Periodontal changes in ortho treatment/certified fixed orthodontic courses by Indian dental academy


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Periodontal changes in ortho treatment/certified fixed orthodontic courses by Indian dental academy

  1. 1. Periodontal changes in orthodontic treatment INDIAN DENTAL ACADEMY Leader in continuing dental education
  2. 2. Introduction The goal of orthodontic treatment is not only to improve facial esthetics and function but also to address to the health of supporting structures and how teeth are placed in them. No matter how talented the orthodontist is, a magnificent orthodontic correction can be destroyed by failure to recognize periodontal susceptibility. Both the short and long term successful outcomes of orthodontic treatment are influenced by the patient’s periodontal status before, during and after active orthodontic therapy, which also includes post treatment maintenance by the patient.
  3. 3. Periodontal pathogenesis is a multifactorial etiologic process and the orthodontist must recognize the clinical forms of inflammatory periodontal diseases. Co-operation between different specialties in dentistry is extremely important in establishing diagnosis as well as in treatment planning. One such interaction exists between orthodontics and periodontics. The interrelationship between orthodontics and periodontics often resembles symbiosis. In many cases, periodontal health is improved by orthodontic tooth movement, whereas orthodontic tooth movement is often facilitated by periodontal therapy.
  4. 4. GINGIVAL AND PERIODONTAL PROBLEMS GINGIVITIS Accumulation of microorganisms around teeth can cause gingival redness, bleeding and edema, changes in gingival morphology, reduced tissue adaptation to the teeth, an increase in the flow of crevicular fluid and other clinical signs of inflammation. Mechanical removal of plaque reduces gingivitis. Removal of supragingival plaque has been shown to have an inhibitory effect on the formation of subgingival plaque.
  5. 5. Gingivitis has been classified as the 1. Initial 2. Early and 3. Established lesions. Only the established lesion can be observed as clinical gingivitis. The important point is that alveolar bone loss has not yet occurred and it is hoped that the lesion can be prevented from spreading onto the surrounding structures. It is therefore crucial to determine the appropriate plaque control intervals for the patient which will prevent bone loss. Pseudo pockets or gingival overgrowth or enlargement of the gingival margin and the papilla, whether it is drug induced or primary plaque related, are exacerbated by poor hygiene.
  6. 6. The risk factors for development of gingivitis include uncontrolled diabetes, pregnancy, systemic illness and poor oral hygiene. Malaligned teeth, rough edges of fillings, unclean oral appliances can irritate the gingiva and increase the risk of gingivitis. Prevention Good oral hygiene is the best prevention against gingivitis because it removes the plaque that causes the disorder. Special appliances and tools may include tooth picks, tooth brushes, flossing techniques, water irrigation or other devices.
  7. 7. PERIODONTITIS: Periodontitis has been defined as an inflammatory disease of specific bacterial origin that progresses with episodic attachment loss of the periodontium. Adult periodontitis is the most common form of Periodontitis. The organisms most often reported to be associated with adult periodontitis are porphyomonas gingivalis, prevotella intermedia and bacteroides forsythus. Prepubertal periodontitis: It is a rare form that appears soon after eruption of primary teeth. It can occur in either the localized or the generalized form.
  8. 8. Localized or generalized juvenile Periodontitis: It occurs in the circumpubertal period. These patients have little plaque and calculus and they respond well to local debridement and supplemental tetracycline therapy. Juvenile periodontitis is characterized by a rapid loss of alveolar bone and periodontal attachment in otherwise healthy adolescents, with onset thought to occur after puberty. It is generally localized to the permanent first molars and incisors, with little gingival inflammation. The correction of malocclusion in juvenile Periodontitis patients after periodontal therapy is a problem if increasing clinical concern, since many teeth with severe alveolar bone loss in these patients can now be treated successfully without extractions.
  9. 9. A general consensus exists that orthodontic treatment has the potential to aggravate preexisting plaque induced periodontal diseases and cause further loss of alveolar bone and attachment. However, it has been demonstrated that if excellent plaque control is achieved during orthodontic treatment, including uprighting and intrusion procedures, then periodontally compromised teeth can be successfully repositioned without further loss of periodontal attachment. The orthodontic patient may be at a greater risk of attachment loss after teeth have become mobile because of tooth movement. The clinical signs of inflammation and tooth mobility must be recognized and controlled during treatment to prevent extensive bone loss.
  10. 10. Periodic monitoring of the periodontal status with probing, microbiologic assessment with immunologic assays, DNA probes and culturing as well as clinical findings are useful in determining scaling intervals, and detecting potential sites for increased risk of attachment loss. These methods may be used to assess the endpoint of the effectiveness of scaling and root planing before orthodontic treatment to ensure that no putative pathogen exists.
  11. 11. Rapidly progressive periodontitis: This occurs commonly in young adults, and the cause of pathogenesis appears to share many of the features of generalized juvenile periodontitis, such as rapid bone loss and depressed neutrophil functions. Refractory periodontitis: This is a disease condition used to define sites present in patients who continue to be infected with periodontal pathogens and who have a high rate of loss of attachment and tooth loss, despite intensive treatment to prevent bone loss.
