This document discusses interdisciplinary periodontics and covers several topics: - The periodontic-endodontic relationship, including pathways of communication between tissues and classification of endo-perio lesions. - The prosthodontic-periodontic relationship and biological considerations like the concept of biological width. - The orthodontic-periodontal relationship and how orthodontic treatment can affect periodontally compromised patients. - It provides details on the diagnosis, characteristics, and treatment planning of different types of endo-perio lesions. Guidelines are presented for margin placement and preventing biological width violation in restorative treatments.

1. Interdisciplinary
Periodontics

2. CONTENTS
 Introduction
 Periodontic-endodontic
interrelationship
 Pathways for communication
between endodontic & periodontal
tissues
 Etiological & contributing factors
 Pathogenesis of endo-perio lesion
 Classification of endo-perio lesion
 Diagnosis
 Lesion characteristics &
diagnostic features of endo-perio
lesions
 Treatment plan
 Prosthodontic- Periodontic-
Restorative interrelationship
 Biologic consideration
 Soft tissue consideration
 Prosthetic consideration
 Special restorative consideration
 Sequence of treatment in preparing
periodontium for restorative
dentistry
 Orthodontic-periodontal
inter-relationship
 Objectives of orthodontic treatment in
periodontally compromised patients.
 Molecules involved in bone remodelling.
 Sequence of events after force
application.
 Sequence of orthodontic treatment in
periodontally compromised patients.
 Tooth movements in periodontally
compromised patients.
 Periodontal surgery for orthodontic
patients.
 Conclusion

3. Introduction
 Interdisciplinary approach in dentistry can be described as the mutual consideration of various dental specialities
accompanied by expansion of the scope of each to produce a synergistic effect on treatment which provides the best
quality of care to the patient.
 Understanding the challenges in diagnosis, treatment and prognosis of combined lesion is crucial to achieve
successful clinical outcome.

4. Periodontic-endodontic interrelationship
Endodontic lesion
An inflammatory process resulting
from noxious agents present in the
root canal system of the
tooth.[Carranza 10th ed.]
Simring & Goldberg 1964
Periodontal lesion
Inflammatory process resulting from
accumulation of dental plaque on the
external tooth surface.
[Carranza 10th ed.]

5.  Developmental origin
a. Apical foramen
b. Accessory canals and lateral canals
c. Congenital absence of cementum
exposing the dentinal tubules at the
cervical region of teeth.
d. Permeability of cementum
e. Developmental grooves
f. Enamel projection and enamel pearls at
the cervical area.
 Pathological origin
a. Empty spaces on the root created
by the destruction of sharpies
fracture.
b. Vertical fibers
c. Idiopathic resorption-internal
and external
d. Loss of cementum due to
external irritants.
 Iatrogenic origin
a. Exposure of dentinal tubules
following root planning.
b. Accidental lateral perforation
during endodontic procedure
c. Root fracture due to
endodontic procedure
[Rotstein et al.,2017]
Pathways for communication between endodontic &
periodontal tissues

6. Etiological & Contributing factors
* Poor endodontic treatment
* Coronal leakage
* Trauma
* Root resorption
* Perforations
* Development malformation
* Cracked tooth syndrome
Contributing factors
o Anaerobic bacteria(>90%)
o Facultative anaerobes
o Rarely aerobes
o HSV
o HCV
o EBV type I
o Extrinsic and intrinsic
agents
Etiological factors
[Rotstein et al.,2017]

7. Etiopathogenesis of endo-perio lesions
 The bacterial profile of endo-perio lesion consisted of Actinobacillus actinomycetemcomitans, Bacteriodes
forsythus, Eikenella corrodens, fusobacterium Nucleatum, P. gingivalis, Prevotella intermedia, treponema
denticola. [Merte K et al., 2000].
 Periodontal pocket exhibited a great variety of species while root canal was limited to gram positive cocci-
peptostreptococcus, and streptococcus or gram positive rods such as actinomyces and Rothia. [Kurihara et al.,
1995].
 Fungi isolated mainly includes candida albicans. Other species are candida glabrata, candida guillermondii,
candida incospicia, rodotorula mucilaginosa.
 Herpes viral infection accelerate tissue destruction due to viraly mediated release of cytokines, chemokines
from inflammatory and non-inflammatory host cells. Other viruses isolated include HSV, HCV, EBV.[Slots J
et al., 2003]

