NOT be moved apart
perform the orthodontic treatment first
After orthodontics, endodontic therapy must be performed.
Following this, periodontal surgery is necessary to divide the
tooth.

34. Orthodontic treatment of periodontal defect Furcation Defects
 If a patient with a Class III furcation defect will be undergoing
orthodontic treatment
If the roots will be moved apart during orthodontic treatment.
Hemisecting the tooth, endodontic therapy, and periodontal surgery
must be completed before the start of orthodontic treatment
After these procedures have been completed, the orthodontist may
place bands or brackets on the root fragments and use a coil spring to
separate the roots.

35. Orthodontic treatment of periodontal defect Furcation Defects
In some molars with a Class III furcation, the
tooth will have short roots, advanced bone
loss, fused roots
It may be more advisable to extract the tooth
with a furcation defect and place an implant
Timing of implant placement
If implant will be used as an anchor to facilitate
orthodontic treatment
The implant must remain embedded in the bone for 6
months before it can be loaded as an orthodontic
anchor.
If the implant will not be used as an anchor for
orthodontic movement
The implant may be placed after the orthodontic
treatment has been completed.

36. Orthodontic treatment of periodontal defect Root Proximity
 Areas of root proximity are difficult for the patient to clean.
 Can be corrected with appropriate orthodontic treatment without
periodontal surgery.
 Leveling the bone, opening up the embrasure space and unraveling
the rotated teeth
 Place the brackets  so with the initial archwires  roots will be
separated
 Radiographs will be needed to monitor the status.
 The crowns may develop an unusual occlusal contact with the
opposing arch  This should be equilibrated to improve the
occlusion.

37. Orthodontic treatment of periodontal defect Hopeless Teeth
Patients with advanced
periodontal disease may have
hopeless teeth
Normally would be extracted
before orthodontics
If these teeth can be useful for
orthodontic anchorage
Extraction is delayed
Three months periodontal recall Is imperative during this process
After orthodontic treatment 6 months period of stabilization
before reevaluating the periodontal
status

38. Post-orthodontic Periodontal Treatment
After orthodontic treatment, the patient should remain on a 3 month periodontal maintenance program.
A nightguard is indicated to control parafunction and can also be used as a post-orthodontic retainer.
Occlusal adjustment to diminish any fremitus from lateral interferences
Take a new set of periapical radiographs.
It takes at least 6 months after band removal for adequate bone remodeling and cessation of mobility.

39. Post-orthodontic Periodontal Treatment
After orthodontic treatment, the patient should remain on a 3 month periodontal maintenance program.
A nightguard is indicated to control parafunction and can also be used as a post-orthodontic retainer.
Occlusal adjustment to diminish any fremitus from lateral interferences
Take a new set of periapical radiographs.
It takes at least 6 months after band removal for adequate bone remodeling and cessation of mobility.