  12. 12. Periodontitis associated with systemic diseases:  Necrotizing ulcerative periodontitis  AIDS associated  Non AIDS associated  Disorders of neutrophil function  Agranulocytosis  Cyclic Neutropenia  Chediak higashi syndrome  other diseases  Hematologic diseases  Leukemia  Anemia  Histiocytosis X  Metabolic diseases  Gauchers disease  Niemann-pick disease  Connective tissue disorders  Ehler-danlos syndrome  Wegeners granulomatosis  Sarcoidosis  Bone diseases  Hypophophatasia  Paget’s disease  Neoplasms  Benign tumors  Malignant tumors
  13. 13. Basic tooth movements and periodontal changes: Orthodontic treatment is based on the premise that when force is applied to a tooth it is transmitted to the adjacent investing tissues, certain structural alterations take place within these tissues which allow for, and contribute to tooth movement. INTRUSION Intrusion alters the cemento-enamel junction and angular crest relationships, and creates only epithelial root attachment: therefore a periodontally susceptible patient is at greater risk of future periodontal breakdown. Tooth movement, when properly executed, improves periodontal condition and is beneficial to periodontal health. Orthodontic forces, when kept within biological limits, do not induce tissue alterations leading to loss of connective tissue attachment and periodontal pocket formation. The gingiva moves in the same direction as that of tooth intrusion but it moves only by about 60%. Gingival sulcus gets deepened by about 40% of tooth intrusion.
  14. 14. Indications: 1.It is indicated for teeth with horizontal bone loss. 2.For increasing the clinical crown length of single teeth Clark in AJO 1991 studied the effect of intrusion on the micro vascular bed and fenestrae in the apical periodontal ligament of rat molar. They found that the decrease in fenestrae numbers per sq.micrometer of endothelium was most marked in the venous capillaries. With intrusive loading, the small arterial fenestrae population was unchanged. Melsen et al in AJO 1989 found that incisor intrusion in adult patients with marginal bone loss had a beneficial effect where the post treatment radiographs showed positive bone remodeling. They also reported that a new connective tissue attachment can be formed during the intrusion of periodontally involved teeth if gingival inflammation is eliminated and root surfaces are adequately scaled.
  15. 15. Ericsson et al (journal of periodontics 1987) have demonstrated in experimental animals that orthodontic intrusion of teeth can shift supragingivally located plaque to a subgingival location, leading to formation of infrabony pockets and loss of connective tissue attachment. These manifestations appear to be related to the increased accumulation of dental plaque around orthodontic appliances and alterations induced in the microbiological composition of subgingival plaque.
  16. 16. Zachrisson et al in measured the gingival pocket depth during treatment and retention in orthodontic patients treated with edgewise appliance and found that pocket depth increased during tooth movement. They reported that the increase was caused by edematous swelling in the gingiva and by tissue accumulation during tooth movement, not by deepening of the pocket. They found that gingival sulcus deepened with tooth intrusion and the dentoperiosteal fibers and dentogingival fibers were parted from the cementum gradually as the tooth intrusion increased. Melsen et al in AJO 1986 studied the tissue reaction related to orthodontic intrusion of teeth and the influence of oral hygiene on this reaction. They found that alveolar bone height was maintained during intrusion. Intrusion can therefore constitute a reliable therapeutic method in the orthodontic treatment of adult patients with a healthy periodontal condition. Intrusion of teeth does not result in a decrease in marginal bone level in periodontally healthy patients provided gingival inflammation is controlled.
  17. 17.
  18. 18. Since orthodontic movement of teeth into inflamed infrabony pockets may create an additional periodontal destruction, and because infrabony pockets are frequently found at teeth that have been tipped or elongated as a result of periodontal disease, it is essential that periodontal treatment with elimination of the plaque induced lesion be performed before the initiation of orthodontic treatment. Maintenance of excellent oral hygiene during the course of treatment is equally important.
  19. 19. EXTRUSION Extrusion or eruption of a tooth or several teeth, along with reduction of the clinical crown height is reported to reduce infrabony defects and decrease pocket depth even causes formation of new bone at the alveolar crest as the tooth erupts, with no occlusal factor present. Raymond yukna et al in AJO 1985 in animal experiments studied the effects of extrusion of single rooted teeth with advanced periodontal disease. Extruded teeth had shallower pocket depths, less gingival inflammation, and no bleeding on probing. Early in the extrusion process, the teeth appeared to be avulsed, with more than three fourths of the root coronal to the alveolar crest. After stabilization, approximately 2 mm of new bone was seen coronal to the original alveolar crest, and the periapical areas had filled in with bone. The extruded teeth had an intact attachment apparatus.