8. Pulpal inflammation
Localized edema,
increase in intra pulpal pressure
Cell death
Inflammatory exudate
Local collapse of venous part
Tissue hypoxia and anoxia
Localised necrosis
Retrograde periodontitis
Endo-perio lesion
Spread of inflammation from dental pulp to periodontium [Gait TC et al., 2013]

9. Periodontal pocket
Attachment loss
Fibrosis, calcification, collagen resorption
Involvement of apical foramen
Retrograde pulpitis
Endo-perio lesion
Spread of inflammation from periodontium to dental pulp [Gait TC et al., 2013]

10. Endo-Periodontal lesions classification
[Simon JH et al., 1972]
Type I: Primary
endodontic lesion
Originally endodontic
problem that extends
from the periapical
foramen or accessory
foramen into the
periodontium.
Type II: Primary endo
and secondary perio
A long standing
endodontic lesion may
result in secondary
involvement of the
periodontium.
Type III: Primary
periodontal lesion
A periodontal pocket
may extend up to the
apex of the tooth,
resulting in
endodontic
involvement.
Type IV: Primary
perio and secondary
endo
Periodontal pocket can
infect the pulp of the
tooth that results in
formation of periapical
lesion.
Type V: True combined lesion
Periodontal and endodontic
lesions develop independently
And join together.

11.  Based on lesion origin [Guldener et al.,
1982].
 Primary endodontic
 Primary periodontal
 Combined periodontal-endodontic lesions
 Periodontitis associated with endodontic
disease [Classification of periodontal diseases
1999].
 Endodontic-periodontal lesion
 Periodontal-endodontic lesion
 Combined lesion
 Based on existing periodontal defect
[Torinejad et al., 1996].
 Lesion of endodontic origin
 Lesion of periodontal origin
 Lesion of combined periodontal endodontic
origin
 Based on the primary disease with its secondary
effect [Khalid et al., 2014].
 Retrograde periodontal disease
• Primary endodontic lesion with drainage through the
periodontal ligament.
• Primary endodontic lesion with secondary periodontal
involvement.
 Primary periodontal lesion
 Primary periodontal lesion with secondary endodontic
involvement.
 Combined endodontic-periodontal lesions.
 Iatrogenic periodontal lesions.

12. Endo-periodontal lesions with root damage
Root fracture or cracking
Root canal or pulp chamber perforation
External root resorption
Endo-periodontal lesions without root damage
Endo-periodontal lesions in
periodontitis patients.
Grade 1- narrow deep periodontal
pocket in 1 tooth surface.
Grade 2- wide deep periodontal pocket
in 1 tooth surface.
Grade 3-deep periodontal pockets in
more than 1 tooth surface.
Endo-periodontal lesions in
non-periodontitis patients.
Grade 1-narrow deep periodontal
pocket in 1 tooth surface.
Grade 2- wide deep periodontal pocket
in 1 tooth surface.
Grade 3-deep periodontal pocket in
more than 1 tooth surface.
[Herrera et al., 2018]

13. Primary endodontic lesion (Type I)
 Results from necrotic degeneration of pulp, extending apically resulting in apical
periodontitis.
 Drain coronally through pdl into the gingival sulcus.
 Clinical appearance mimics that of periodontal abscess-that is a sinus tract originating
from the pulp that opens into periodontal ligament.

14. Primary endodontic lesion with secondary
periodontal involvement (Type II)
 The endodontic lesion is long standing results in chronic periapical lesion with drainage
through gingival sulcus.
 Draining track from sulcus superimposed by plaque and calculus resulting in pocket
formation.
 Angular bone loss starting from initial site of endo-periodontal communication.
 It may also caused due to root fractures, iatrogenic perforation by improper placement of
pins and post.

