PERIO

1. ORTHODONTICS AND
PERIODONTICS
INTER-RELATIONSHIP
1
PRESENTED BY:
DR LAVEENA SINGHAL
GUIDED BY:
DR SPHOORTHI A
BELLUDI

2. Introduction
Benefits Of Orthodontic Therapy
Periodontal Tissue Response To Orthodontic Forces
Influence Of Tooth Movement On The Periodontium
Microbiology Associated With Orthodontic Bands
Sequence Of Periodontal/Orthodontic Treatment
CONTENTS

3. Pre-orthodontic Osseous Surgery:-
-Osseous craters
-Three wall intra-bony defects
 Orthodontic treatment of osseous defects:-
 -Hemi-septal defects
 -Advanced Horizontal bone loss
 -Furcation Defects
 -Fractured Teeth/Forced Eruption


4. Orthodontic treatment of gingival discrepancies:-
-Uneven gingival margins
-Open gingival embrasures
Muco-gingival considerations
Implants and Orthodontics
Oral hygiene maintenance
Conclusion

5. PERIODONTICS
Orthodontics
Restorative
Dentistry
Prosthodontics Oral Surgery
5
“When you add all that periodontics has to offer to all
the other disciplines, the limits of what we can achieve
together are almost as boundless as space itself ”
Michael K .McGuire ( Houston )
(President A.A.P 2001)

6. Orthodontic tooth movement may be a substantial benefit to the
perio-restorative patient.
 Many adults who seek routine restorative dentistry, have
problems with tooth malposition that compromise their ability to
adequately clean and maintain their dentitions.
 If these individuals also are susceptible to periodontal disease,
tooth malposition could be an exacerbating factor that could
cause premature loss of specific teeth.
INTRODUCTION

7.  Individuals seeking orthodontic therapy with
underlying gingival or osseous periodontal defects,
can be improved during orthodontic therapy by the
appropriate tooth movement.
7

8.  Orthodontic treatment is based on the principle that
if prolonged pressure is applied to a tooth, tooth
movement will occur as the bone around the tooth
remodels. Bone is selectively removed in some
areas and added in others.
 Since the bony response is mediated by the
periodontal ligament, tooth movement is primarily
a periodontal ligament phenomenon.
8

9.  An intimate relationship exists between malocclusion,
orthodontic treatment, gingival and periodontal health.
 It is therefore essential to identify patients who have
gingival and periodontal diseases or are at risk of
developing them to establish a comprehensive treatment
strategy.
 This requires a teamwork involving the periodontist and
the orthodontist to monitor all aspects of the oral health
before, during, and after a course of orthodontic therapy.
9

10. 1. Aligning crowded anterior teeth permits
the patient better access to adequately clean all
surfaces of their teeth.
 This could be an advantage for patients who are
susceptible to periodontal bone loss or do not have
the dexterity to adequately maintain their oral
hygiene.
BENEFITS OF ORTHODONTICS FOR A
PERIODONTAL PATIENT

11. 2. Vertical orthodontic tooth repositioning can
improve certain types of osseous defects in
periodontal patients. Often, the tooth
movement eliminates the need for resective
osseous surgery.
11

12. 3. Orthodontic treatment can improve the esthetic
relationship of the maxillary gingival margin level
before restorative dentistry. Aligning the gingival
margin orthodontically avoids gingival
recontouring, which potentially could require
bone removal and exposure of the roots of the
teeth.
12

13. 4. The fourth benefit of orthodontics is for the patient
who has suffered a severe fracture of a maxillary
anterior tooth, which requires forced eruption to
permit adequate restoration of the root. In this
situation, erupting the root allows the crown
preparation to have sufficient resistance form and
retention for the final restoration.

14. 5. Orthodontic treatment allows open gingival
embrasures to be corrected to regain lost papilla.
6. Orthodontic treatment could improve adjacent tooth
position before implant placement or tooth
replacement. This is especially true for the patient who
has missing teeth for several years and has
drifting and tipping of the adjacent teeth.