  20. 20. The improved periodontal condition resulting from extrusion may have been due to both physiologic and microbiologic changes in the local environment. The subgingival microbial plaque may have been converted to a supragingival plaque by the extrusive tooth movement, thereby lessening its pathogenicity and effect on gingival tissues. This is the reverse finding of Ericsson et al who reported that orthodontic treatment which involves intrusion of a tooth in a plaque infected dentition may shift a supragingivally located plaque into a subgingival location. Marc et al in J. of periodontology 2000 studied the periodontal health of orthodontically extruded impacted teeth. Most impacted teeth were extruded after minor periodontal surgery. They found no difference between test and control teeth, except gingival width, which was 1 mm larger for the spontaneously erupted teeth. This study demonstrated that orthodontic extrusion of impacted teeth does not jeopardize their periodontal health
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  22. 22. FORCED ERUPTION: It helps to save an isolated tooth in which caries, trauma, or iatrogenesis have destroyed the clinical crown by bringing the fractured, diseased or prepared margins of the neck of the tooth more coronally to reestablish biological width. Although forced eruption is associated with an increase in the width of attached gingiva, mucogingival junction remains unaltered. Fibrotomy, which is done before active eruption, is essential for success of the procedure. For shallowing out of isolated intraosseous defects. Increase clinical crown length of single teeth.
  23. 23. Forced eruption was first introduced by Ingber in 1974 for the treatment of one walled and two walled defects. Extrusion results in a coronal position of the connective tissue attachment and the bony defect are shallowed out. Because of extrusion, the tooth is in supraocclusion and will need to be shortened. During the elimination of an intraosseous defect by means of extrusion, the relationship between CEJ and the crest of alveolar bone is maintained. When the goal of treatment is to extrude the tooth out of periodontium as required during crown fractures, extrusion has to be combined with fibrotomy. The supporting soft tissue structures will also follow the bone during extrusion without fibrotomy. Kajiyama et al in AJO 1993 found that in experimental animals, the free gingiva moved about 90% and the attached gingiva about 80% of the extruded distance. The width of the attached gingiva and the clinical crown length increased significantly whereas the position of the mucogingival junction remained unaltered.
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  25. 25. ROTATION Relapse tendencies exist in a fairly high percentage of treated malocclusion and it is greatest for rotation corrections. The fibrous elements of the periodontal ligament adapt to tooth movement in possibly 2 mechanisms: 1.Progressive osteogenic and cementogenic activity plays an active role in the shortening of the extended fibers during tooth movement. 2.The stretching of the wavy collagen fibers and reorientation of their directional morphology permits a certain amount of tooth movement. Brauer et al found that transsecting the supracrestal fibers with vertical incisions mesial and distal to the rotated teeth may reduce the danger of relapse. He reported a significant reduction in relapse after an initial retention of 4-8 weeks. Edwards et el in AJO 1970 concluded that a simple surgical method of severing all supracrestal fiber attachment of a rotated tooth can significantly alleviate relapse following rotation, without apparent damage to supporting structures of the
  26. 26. SPACE CLOSURE: Wennstrom et al in AJO 1993 evaluated in animal experiments the effect of orthodontic tooth movement on the level of the connective tissue attachment in sites with infrabony pockets. They found that orthodontic movement of teeth into infrabony pockets may be detrimental for the periodontal attachment when realignment of teeth that have been tipped and/or elongated as a result of periodontal disease is considered. Hence periodontal treatment directed at elimination of the plaque-induced lesion should precede the initiation of orthodontic therapy and proper oral hygiene maintained during the course of orthodontic treatment.
  27. 27. Tulloch et al in AJO 1983 undertook a study to determine the incidence and possible association of gingival invaginations seen during space closure with gingival health and stability of extraction-space closure. An infolding or invagination of gingival tissue commonly forms during the orthodontic approximation of teeth. The clinical appearance of these invaginations ranges from a minor one-surface crease in the attached gingiva to a deep cleft that extends across the interdental papilla from the buccal to the lingual alveolar surface. The precise cause of these invaginations remains unclear. The study revealed that Gingival invaginations occur commonly during orthodontic treatment that involves first premolar extraction and space closure. Although they may decrease in size or even resolve, many invaginations persist for years after treatment.
  28. 28. Invaginations are more common, complex, severe, and persistent in the mandibular arch than in the maxillary arch. Their formation is not related to the width of the attached gingiva, canine inclination, or overall gingival health. Gingival invaginations do not seem to be associated with extraction space reopening. The presence, severity, and complexity of invaginations appear to impair the patient's ability to maintain adequate gingival health in the extraction area.
  29. 29. According to Rönnerman et al AJO 1980, one cause of relapse after orthodontic space closure has been related to the compression of the transseptal fibers and their general toughness and resistance. The reason for relapse may be an increased appearance of glucoseaminoglycans in the intercellular substance of the connective tissue. Such substances may cause a very elastic gelatinous tissue, facilitating relapse after the orthodontic closure of the extraction site. After orthodontic closure of an extraction site with a fixed appliance, the gingival tissue as a rule becomes hyperplastic when the space diminishes. The teeth that are moved together thereby push the gingiva in front of them, and a fold or invagination of epithelium and connective tissue is formed. Edwards has recommended surgical removal of the excess gingival tissue that appears in papillary form buccally and lingually between the teeth that have moved
  30. 30. Traumatic occlusion and orthodontic treatment Studies indicate that traumatic occlusion forces 1. do not produce gingival inflammation or loss of attachment in pts with healthy periodontium not aggravate and cause spread of gingivitis 3.May aggravate an active periodontitis lesion i.e. may be a co- destructive factor 4.May lead to less gain of attachment after periodontal treatment. Some studies conclude that occlusal adjustments should be carried out in the evidence of trauma after the control of inflammation
  31. 31. Burgett et al in J. of periodontology have demonstrated that there is a significant gain in attachment in patients who received occlusal adjustment as part of treatment plan. 1.The importance of reducing jiggling of teeth after orthodontic treatment of patients with moderate or advanced periodontitis may be significant 2.Studies demonstrate that bone dehiscences caused by jiggling forces will regenerate after elimination of trauma. 3.Occlusal adjustments may be a factor in the healing of periodontal defects, especially bone defects.