15. Primary periodontal lesion (Type III)
 Results from periodontal pocket formation progresses apically to involve dental pulp.
 Pulp test indicate clinically normal pulpal reaction.
 The involved tooth is associated with true periodontal pocket.
 Periodontal treatment resolves the condition and endodontic treatment is not required as
pulp is vital.

16. Primary periodontal lesion with secondary
endodontic involvement (Type IV)
 The tooth is associated with deep periodontal pocket with a history of chronic
periodontal problem.
 Deepened periodontal pocket results in involvement of pulp.
 The microbiota of root canal shows strong correlation with that of periodontal pockets.

17. True combined endodontic and periodontic
lesion (Type V)
 Significant periodontal involvement with considerable attachment loss.
 Two independent lesions merged to form a combined lesion.
 Pulp vitality test indicate pulp necrosis.
 The radiographic appearance of the lesion similar to vertically fractured tooth with a
tear drop bone defect.

18. Diagnosis
1. Visual inspection
2. Palpation
3. Percussion
4. Mobility
5. Radiographs
6. Pulp vitality testing
7. Fistula tracking
[Simon JHS et al., 1980]

19. Lesion characteristics & diagnostic features of endo-perio lesions
Type of Lesion Pain
character
Swelling Pockets Radiographic
features
Tooth Vitality
Primary
endodontic
Moderate to
severe
possible None unless
sinus tract
Possible
periapical
radiolucency
Non-vital
Primary
endodontic
secondary
periodontic
Moderate to
severe
Likely Evident with
sinus tract
Radiolucency
from apex to
sulcus, decreased
crestal bone
height
Non-vital
Primary
periodontic
None to
moderate
Possible Moderate Decreased crestal
bone height
Vital
Primary
periodontic
secondary
endodontic
None unless
acute endo
Possible Severe Bone loss
approaching apex
Vital
Combined pulpal
periodontal
lesion
Moderate to
severe
Likely Severe,
connects with
periapex
Bone loss
extending to apex
Non-vital
[Rotstein et al.,2017]

20. Primary endodontic lesion
Primary periodontal
lesion Primary endodontic
lesion with secondary
periodontal
involvement
Primary periodontal lesion with
secondary endodontic
involvement
True combined
lesion
Endodontic therapy
Re-evaluate after
endodontic therapy and
do periodontal therapy if
required
Periodontal therapy
Re-evaluate after periodontal
therapy and do endodontic therapy
if required
Due to iatrogenic exposure or
root fracture
Start with endodontic treatment first and
then periodontal treatment
Start with endodontic treatment
first and then periodontal
treatment
Start with endodontic
treatment first and then
periodontal treatment
Complete the endodontic therapy and if
periodontal regenerative therapy is required,
perform the required procedure
Re-evaluate after 2-3 months and do
periodontal therapy if required
Seal the exposure with a suitable
material and complete endodontic
treatment
Root fracture
management
Re-evaluate after2-3
months
Periapical resolution
No periapical
resolution
Tooth mobility>grade
1 Splinting
Hopeless
Root resection
Bicuspidization
Hemisection
apicoectomy
[Rotstein et al.,2017]Management of endo-perio lesions

21. Periodontic- Restorative interrelationship
 A sound periodontium provides a firm foundation for an esthetic and functional prosthesis.
 The practise of restorative dentistry has reciprocal relationship with the maintenance of periodontal
health.
 Before commencement of any restorative procedure assessment of periodontal structures of the bone,
the gingiva, the inter dental papilla, the teeth and the biologic space should be done.