15.  Gingival recession and clefts
 Root resorption
 Reduction in alveolar bone height
 Mobility
 Periodontitis
HARMFUL EFFECTS
Gingival and periodontal changes related to
orthodontic treatment can be listed as follows:
15

16.  Exaggerated plaque accumulation during orthodontic
treatment may facilitate the formation of localized,
deep pockets.
 Teeth with inadequate attached gingiva occasionally
develop localized recession.
 Root resorption, decreased alveolar bone height &
mobility are associated with excessive orthodontic
forces.
16

17. Malocclusion in relation to
gingival and periodontal health
17

18. Malocclusion in general or a single
misplaced tooth can lead to
 Gingival inflammation
 Inadequate width of
attached gingiva
 Root resorption
 Deficient alveolar bone
height
18

19. Effect of tooth malocclusion on the
gingival and periodontal tissues
1. Malocclusion facilitates plaque accumulation and
calculus formation.
2. Abnormal occlusal forces-food impaction
3. Poor gingival contour
4. Change in alveolar bone architecture
19

20. Clinical conditions which predispose to
periodontal disease are-
 Crowding
 Increased over jet and overbite
 Cross bite
 Open bite
 Inadequate or poor lip seal
 Mouth breathing
 Tooth rotations
20

21. Crowding may adversely affect the health of the gingiva
and the periodontium if:
 Crowding creates inaccessible corners between and
around the teeth which lead to plaque accumulation.
 Teeth displaced from the line of the arch receive their
occlusal load non-axially, leading to a lateral force
component each time the teeth come together.
 If interproximal contacts are poor—the inter cuspation
of opposing teeth may cause food impaction.
21
CROWDING

22. Increased over jet
Inadequate lip cover and abnormal anterior oral seal
Reduces the capacity for natural food clearance from the area
leading to
Food debris and plaque accumulation, particularly in the labial
gingival area of the maxillary incisors
22

23. DEEP OVERBITE
Brings the mandibular incisal edges in contact with the cervical
part of the upper incisors or with the gingiva itself
trauma
Leads either to inflammation due to food impaction, or ulceration due
to direct and blunt trauma from the opposing teeth
23

24. Cross bite
 Facilitates plaque accumulation
 Increases gingival inflammation
 May cause gingival recession
24

25. Open bite
Plaque collection around the anterior teeth,
accumulating with succeeding meals
Gingival hyperplasia
Leads to
Gingival inflammation
25

26. Rotations
Mild rotations of individual
teeth are not usually associated
with a deterioration in the
health of the gingiva, but when
the rotation is severe, it can
lead to reduction in supporting
alveolar bone.
26

27. FOLLOW-UP
 The effect of orthodontic treatment on the periodontal
tissues is not only during active treatment but
continues even after its completion.
 Thus, volumatous reduction of alveolar bone and
thinning of gingiva during orthodontic treatment will
pre-dispose the patient to future periodontal
breakdown.
27

28. Placement of orthodontic appliance
Interferes with natural food sluiceways
Leads to accumulation of food in close
approximation with teeth and gingiva
Inflammation of gingiva
28

29. Also, patients with a newly fitted orthodontic
appliance may overzealously perform oral hygiene
procedures to maintain oral hygiene, leading to
trauma of the gingiva and teeth with resulting
recession.
29

30. EFFECTS OF DIFFERENT ORTHODONTIC APPLIANCESON
PERIODONTIUM
30

31. Removable appliance
 Removable appliances comprise an acrylic base,
with a fitting surface closely adapted to the
palatal area of the maxilla and to the lingual side
of the mandible. They are held in place by clasps
and carry expansion screws and springs for the
movement of individual or groups of teeth.
 Even the most accurately fitting appliances will
collect food underneath them during meals and
will retain and protect this food accumulation
against natural clearance by the tongue and
cheeks
31