  32. 32. PERIODONTAL CONSIDERATIONS IN SURGICAL EXPOSURE: It is often seen that teeth have a delayed eruption and at times do not erupt at all. In such conditions, management of the periodontal tissues is very much vital. According to the current concepts, electro surgery or lasers should be avoided for such cases, but their use could be restricted towards removing the overlying tissue. Prato et al in J. of periodontology 2000 compared the width of keratinized gingiva after orthodontic therapy for buccally erupting premolars that had been pretreated by extraction of deciduous teeth alone versus interceptive mucogingival surgery. It was noted that there was no significant difference in the mean width of keratinized tissue at the start of treatment.
  33. 33. By the end of treatment, mean width at the site where mucogingival surgery was performed was found to be significantly higher (2.3 mm) than the site where extraction alone was performed (1.3 mm). This proved conclusively that mucogingival surgery was an effective technique to maintain keratinized tissue in correspondence with buccally erupted teeth. Mucogingival interceptive therapy in patients with buccally erupting teeth is performed to prevent the ectopic permanent tooth from developing periodontal lesions. Christina Hansson et al in angle 1998 reviewed the periodontal status of patients who had unilateral palatal impacted canines and their adjacent incisors 1-18 years post treatment. The results showed greater mesial probing depth of the canines on the treated side, on the adjacent lateral incisors distolingually, and on the first premolars mesiolingually. In general, the results showed a good gingival and periodontal status with slight differences between treated and untreated sides.
  34. 34. Kohavi et al in AJO 1984 found that the extent of surgical exposure and the degree of orthodontic force had a definite impact in the loss of bone support of teeth. He studied the consequences of surgical exposure for the purpose of effecting orthodontic treatment. Patients who had been treated orthodontically for unilateral impaction of maxillary canine were studied. No significant difference was found in light and heavy exposure group as far as plaque index, gingival index and pocket depth was concerned. Bone loss was found to be greater for heavy exposure group. The most serious damage in the treatment of a palatally impacted tooth is the result of surgical intervention that exposes the buried tooth to beyond CEJ and will express itself in the form of loss of bone support.
  35. 35. MUCOGINGIVAL PROBLEMS  Mucogingival deformities in children and adults have been described as recession, gingival clefts and localized pathologic recession. Inadequate keratinized gingiva, minimal attached gingiva, coronally attached frenal and muscle attachments, abnormal tooth position, fenestrations or bony dehiscence in the alveolus and other factors have been predisposing and etiologically related pathosis.
  36. 36. Etiologic factors for recession Factors that may be etiologic or predisposing to mucogingival problems of the mandibular incisors may be developmental or acquired. ( Geiger AJO 1980)  Developmental 1.ectopic tooth bud development and eruption 2.inadequate arch length with crowding and rotation 3.excessive labial inclination 4.fenestration of labial alveolar bone 5.coronally positioned frenal and muscle attachments Acquired 1.plaque and salivary accretions 2.chronic inflammatory gingivitis 3.magnitude and direction of orthodontic forces 4.functional malocclusion
  37. 37. When a mandibular incisor is lingually displaced, the alveolar bone housing is extremely thin on the lingual aspect and quite thick on the labial aspect. In such cases, excessive labial tipping may result in further lingual movement of root apex, which may fenestrate the lingual plate. The ability to torque such teeth is limited. The direction of tooth movement should be away from the thin attachment apparatus. When such movement is possible, an increase in attached gingiva may occur. Mandibular incisors that have a marked labial inclination may also have a thin alveolar bone. The anterior thrust of class II elastics might cause breakdown of the fragile gingival attachment. In some cases, teeth which initially exhibited some localized pathologic recession may show no loss of attachment despite the prolonged use of class II elastics. This suggests that destruction may not be predictable despite the application of some degree of labial force and that only the prevention of gingival inflammation may be critical.
  38. 38. Abnormal frenal and muscle attachments Abnormal frenum and muscle pull has been considered detrimental to periodontal health by pulling away the gingival margin from the tooth contributing to accumulation of plaque and calculus, and leading to inflammation and pocket formation. Adequate depth of the vestibule has been similarly held significant. Several surgical procedures to deepen the vestibule as well as to reduce the height of frenal attachments have been developed as preventive therapeutic measures. Occasionally in the developing dentition, abnormal frenal or muscle attachments may extend onto the crest of the alveolar ridge. The erupting tooth may pass through the alveolar gingiva and be deficient in keratinized tissue. Surgical recession will ensure normal eruption of the tooth with adequate attached gingiva.