22. • After gingival inflammation subsides, the gingival tissue shrinks resulting in the relocation of gingival
margin.
• Inflammation around the abutment teeth compromises their overall health.
• Increased occlusal load over the abutment teeth may facilitate the rapid spread of inflammation and
periodontal destruction.
• Inflammation of periodontium results in inaccurate placement of restorative margins.
• Impression making result in inaccurate model preparation in teeth showing mobility
Why periodontal health a pre-requisite for restorative treatment? [Kois JC et al., 1996]

23. Concept of biological width
The dimensions of biological width as proposed by
Gargiulo et al., 1961.
Biologic width is defined as the physiologic dimension of the junctional epithelium and
connective tissue attachment.
Biological consideration

24.  Restorations placed too far below the gingival tissue crest will impinge on the gingival attachment and create
violation of biologic width.
 Two different responses can be observed from the involved gingival tissue
• Bone loss of an unpredictable nature along with gingival tissue recession will occur as the body attempts
to recreate room between the alveolar bone and the margin to allow space for tissue reattachment.
• Bone level appears to remain unchanged but gingival inflammation develops and persist.

25. Biological width evaluation
 Clinical examination
 The most important findings associated with violation of biologic width is chronic
inflammation in gingiva.
 Bleeding on probing, localised gingival hyperplasia, gingival recession, pocket
formation, clinical loss of attachment.
 Bone sounding
 Identified by estimating the distance between gingival margin and alveolar crest.
 The sulcus depth is subtracted from the total distance from gingival margin and
alveolar crest.
 If this distance is less than 2mm at one or more locations, the biologic width is
violated.
 Radiographic examination
 The distance from the margin of the restoration and alveolar crest can be measured on
radiographs.

26. Guidelines to prevent biologic width violation
Margin placement guidelines
 The patients existing sulcular depth be used as a guideline in assessing the biologic width requirement for that
patient.
 The base of the sulcus can be viewed as the top of the attachment.
 3 rules should be followed
Rule 1
If the sulcus probing depth is 1.5 mm or less than that, the gingival margin is placed 0.5 mm below the gingival
tissue crest.
Rule 2
If sulcus depth is >1.5 mm, the margin of restoration is placed one half the depth of the sulcus below the tissue
crest.
Rule 3:
If the sulcus depth is >2mm, the gingival tissue is evaluated for going gingivectomy or for crown lengthening.

27.  Kois et al., 1996 suggested placement of restoration margin based on bone sounding
measurements into three categories.
Normal crest
 Measurement is 3 mm at mid-facial region and 3mm to 4.5mm at proximal region.
 The margin of the restoration should be placed no closer than 2.5mm from alveolar bone in
these cases.
 The gingival tissues around these restoration well tolerates the restoration and tends to be
stable for long duration of time.
High crest
 The mid-facial measurement is less than 3mm and proximal measurement also less than 3mm.
 Not possible to place intracrevicular restoration because the margin will be too close to
alveolar bone.
 Results following tooth extraction, edentulous sites with collapsed interproximal papilla.
Low crest
 The mid-facial measurement is greater than 3mm and proximal site greater than 4.5mm.
 Most susceptible to recession.

28.  Surgical crown lengthening
Indications:
 Relocation of margins of restorations those impinge on biologic width.
 Placement of subgingival restoration margin
 Root fracture in the cervical third of the root
 For esthetic improvement in the smile by increasing clinical crown length
 Teeth with excessive occlusal wear or incisal wear.
 In conjunction with tooth requiring hemisection or root resection.
Management of violated biological width
Apically repositioned flap
Gingivectomy
[Kuller N et al., 2009]

29. Healing following crown lengthening
 Restorative procedure should be started after new gingival crevice has been established.
 Restorative procedure should be delayed until 3 to 6 months post surgery.
 The longer period reduces the risk for gingival margin shrinkage.
 The re-shaping of provisional restorations may be done 3-4 weeks post surgically.

30. Contraindications:
 In case where excessive bone removal will significantly jeopardize periodontal support.
 Tooth with unfavourable crown root ratio.
 Cases where procedure may result in clinically unesthetic results.
 Teeth where the procedure will cause increased risk of furcation involvement.
 Non-restorable teeth.

31. TISSUE RETRACTION [Kois JC et al., 1996]
 For rule 1 margin
• 2 cords are used
• 1st cord is placed 0.5mm below the prepared angle
• 2nd cord is displaced the first cord apically and sits between the margin and tissue.
 For rule 2 margin
• 2 large diameter cords are used
• Thick cord is placed for impression
This process
 Protects the tissues
 Creates the correct axial reduction
 Establishes a desired sub-gingival level margin.