32. Fixed appliance
Arch wires along with bonded brackets interfere with
oral hygiene maintenance
Facilitates plaque accumulation
Leads to compromised gingival and periodontal health
32

33. Effect of bands and bonded tubes
 Tubes and cemented
bands with tubes are
associated with increased
plaque accumulation and
resultant gingival
inflammation.
 However, with bands the
gingival reaction is more
exaggerated during the
treatment period .
33

34.  Tooth movement during orthodontic therapy is the
result of placing controlled forces on teeth.
 In the elderly, the tissue response to orthodontic
forces including both cell mobilization and conversion
of collagen fibers is much slower than in children and
teenagers. This is due to reduced cellular activity and
the tissues becoming richer in collagen.
PERIODONTAL TISSUE RESPONSE TO
TOOTH MOVEMENT

35. In adults, hyalinized zones are formed more easily on the
pressure side of an orthodontically moved tooth, and
these zones might temporarily prevent the tooth from
moving in the intended direction.
This delay in tooth movement varies from short (with the
application of light forces) to long periods of time (with
heavier forces).

36. The hyalinized zone is eliminated by reorganization of
the area through resorption by the marrow spaces
(undermining resorption) and the adjacent areas of
unaffected PDL and alveolar bone.
Once the hyalinized zone is removed, teeth can move
again. It has been shown that regeneration of the PDL
does not occur when inflammation is present in the
periodontal tissues. Thus, inflammation must be
controlled through periodontal treatment.

37. 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.
Thus, treatment is often limited to different types of
tooth alignment.

38.  Lindhe(1989) recommended that in the initial stage of
orthodontic treatment in adults, an interrupted force of
20-30g should be used, which can be later increased to
30-50g in case of tipping and 50-80g in case of bodily
movement which brings about 0.5- 1.0mm/ month.
Force is based on the marginal bone loss and the amount
of bone remaining

39. Re et al, in a 12-year report, showed orthodontic
treatment is no longer a contraindication in the therapy
of severe adult periodontitis. In such cases, orthodontic
treatment might enhance the possibilities of saving and
restoring a deteriorated dentition.

40.  Orthodontic movement of endodontically treated
teeth is also possible because the response of the
PDL, and not the pulp, is the key element in such
movement.(Wickwire 1974)
 Light interrupted forces should be used because
evidence indicates that such teeth are slightly more
prone to root resorption during orthodontic treatment
than are teeth with normal vitality.

41. Periodontal tissue response to orthodontic force
Force Tissue response
Strong heavy force (forces far exceeding PDL on pressure side of tooth is crushed
capillary blood pressure) resulting in local ischemia and degeneration
of PDL hyalinization more delay in tooth
movement
Moderate force (forces exceeding PDL strangulation resulting in delay in bone
capillary force) resorption
Light force (forces less than capillary PDL ischemia with simultaneous bone
blood pressure) resorption and formation more
continuous tooth movement

42. EFFECTS OF ORTHODONTIC TREATMENT ON PERIODONTAL
Term Effects
Short Gingivitis and gingival enlargement
No attachment loss
Effects are reversible
Long Root resorption (1.0-1.5mm)
Attachment loss in areas of active periodontitis
Effects are often irreversible

43. The main short-term effects of orthodontic bands on the
periodontium are gingivitis and gingival enlargement.
Gingival enlargement occurs after placement of a fixed
appliance. This condition rapidly improves within 48
hours after the appliance is removed.
The increase in probing depth during orthodontic
treatment has also been attributed to this enlargement.

44. Because this gingival enlargement is also seen in
patients with good oral hygiene, mechanical irritation
caused by the band or cement, in addition to trapped
plaque, can be implicated.
When such iatrogenic irritations are inevitable, the
risk of loss of attachment can be anticipated.