  39. 39. Fan shaped frenal attachment
  40. 40. Orthodontic force and labial recession: Teeth having adequate attached gingiva occasionally develop localized recession during treatment. It has generally been assumed that such destruction has been associated with excessive force that has not permitted repair and remodeling of alveolar bone. It is more likely that the direction and extent of tooth movement have forced the tooth through the cortical plate. This concept is supported in cases of severe gingival recession consequent to tooth movement, in which remaining gingival attachment appears relatively free of inflammation. Such sequelae may be readily explained if the direction of tooth movement has been towards areas of attachment deficiency. When adverse forces and local factors do not exist, however, the prior presence of an unseen dehiscence should be suspected. Chronic marginal gingivitis may rapidly destroy the marginal alveolar bone and gingival attachment during the application of modest forces normally well tolerated by the
  41. 41. Mandibular incisors with minimal attached gingiva may be particularly susceptible to the adverse effect of a cross bite or an edge to edge occlusion. If the resulting occlusal forces are in the direction of the inadequate gingival attachment, they may accentuate the destructive capacity of the inflammatory process and crestal alveolar bone may be lost. If the destruction of the gingival attachment has resulted in deep gingival cleft with denudation of half the length of the root, tooth movement may at best prevent further destruction. If a gingival graft becomes necessary, the new environment provided by tooth alignment will enhance the surgical repair. Areas of minimal attached gingiva with good alignment may only require frequent maintenance visits.
  42. 42. Sabine Ruf et al in AJO 1998 studied the effect of orthodontic proclination of lower incisors in children and adolescents on the possible development on gingival recession. Either no recession developed or preexisting recession remained unchanged during herbst therapy. No interrelationship was found between the amount of incisor proclination and recession. Artun and Kronstad in AJO 1987 found that gingival recession in adults developed mostly during the active phase of orthodontics and the first 3 years after appliance removal. Later only negligible recession took place. Melsen et al in EJO 2003 studied the influence of labial movement of lower incisors on the gingival margin. They found that controlled proclination under maintenance of good oral hygiene can be carried out in periodontally healthy patients without any risk to the periodontium. New recessions and dehiscences developed in 10% of the sample patients.
  43. 43. Vardimon et al in J. of periodontics 2001 found that orthodontic tooth movement is a stimulating factor of bone apposition. Conversion in repair pattern was seen which supported the link between tooth movement and enhanced bone deposition. Clinical implication suggests incorporation of orthodontic tooth movement in regenerative therapy. Handelmann et al in Angle 2000 in a review of non surgical RPE cases have shown that buccal attachment loss was not statistically significant for males when the adult expansion group was compared to the adult control group. The average increase in crown length was 0.5 mm. They suggested that patients who demonstrated the largest increase in gingival recession following RME would be the oldest, those who had the greatest maxillary transarch deficiency, those with the greatest amount of transarch expansion, and those who initially had the longest crown heights.
  44. 44. Interdental recession: Causes of open gingival embrasures Severely malaligned maxillary incisors Dimensional changes in the interdental papilla Location and size of interproximal contact. divergent root angulation Triangular shaped crowns. Interdental recessions manifest as dark triangles between teeth. Main indication of correction of interdental recession is esthetics.
  45. 45. Options available for treatment of interdental recessions are mucogingival surgeries with coronally positioned grafts and GTR provision of gingival prosthesis orthodontic paralleling of the roots of neighboring teeth mesiodistal enamel reduction The principle involved in stripping is to recontour the teeth which have an abnormal shape. By this procedure, a good occlusion with optimal tooth contact point relationships and normal interdental gingival papillary contours will be achieved. When crowding is unraveled in orthodontic patients, the contact points are located in the incisal thirds. The amount of tooth material to be removed by enamel reduction will be around 0.5-0.75 mm. After diastema is created, the space is closed orthodontically. As this takes place, roots of neighboring teeth come closer and the contact point is lengthened and the reduce papilla can fill the embrasure.
  46. 46.  Kokich et al AJO 2001 determined the prevalence of posttreatment open gingival embrasures in adult orthodontic patients. A posttreatment alveolar bone– interproximal contact distance greater than 5.5 mm was associated with open gingival embrasures. Short and more incisally positioned posttreatment interproximal contacts were associated with open gingival embrasures. An increase in Interproximal contact–incisal edge distance by 1-mm increased the chances of an open gingival embrasure by 78% to 97%.
  47. 47.
  48. 48.
  49. 49. PERIODONTAL SURGICAL PROCEDURES: GINGIVAL CURETTAGE: Curettage means scraping of the gingival wall of a periodontal pocket to remove infected and necrotic tooth substance. It removes the inflamed soft tissue lateral to the pocket wall. The aim of curettage is to reduce pocket depth by enhancing gingival shrinkage and new connective tissue attachment. It can be performed as part of new attachment attempts in moderately deep infrabony pockets located in accessible areas where a type of closed surgery is deemed advisable. It can be done as a non definitive procedure to reduce inflammation prior to pocket elimination using other methods or in patients in whom more aggressive techniques are contraindicated. It is also performed on recall visits as a method of maintenance treatment for areas of recurrent inflammation and pocket deepening.