32. Soft tissue consideration
 Inter proximal embrasure form
• The inter proximal embrasure created by restorations and the form of the inter dental papilla have a
unique and intimate relationship.
• The ideal inter proximal embrasure should house the gingival papilla without impinging on it and
should also extend the inter proximal tooth contact to the top of the papilla so that no excess space
exist to trap food or to be esthetically displeasing.
[Carranza F et al., 2006]

33. Any change in shape or form of embrasures
Change in height and form of papilla
Food impaction, accumulation of microorganisms and plaque accumulation
Too wide embrasure
Flattened and blunt papilla
Too narrow embrasure
Inflamed papilla
Ideal embrasure
Healthy and pointed papilla
[Carranza F et al., 2006]

34. Correction of improper gingival embrasures
 Direct bonded restoration: move the contact towards papilla
 Indirect restoration: contour and embrasure should be established in provisional restoration.
 Management of gingival embrasure form for patients with gingival recession will vary depending on
whether it is in the anterior or posterior region.
• Anterior region: carry inter proximal contacts towards papilla
• Posterior region: moved far enough apically
[Carranza F et al., 2006]

35.  Gingival phenotype
• Influences restorative treatment outcome.
• Two biotypes: thick flat and thin scalloped.
• Predictable results after root coverage procedure in thick flat biotype.
• High risk of soft tissue recession with scalloped type.
 Gingival contour
• An uneven contour of gingiva may give asymmetric appearance which gives an unesthetic smile.
• The gingiva shrinks when the inflamed periodontium is treated and results in exposure of tooth restoration
interface.
• The height of the gingival margin of central incisors and canines should be at the same level.
• Correct orientation of the zenith and gingival height contour is important.
• The gingival zenith assist in forming desired axial inclination of the teeth.
[Bennani et al., 2017]
[Bennani et al., 2017]

36.  Importance of attached gingiva
• The band of attached gingiva is important to dissipate muscular pull forces.
• Minimise the risk of gingival recession
• Care should be taken while placing intrasulcular restoration margins with inadequate width
of attached gingiva.
[Bennani et al., 2017]

37.  The pontic should provide an occlusal surfaces that stabilizes opposing teeth, allows for normal mastication and
does not over load the abutment teeth.
 Pontic design
Prosthetic considerations
[Jhon et al., 2015]

38.  Restoration contours
Two aspects of coronal contour, key to good tissue integration, are
• Cervical contour
• Interproximal contour
Cervical contour:
• Coronal contour requirements are that they should resemble the natural teeth but also in doing so provide an
environment that promotes optimal gingival health.
• These contours are normally determined by tooth anatomy, periodontal condition, margin placement and access to oral
hygiene.
• Properly contoured facial, lingual and interproximal surfaces will avoid any impingement on the soft tissue and prevent
plaque accumulation.
• Padbury et al., 2007 state that buccal and lingual contours should be flat, usually < 0.5 mm wider than the cemento–
enamel junction, and that furcation areas should be barrelled out to allow for easier oral hygiene access.

39. Interproximal contour:
• These are considered as even more important than the facial and lingual contours.
• Interproximal contours are critical as they have an immense impact on the shape and health of the papilla,
especially when the roots of the adjacent teeth are close together.
• Overbuilding the interproximal contours will impinge on the inter dental papilla space and considerably
reduce access to oral hygiene, resulting in inflamed and hypertrophied papilla.
• proximal surfaces should not be under-contoured and will result in loose interproximal contacts lead to
food impaction and are often uncomfortable for the patient which result in poor esthetics, poor phonetics
and lateral food impaction. [Bennani et al., 2017]