45.  In patients with no periodontal disease and with good
oral hygiene, including adults with reduced but healthy
periodontium, proper orthodontic treatment causes no
significant long-term effects on periodontal attachment
and bone levels.
 However, in adults with active periodontitis (plaque-
infected deep pockets evidenced by bleeding on
probing), orthodontic tooth movement might accelerate
the disease process, even with good oral hygiene.
45

46.  Two retrospective studies done by Polson &
Sadowsky in adults concluded that no significant
damage to the periodontium occurred after
orthodontic therapy.
46

47.  In a 2-year post-orthodontic study, 30 women who had
multi-banded therapy were compared with 30 age-
matched controls.
It was found that the orthodontically treated patients had
a higher prevalence of root resorption (17% vs 2%),
although there was a lower prevalence of mucogingival
defects (5% vs 12%).
This root resorption was most common in the maxillary
incisors followed by the mandibular incisors. Root
resorption is a side effect of orthodontic treatment; it is
usually minor, about 1 to 1.5 mm.

48.  In a cross-sectional study by Polson 1984, radiographic
crestal bone levels in 104 adults, who had completed
orthodontic therapy at least 10 years previously, were
shown to be no different from 76 matched control
subjects.
 But another study in adolescents indicated that up to
10% of the 38 children had significant loss of
attachment (mean, 1-2 mm) in 2 years.
48

49.  In 2008, Bollen conducted two systematic reviews to
address the following questions:
(i) does a malocclusion affect periodontal health ??
(ii) does orthodontic treatment affect periodontal health??
 The first review found a correlation between the presence
of a malocclusion and periodontal disease
 The second review identified an absence of reliable
evidence on the effects of orthodontic treatment on
periodontal health.
49

50.  Another systematic review of controlled evidence
by Bollen suggested that orthodontic therapy was
associated with
 0.03mm gingival recession
 0.13mm alveolar bone loss
 0.23mm on increased pocket depth
50

51. Gingival response to orthodontic force
 The gingiva rotates to the same degree and in the same
direction of the tooth.
 Extensive rotational movement causes the rotational
gingiva to be compressed in the interdental area in the
direction of rotation.
 From a clinical point of view, special attention should
be given to the possible consequences of excessive
labial tooth movement, especially that of incisors, which
may bring about irreversible gingival recession. 51

52. Sequence of therapy
52

53. QUENCE OF PERIODONTAL/ORTHODONTIC
TREATMENT
 Proper sequencing of treatment between orthodontist
and periodontist is crucial for a successful result.
 Certain periodontal problems can be treated
→Before orthodontic therapy
→During orthodontic treatment &
→After orthodontic therapy
 Accurate diagnosis and careful planning by the
orthodontist and the periodontist are required to put
treatment in the proper sequence.

54.  Three important points should be addressed when
utilizing orthodontic treatment as part of periodontal
therapy-
1. Severity of the periodontal problem and the possibility
of improving it by orthodontic treatment.
2. Level of remaining bone
3. Possibility that the periodontal problem may worsen
without orthodontic correction.

55.  Abnormal frenum that attaches at or near the free
gingival margin of mandibular incisors and premolars
should be corrected before orthodontic procedures are
performed.
These teeth usually have minimal attached gingiva
and require frenectomy and gingival grafting to
prevent clefting and recession during orthodontic
therapy.
Before Orthodontic Therapy

56. Patients with pre-existing gingival recession may have
underlying labial bony dehiscence. If these patients have
1 mm or less attached gingiva, a gingival graft is
recommended prior to orthodontics to prevent further
recession.
Some osseous periodontal problems should be treated
before orthodontic procedures are undertaken.

57.  Incipient hemiseptal or vertical osseous defects often
resolve during orthodontic therapy by selective tooth
extrusion. Patients with these types of defects may
require only elimination of soft tissue inflammation prior
to orthodontic therapy.
 Pre-orthodontic periodontal surgery may not be
necessary in such cases.
 Incipient inter-proximal osseous craters usually do not
disappear with Phase-I therapy only. In these patients,
periodontal surgery for crater may be necessary.