  50. 50. GINGIVECTOMY: Gingivectomy means excision of gingiva. By removing diseased tissue and local irritants, it creates a favorable environment for gingival healing and the restoration of a physiological gingival contour. Indications: Elimination of suprabony pockets, if the pocket wall is firm and fibrous. Elimination of gingival enlargements. Contraindications: When osseous surgery is needed. Bottom of pocket located apical to the mucogingival location. Esthetic considerations, particularly in the anterior maxilla.
  51. 51. According to Kokich et al in Sem. Orthod 1996, the relationship of the gingival margin of the six maxillary anterior teeth plays an important role in esthetic appearance of teeth. In some instances, it may be necessary to increase the clinical crown length of one or several teeth during or after orthodontic treatment. If a gingival margin discrepancy exists and the patient’s lip does not move to expose the discrepancy, then no treatment is required. If the discrepancy is apparent, one of the four possible treatment modalities may be undertaken: Gingivectomy Intrusion and incisal restoration Extrusion with fibrotomy and porcelain crown. Surgical crown lengthening
  52. 52. The Gingivectomy technique is useful in improving orthodontic results, especially in cases with missing maxillary central or lateral incisors, after premolar auto transplantation or in gummy smiles. It is possible to permanently increase the clinical crown length after orthodontic treatment by labial gingivectomy technique. In adult patients with vertical maxillary excess, orthognathic surgery is necessary to correct a gummy smile. In patients with delayed apical migration of gingival margins, usually seen between 12 and 15 years of age, the timing of gingival surgery (before or after orthodontic appliances are removed) depends on the wear at the incisal edges of the central and lateral teeth.
  53. 53.
  54. 54. GINGIVOPLASTY: Gingivoplasty is the reshaping of gingiva to create physiologic gingival contours, for the sole purpose of recontouring the gingiva in the absence of pockets. Gingival and periodontal diseases often produce deformities in the gingiva that interferes with normal food excursion, collect plaque and food debris and aggravate the disease process.
  55. 55. Crown lengthening  A simple localized gingivectomy to the bottom of the clinical gingival sulcus will increase the crown length. As shown in a human experimental model, nearly 50% of the excised tissue will regenerate and become clinically and histologically indistinguishable from normal gingiva. This means, that if a labial probing pocket depth of 4mm is recorded on the cuspid, a gain of 2mm in crown length can be anticipated. Even if the excision is extended into the alveolar mucosa, the coronal part of the regenerated gingiva will still become keratinized. Careful oral hygiene procedures, using single-tufted brushes, are required for two months after the gingivectomy so that the regenerated gingiva will appear entirely normal.
  56. 56. Gingival extension procedures This consists of surgical deepening of the mucogingival line. To prevent the mucogingival line from creeping back coronally, a free mucosal or a gingival autograft obtained from the palate is placed. Free gingival autografts: They are used to create a widened zone of attached gingiva. The donor sites may be attached gingiva, masticatory mucosa, edentulous areas and hard palate. They are also used for the coverage of nonpathologic dehiscences and fenestrations.
  57. 57. FIBROTOMY: Methods to reduce of relapse of orthodontically treated teeth, especially rotated teeth include 1.Complete correction or over correction of rotated teeth. 2.Stable long term retention with bonded lingual retainers. 3.Use of fibrotomy Periodontal fiber bundles that influence stability are the principal fibers of PDL and the supra alveolar fibers. Fibers of PDL remodel completely only after 2-3 months. The supra alveolar fibers are stable and have a slower turnover.
  58. 58. The supra crestal gingival tissues contribute to rotational relapse and hence the technique of ‘Circumferential Supracrestal Fibrotomy’. The transseptal fibers are cut interdentally by entering the PDL space. Clinical healing occurs in 7-10 days The fibrotomy procedure is not indicated during active tooth movement or in the presence of gingival inflammation. When performed in healthy tissues after orthodontics, there is minimal attachment loss. Edwards in AJO 1988 studied the long term effect of fibrotomy. It was found that CSF was more effective in the maxillary anterior than the mandibular arch. It was more effective in alleviating rotational than labiolingual relapse. There was no clinically significant increase in sulcus depth nor any gingival recession that was observed.
  59. 59. FRENOTOMY: Hyperplastic types of frenum with fan shaped attachment may obstruct diastema closure and hence surgical intervention is desirable. In the past frenectomy was undertaken. The complication with frenectomy is that the complete removal of the frenum may result in gingival recession between the central incisors. Hence frenotomy with only partial removal of the frenum with the purpose of relocating the attachment in a more apical direction is currently undertaken. Tissue healing is uneventful although some scarring may occur.
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  61. 61. REMOVAL OF GINGIVAL CLEFTS: Incomplete adaptation of supporting tissues during space closure may result in invaginations or infolding or clefts in the gingiva. A simple removal of only the excess gingiva in the buccal and lingual areas would be sufficient to alleviate the tendency of teeth to separate after space closure.