40.  Margin design:
• When teeth are prepared for fixed prostheses, care must be exercised not to traumatize gingival tissues,
especially in areas of thin or minimally attached gingiva, as recession may consequently follow, leading to
a compromise in the esthetic outcome.
• The type of finish line chosen can increase the potential for trauma to the epithelial attachment.
• A shoulder finish line can be formed subgingivally while keeping the rotary instrument totally embedded
in the peripheral tooth contours, therefore avoiding tissue trauma.
• To minimise the likelihood of adverse effects on the soft tissue, Sous et al., (2009) recommend using
ultrasonic tips when creating the subgingival finish lines.[Jhon et al., 2007]

41.  Margin placement
Rationale for subgingival extension of margin
1. To create adequate resistance and retentive form in the preparation.
2. To make significant contour alterations because of caries or other tooth
deficiencies.
3. To make the tooth/restoration interface by locating it subgingivally.
Supra gingival Equi gingival Sub gingival
[Jhon et al., 2007]

42.  Marginal integrity
• Plaque accumulation may lead to clinical consequences, such as gingival inflammation
and recession, which may have an impact on the final esthetic result.
• Lang et al. (2012) demonstrated that the placement of subgingival overhangs resulted in
changes to the microflora to that which resembles microflora harvested from adult
chronic periodontitis.

43. Sequence of treatment in preparing
periodontium for restorative dentistry
 Control of active diseases
• Emergency treatment
• Extraction of hopeless teeth
• Oral hygiene instructions
• Scaling and root planing
• Reevaluation
• Periodontal surgery
• Adjuctive orthodontic therapy
 Pre-prosthetic surgery
• Management of muco gingival problem
• Preservation of ridge morphology after
tooth extraction.
• Crown lengthening procedures.
• Alveolar ridge reconstruction.
[Vincent et al., 2017]

44. Orthodontic-periodontal interrelationship
 The interrelation focus on identification of the periodontal problem that could become more complicated during
orthodontic treatment and conversely, those can benefit orthodontic therapy. Orthodontic tooth movement improves
periodontal health in many cases and vice versa.[Akkerman JE et al., 1997]
 Adjunctive periodontal procedures along with orthodontics are required on many occasion for, a stable and
esthetically acceptable outcome.

45. Objectives of orthodontic tooth movement in
periodontally compromised patients
 Allows better maintenance of oral hygiene
 Appropriately transfer occlusal forces to the alveolar bone.
 Contributes normal vertical dimension
 Establish appropriate crown root ratio
 Facilitate improved bone support
 Improves position and angulation of the abutment for better maintenance of dental and periodontal health.
[Akkerman JE et al., 1997]

46. Molecules involved in bone remodelling during
orthodontic movement [Patil et al., 2013]

47.  Osteoblasts
• These are of mesenchymal origin, are primarily the bone forming cells.
• Osteoblasts synthesize and secrete the extra cellular organic matrix of bone including type I collagen,
osteocalcin, osteopontin, osteonectin, alkaline phosphatase, proteoglycans and growth factors.
• The transcription factor Cbfa1 is the earliest expressed and most specific marker of bone formation.
• Osterix is another gene playing a vital role in bone formation that functions downstream of Runx2.
• Integrins, a protein present in the cell membrane of osteoblast translate mechanical strain into a signal
which in turn stimulates a gene to make the cell develop ligands. Ligands in turn allow intracellular
communication, which stimulates undermining resorption allowing OTM.[Patil et al., 2013]

48.  Osteocytes
• They were histologically thought to be trapped osteoblasts in the matrix and whose function was
considered to provide support and sustenance to the bone.
• Osteocytes are now understood to be very proprioceptive and responsive cells of bone.
 Osteoclasts
• Differentiate from monocyte-hemopoietic cells are multinucleated giant cells found in bay-like
depressions of bone called Howship’s lacunae.
• Active osteoclasts exhibit high content of a specific chemical marker, tartrate resistant
acidphosphatase (TRAP), which participates in signaling active bone resorption.[Patil et al., 2017]

49.  Cytokines [Satos et al., 1990]
The cytokines involved in bone metabolism include IL-1, TNF-α, IL-2, IL-3, IL-6, IL-8, IFN-ϒ,
Osteoclast differentiation factor.
Stimulates osteoclastic function through IL-1 type 1 receptor,
chemo attractant for leukocytes, stimulates fibroblast, endothelial
cells, osteoclast and osteoblast.
IL-1
TNF-α Differentiation of osteoclast progenitors to osteoclast in the presence
of M-CSF.
IFN-ϒ
Induces MHC complex in macrophage upregulates the synthesis of IL-
1 and TNF α.
Cause bone resorption by apoptosis of effector T-cells.