58.  The patient susceptibility, level of home care, response
to Phase-I therapy, and ability to maintain oral hygiene
during orthodontic therapy are factors in determining the
timing and need for corrective treatment prior to
orthodontic treatment.
 Moderate and advanced osseous problems may require
surgical periodontal therapy before orthodontic
treatment.
 Patients with bone loss and generalized osseous craters
usually require periodontal surgery and may need
osseous recontouring of the defect prior to banding.

59. DURING TREATMENT
 During orthodontic therapy, all patients should have
periodontal maintenance therapy at least every 6
months.
Patients with periodontal problems could receive
thorough oral prophylaxis at 2 to 4 month interval,
depending on the patient’s response to therapy and the
severity of the periodontal problems.

60. Soft-tissue surgery is often indicated near the end of
orthodontic treatment to improve esthetics by
harmonizing anterior gingival margins.
The surgical procedures include gingivectomy in
minor situations and apically positioned flaps to
increase crown length in other patients.

61. After orthodontic appliances are removed,
Patients with incipient to advanced osseous problems
should follow a systematic program of maintenance,
stabilization, occlusal adjustment, and re-evaluation
prior to undergoing any other surgical therapy.
The frequency of recall maintenance visits depends on
the patient's response to oral prophylaxis and level of
oral hygiene.

62. After about 6 to 9 months of maintenance and
stabilization, the periodontist must re-evaluate the
patient. This re-evaluation includes probing the sulcus
depths, evaluating radiographs, and checking tooth
mobility and comparing it to the pre-orthodontic
charting.

63.  Only after this period of time can the periodontist
adequately determine those areas that may require further
periodontal therapy.
At this time, periodontal surgery may be needed and may
include one or more of the following: osseous correction
of unresolved craters, cosmetic soft-tissue surgery grafting
to cover areas of gingival recession, and fibrotomy to
reduce the risk of rotational relapse.

64. Treatment of rotation is easy to accomplish but often
difficult to maintain.
•Reorganization of PDL fiber complexes, and
surrounding collagenous and elastic fibers, occurs after
orthodontic tooth movement to accommodate the new
tooth positions.
Effect Of Circumferential
Supracrestal Fiberotomy

65.  Sharpey’s fibers of the newly formed bundle bone,
supra-alveolar and transseptal fibers, and the principal
fibers of the PDL (oblique fibers) undergo re-
arrangement even after a retention period of 4 to 6
months.
Hence, the retention period should continue for at
least 12 months to allow time for remodeling of these
periodontal tissue fibers.

66. Technique was first introduced by Edwards.
Technique: After infiltration with a local anesthetic,
the procedure consists of inserting the sharp point of
a surgical blade no. 11 into sulcular area and severing
the epithelial attachment surrounding the involved
tooth.

67.  It is estimated that Supra-crestal fibrotomy reduces the
mean relapse by almost 30%.
 No significant increase in sulcus depth or signs of
gingival recession are seen after Supra-crestal
fibrotomy.
 Supra-crestal fibrotomy should be performed towards
the end of the finishing phase of active orthodontic
treatment to minimize the relapse caused by the network
of elastic supra-crestal gingival fibers.
67

68. Microbial concentration during
orthodontic therapy
68
 During past decades,the relationship of dental plaque to
periodontal disease has been thouroughly researched and
reported in dental literature.
 Ecological plaque hypothesis suggest that a change in the
environment could be a key factor that would trigger a shift in
balance of resident plaque microflora into more pathogenic
strains.
 One environmental change that alters the nature of dental
plaque is the placement of orthodontic appliances. It increases
the no. of areas for potential plaque retention and thus posing a
primary problem for the patients to maintain adequate plaque
control.

69.  An overall increase in salivary bacterial counts occurs
after placement of bands.
Increase in Lactobacillus has been shown to occur
after orthodontic band placement.
2-3 fold increase in numbers of motile organisms have
been reported at sites, 6 months after appliance
placement.