  62. 62.
  63. 63. DISTRACTION OSTEOGENESIS OF THE PERODONTAL LIGAMENT DO is the process of growing new bone by mechanical stretching of pre existing bone tissue. A new concept of distracting the PDL is proposed to elicit canine retraction in 3 weeks. This is called dental distraction. The PDL acts as a suture between the bone and the tooth. Liou and Huang in AJO 1998 studied patients who needed canine retraction and first premolar extractions in the maxilla and mandible. At the time of first premolar extraction, the interseptal bone distal to canine is undermined grooving vertically inside the extraction socket both buccally and lingually. Activation of 0.5 – 1 mm/day can be carried out immediately after extraction.
  64. 64. It was observed from this study that the periodontal ligament can be rapidly distracted without complications. Changes in the periodontal ligament on the mesial side of the canine can be classified into 1. stretching and widening of the PDL 2. active growth of new bone spicules in the distracted PDL during the second week 3. Recovery of the distracted PDL during the fourth week. 4. remodeling of striated bone from the fourth week to the third month after distraction 5. maturation of the striated bone
  65. 65. ADULT ORTHODONTICS: The changes that are seen in the PDL as a result of ageing are IN GINGIVA Diminished keratinisation Reduced stippling Increased width of attached gingiva Decreased connective tissue cellularity Increased intercellular substance Reduced oxygen consumption Thinning of oral epithelium Atrophy of connective tissue with loss of elasticity
  66. 66. IN PERIODONTAL LIGAMENT Increased elastic fibers Decreased vascularity Decreased mitotic activity An increase in the width of the ligament IN ALVEOLAR BONE AND CEMENTUM Osteoporosis Decreased vascularity Decrease in healing capacity Continuous increase in the amount of cementum
  67. 67. Adult patients present a challenge to orthodontists because they have high esthetic demands and they often have dental conditions that may complicate treatment, such as tooth wear, poorly contoured restorations and periodontal diseases. Advanced periodontal disease may cause pathologic tooth migration involving a single tooth or a group of teeth. The sequelae may be tipping and extrusion of one or several incisors, and development of a single diastema or multiple spacing of the front teeth. In such cases orthodontic treatment may be required for cosmetic reasons to attain an aligned front tooth segment. Artun and Nelson on AJO 1997 found a close relation between age and cumulative loss of attachment. Adult orthodontic patients are more likely to present with periodontal pockets than adolescents. It is thought that age is a predisposing factor for bone loss during orthodontic treatment. Resistance to periodontal breakdown is reduced with age.
  68. 68. adults may be at a higher risk than adolescents for periodontal breakdown during appliance therapy. Mean bone loss in adults not undergoing orthodontic therapy was found to be 0.07-0.11 mm. Bone loss for the average orthodontic patient was found to be 0.31 mm suggesting that adults have an increase rate of periodontal breakdown. Boyd et al in AJO 1989 monitored the periodontal status of 20 adults and 20 adolescents undergoing fixed orthodontic treatment. They found that during the course of fixed orthodontic treatment, 1. Tooth movement in patients with a reduced but a healthy periodontium does not result in significant loss of attachment 2. Tooth loss for periodontal reasons may occur in adults with severely periodontally compromised teeth that have pocket depths greater that 6 mm or advanced furcation involvement.
  69. 69. 3. Adolescents are likely to show significantly more plaque accumulation and gingival inflammation during treatment than adults. Kurashima et al in AJO 1963 reported that the periodontal ligament fibers in an adult are more organized and the normal fibroblast turnover is substantially reduced resulting in alteration of overall elastic properties. It was found that a lower force is desirable for orthodontic tooth movement in adults particularly during the initial application of the load. In periodontally compromised dentitions, the loss of alveolar bone results in the center of resistance of the involved teeth moving apically, and the net effect is that teeth are more prone to tipping than to moving bodily.
  70. 70. CHANGES IN PDL DURING ORTHODONTIC TREATMENT: Yoshiki Nakamura in AJO 1996 studied the degenerating tissue changes in the PDL during tooth movement. There were two types of degenerating tissues found in the compressed periodontal ligaments: 1. type A tissue stained differently from collagen and the other 2. type B tissue showed the same color as collagen. The electron micrograph showed deposition of fibrin in type A tissue. No collagen fibers with typical bandings were seen in either tissue. The results indicated that collagen degradation, fibrin deposition, and calcification occurred in the degenerating tissues, especially in type A tissue during the experimental tooth movement.
  71. 71. Tanaka described histologically and immunohistochemically the degenerating tissues in the periodontal ligament during the tooth movement. That study showed two types of degenerating tissues in the compressed periodontal ligament; a collagenous type and another that was noncollagenous. Reitan in 1957 noted the degenerating tissues in the periodontal ligament on the pressure side during the tooth movement and termed these areas hyalinized tissues because the degenerating tissues usually stained eosinophilically with glass-like structures, with hematoxylin-eosin (H-E) stain.