50.  Satos et al., (1990) demonstrated the expression of both IL-1 and TNF-α increased in PDL cells and alveolar bone
during orthodontic tooth movement.
 Another important cell signalling system involved in bone remodelling is RANKL/RANK/OPG system.

51.  Growth factors
• Growth factors involved in bone remodelling involves FGF, EGF, PDGF, TGF-β, IGF, BMP, CTGF,
• FGF and IGF acts on fibroblast, endothelial cells, myoblasts, chondrocytes, osteoblasts.
• PDGF migrates from the blood vessels to the extravascular space because of inflammation resulting from
orthodontic force.
• CTGF is associated with ECM remodelling during anabolic bone remodelling which stimulates proliferation of
osteoblast precursors and promotes mineralisation of new bone by osteoblast. [Satos et al., 1990]
 Transcription factors
• The non-collagenous bone matrix protein include osteopontin, bone sialoprotein, osteocalcin and osteonectin.
• These proteins play important role in initial mineralization of bone.

52. The role of inflammation in orthodontic tissue remodeling.
[Patil et al., 2007]

53. Sequence of events after force application
Movement of PDL fluid
Development of strain in cells and ECM
Direct transduction of mechanical
forces to nucleus
of cells leading to activation of specific genes
Release of nociceptive and
vasoactive neuropeptides
Interaction with endothelial cells
Adhesion of circulating leucocytes
to endothelial cells
Plasma extravasation from
dilated blood vessels
Diapedesis of leucocytes into
extravascular spaces
Synthesis and release of
signal molecules(cytokines, GF, CSFs)
from leucocytes
Interaction with various
paradental cells
Activation of cells to participate
in modeling and remodelling
of paradental tissues
[Patil et al., 2007]

54. Sequence of orthodontic treatment in periodontally
compromised patients
Periodontal examination
 Periodontal screening
and recording
 Periodontal probing
 Attached gingiva
 Radiographs
 parafunction
Pre-orthodontic periodontal
therapy
• Pre-orthodontic osseous surgery
 Osseous craters
 Three wall intra bony defects
 Hemiseptal defects
 Furcation defects
 Root proximity
• Pre-orthodontic gingival surgery
 Gingival grafting
 Root coverage
Orthodontic treatment
 Appropriately selected fixed
orthodontic appliance.
 Constant monitoring of
periodontal health
Post-orthodontic phase
 Retention for more than 6 months
 Definitive restorative and occlusal
 therapy
 A three month periodontal
 Maintenance program
[Patil et al., 2007]

55. Various tooth movements in periodontally
compromised patients [Joseph S et al., 2017]
 Labial tooth movement /proclination
 May result in recession, especially in lower anteriors.
 The tissue biotype , as well as thickness of the alveolar bone over the root surface should be evaluated.
 Molar uprighting
 Results in improvement in pocket probing depth and in the crown root ratio.
 Furcation may get worsened by molar uprighting
 Kessler et al., 1976 reported orthodontic molar uprighting may result in a greater degree of furcation
involvement and tooth mobility.
 Lang et al., (1977) molar uprighting is a predictable procedure if excellent oral hygiene is maintained.

56.  Extrusion [Bishara S E et al.,2009]
 For increasing the length of clinical crown, change the height of free gingival margin, re-establishment of
crestal bone level.
 Forced extrusion without supra-crestal fibrotomy results in bone remodelling with the increase of width of
attached gingiva, crestal bone deposition, and some gingival margin recession.
 Intrusion [Bishara S E et al.,2009]
 Indicated in cases with horizontal bone loss and in supra erupted teeth.
 For orthodontic intrusion in periodontally compromised cases there is a significant improvement in clinical
attachment when bacterial biofilm and inflammation are completely controlled.
 Light application of force results in efficient tooth movement and reduces the chance of root resorption.