  72. 72. Occasional periodontal complications may arise during adult orthodontic therapy although they may also be seen in the adolescent patients. Adult patients with pre existing periodontal disease are considered to be at considerable risk during orthodontic treatment. Prior to orthodontic treatment, it is mandatory that periodontal disease be properly controlled with debridement and reinforcement of oral hygiene. Periodontal problems are generally minimal and in frequent in adolescents. Potential benefits of orthodontic treatment: Improved width of attached gingiva especially when moving a labially positioned tooth lingually. Induction of bone formation
  73. 73. Can re-establish biologic width in teeth with subgingival restoration margins by forced eruption. Closure of spaces of extracted teeth may help prevent periodontal disease complications Harmful effects: Gingival and periodontal changes related to orthodontic treatment are, in general, transient with no permanent damage. However, lengthy orthodontic treatment, accompanied with sustained poor oral hygiene leads to gingival and periodontal damage. The deleterious effects include gingivitis, gingival hyperplasia, marginal periodontitis, gingival recession at extraction sites, loss of attachment, interdental clefts, especially at vestibular aspects of extracted mandibular premolars, reduced width of keratinized gingiva, marginal bone loss and apical root resorption.
  74. 74. CHANGES IN PDL FOLLOWING ORTHODONTICS: Periodontal tissues adapt to teeth that are moved orthodontically along the dental arch. Furthermore, experimental studies have shown that orthodontic tooth movements along the arch will not result in loss of periodontal support provided the gingival tissue is kept free of inflammation If the alveolar bone becomes thinned out during orthodontic intervention due to expansion, the gingival tissue may be more susceptible to long-term recession. Årtun and Krogstad in AJO 1987 studied on the periodontal status of mandibular incisors following excessive proclination. They found that development of bone dehiscence and some gingival retraction during excessive proclination of mandibular incisors seem to be inevitable, especially in patients with thin alveolar housing.
  75. 75. Retention of teeth with reduced periodontal support Dentitions with reduced periodontal support show a marked tendency to return to their pretreatment position following active appliance therapy. Thus, semi-permanent or permanent retention may be required. Thin, flexible spiral wire bonded to the lingual surface of each tooth in a segment may represent a simple and effective way of retaining realigned front teeth
  76. 76. Vascular changes in the PDL following force application: Murrel and Yen in AJO sep 1996 studied on the vascular changes in the periodontal ligament after removal of orthodontic forces. The pattern of blood vessel distribution in the periodontal ligament was likely affected by changes in the direction of tooth movement produced by the application and removal of the orthodontic force. Changes in blood vessel number and density were associated with the direction of tooth movement. The periodontal vascular distribution and density was summarized as follows: 1. increased after application of orthodontic force, 2. transient decrease subsequent to removal of force, 3. transient increase during reactivated distal drift, and 4. normalization. Normalization was achieved during an interval equivalent to the duration of orthodontic force, suggesting that the vasculature could be a factor in production of tissue forces resulting in relapse of relocated teeth.
  77. 77. Long-term effects of orthodontic treatment on periodontal health: Sadowsky and BeGole in AJO 1981 evaluated the periodontal health of a large group of patients who had received comprehensive orthodontic treatment during adolescence at least 12 years previously and compared the periodontal health of this group with that of a group of similar adults who had malocclusions that had not been orthodontically treated. The findings were: While no differences were observed in the prevalence of moderate to severe periodontal disease, the orthodontic group manifested a greater prevalence of mild to moderate periodontal disease than the control group in the maxillary posterior and mandibular anterior regions of the mouth.
  78. 78. 2. A greater prevalence of mild to moderate periodontal disease was found in the posterior regions of the mouth in those orthodontic patients whose treatment included extractions than in those treated without extractions. Polson in AJO 1988 evaluated the clinical periodontal status of persons who had completed orthodontic therapy at least 10 years previously and compared the findings to those of adults with untreated malocclusions. The comparisons showed no significant differences between the groups for any of the periodontal variables. It was concluded that orthodontic treatment during adolescence had no discernible effect upon later periodontal health.
  79. 79. Zachrisson suggested that a relationship may exist between orthodontic therapy and conversion of gingivitis into periodontitis— for example, orthodontic bands may increase subgingival plaque retention. Furthermore, orthodontic movement resulting in tooth intrusion may shift supragingival plaque into a subgingival location and predispose toward destructive periodontitis. Long-term effect of root proximity on periodontal health after orthodontic treatment were studied by Årtun and Kokich in AJO 1987. No statistically significant differences in inflammation, level of attachment, and bone level were observed between root proximity sites and control sites. The results indicate that anterior teeth are not predisposed to more rapid periodontal breakdown when roots are in close proximity.
  80. 80. Preventive program for orthodontic patients Before orthodontic treatment: control active periodontal disease and caries Risks of treatment have to be explained to the patient. Awareness of the existing problem and the possible complications that may arise during treatment must be explained. During orthodontic treatment: Emphasis on oral hygiene. brushing instructions. check plaque removal effectiveness periodic periodontal evaluation and check up After orthodontic treatment Patient must be motivated to maintain good oral hygiene. Maintenance of routine dental check ups.
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