57.  Orthodontic correction of trauma from occlusion [Bishara S E et al.,2009]
 A properly aligned dentition with a stable occlusion is a good prognostic factor for long term periodontal
maintenance of the patient.
 Correction of missing interdental papilla
 Requires a combination of enameloplasty (inter-proximal reduction), tooth movement and selective addition of
composite resin.
 Correction of gummy smile [ Melson B et al., 2004]
 The main reasons include growth pattern of maxilla, retardation of the physiological apical migration of
gingival margin with thick gingival biotype or extrusion of maxillary anterior teeth.

58. Periodontal Surgery for Orthodontic Patients
 Pericision- Circumferential Supracrestal Fiberotomy [Edwards et al., 1970].
• Relapse of severely rotated teeth due to rebound of elastic fibres in the supracrestal tissues can be
reduced by pericision.
• Inserting a surgical blade into the gingival sulcus and severing the epithelial attachment surrounding the
involved teeth.
• The blade also transects the transseptal fibers by interdentally entering the periodontal ligament space.

59.  Frenectomy / Frenotomy
• [Bergstrom et al., 1973] stated that the probability for diastema in the long run is the
same whether or not frenectomy is preformed. Earlier frenectomy extending into palatal
surface was advocated. But this leads to loss of inter dental papilla between upper
central incisors.
• So, the frenotomy by [Edwards1977] was introduced, which represents a more gentle
operation, with only partial removal of frenum and with the purpose of relocating the
attachment in an apical direction.
 Removal of gingival invagination (CLEFTS) [Bragger et al., 1992]
• Incomplete adaptation of supporting structures during orthodontic closure of extraction
spaces - infolding or invagination of the gingiva.
• The clinical appearance of such invagination : a minor one surface crease to deep clefts
that extend across the interdental papilla.

60.  Gingivectomy
• If gingival margin discrepancy is present, but the patients lip does not moves upward to expose
the discrepancy upon smiling, it does not require correction.
• If the gingival discrepancy is apparent, however, one of four different techniques may be used.
 Gingivectomy
 Intrusion and incisal restoration or porcelain laminate veneer
 Extrusion + fiberotomy + porcelain crown
 Surgical crown lengthening, by flap procedure and ostectomy/osteoplasty of bone
[Bragger et al., 1992]
 Periodontally accelerated osteogenic orthodontics
• Wilcko et al., 2001 reported a revised corticotomy-facilitated technique - (PAOO) is a
combination of a selective decortication facilitated orthodontic technique and alveolar
augmentation.
• With this technique, one teeth can be moved 2-3 times further in one third or one fourth of the
time required for traditional orthodontic therapy.

61. Periodontal problems associated with orthodontic
treatment [Joseph S et al., 2017]
 Gingivitis and inflammatory gingival enlargement
 Increased probing depth
 Root resorption, alveolar bone resorption
 Increase in the periodontal bone defects
 Hyalinization or necrosis
 Increase in lactobacillus

62. Conclusion
 Endo- perio lesions commonly present a diagnostic and treatment dilemma. With careful diagnosis and
treatment planing, in most of the cases, the involved teeth can be saved with a good prognosis.
 To achieve adequate harmony between periodontal tissue and restorations, it is important to determine the
biologic response of the tissue that is anticipated after placement of the restoration. Minimal encroachment on
the sub gingival tissue can lead to deleterious effects on periodontium. Sub gingival restorations should have
highly precise finish line so that minimal inflammatory reaction is there after restoration is placed.

63.  There is a universal consensus regarding maintenance of good oral hygiene during orthodontic treatment. In a
periodontally compromised cases, the overall success of the orthodontic treatment depends on the combined
effort and close monitoring of the case, both by an orthodontist and a periodontist. Hence these cases need
special attention and should carefully planned and treated.