70. Increases in anaerobes and Prevotella intermedia
A decrease in facultative anaerobes.
This shift in the sub-gingival microflora to a
periopathogenic population is similar to the microflora at
periodontally diseased sites.

71. Pre-orthodontic osseous
surgery

72. Osseous Craters:
An osseous crater is an interproximal, two-
wall defect that does not improve with
orthodontic treatment
Shallow craters (i.e. 4-5-mm pocket) is
maintained non-surgically during orthodontic
treatment.
However, if surgical correction is necessary,
This type of osseous lesion is
eliminated by reshaping the defect and
reducing the pocket depth. This in turn
enhances the ability to maintain these
interproximal areas during orthodontic
treatment.

73. Three wall intrabony defects
Three wall intrabony defects are
amenable to pocket reduction with
regenerative periodontal therapy.
Bone grafts using either autogenous
bone from the surgical site or allografts
along with the use of resorbable
membranes have been successful in
filling three wall defects.
If the result of periodontal therapy is
stable 3 to 6 months after periodontal
surgery, orthodontic treatment may be
initiated.

74. Orthodontic treatment of
osseous defects

75. Hemiseptal Defects
Hemiseptal defects are
one- or two-wall
osseous defects that are
often found around
mesially tipped teeth or
teeth that have supra-
erupted.
In the case of the tipped
tooth, uprighting and
eruption of the tooth
levels the bony defect.

76. If the tooth is supra-erupted, intrusion and leveling of
the adjacent cementoenamel junction can help level the
osseous defect.
Before initiating the treatment, periodontal
inflammation should be controlled.

77. In the periodontally healthy patient, orthodontic brackets
are positioned on the posterior teeth relative to the
marginal ridges and cusps.
When marginal ridge discrepancies are encountered, the
decision as to where to place the bracket or band is not
determined by the anatomy of the tooth.
In these situations, it is important to assess these teeth
radiographically to determine the interproximal bone
level.

78.  If the bone level is oriented in the same direction as
the marginal ridge discrepancy, then leveling the
marginal ridges will level the bone.
 However,
If the bone level is flat between adjacent teeth and
the marginal ridges are at significantly different
levels, correction of the marginal ridge discrepancy
orthodontically will produce a hemiseptal defect in the
bone. This could cause a periodontal pocket between
the two teeth.
78

79.  In some patients, a discrepancy may exist between both the
marginal ridges and the bony levels between two teeth.
However, these discrepancies may not be of equal
magnitude.
 In these patients, orthodontic leveling of the bone may still
leave a discrepancy in the marginal ridges.
 In these situations, the crowns of the teeth should not be
used as a guide for completing orthodontic therapy.
 The bone should be leveled orthodontically and any
remaining discrepancies between the marginal ridges should
be equilibrated.
 This method produces the best occlusal result and improves
the periodontal health.
79

80. During orthodontic treatment, when teeth are being
extruded to level hemiseptal defects, the patient should
be monitored regularly.
Initially, the hemiseptal defect has a greater sulcular
depth and is more difficult for the patient to clean. As
the defect is ameliorated through tooth extrusion,
interproximal cleaning becomes easier.
The patient should be recalled every 2 to 3 months
during the leveling process to control inflammation in
the interproximal region.

81. Advanced horizontal bone loss
 In a patient with advanced
horizontal bone loss, the bone
level may have receded several
millimeters from the CEJ- The
crown-to-root ratio becomes less
favorable.
 By aligning the crowns of the
teeth by orthodontic treatment
perpetuate tooth mobility due to
unfavorable crown-to-root ratio.

82.  In addition, by aligning the crowns of the teeth and
disregarding the bone level, significant bone
discrepancies occur between healthy and
periodontally diseased roots.
 It is necessary to consider bone level as a guide to
position the brackets on the teeth
 The goal of equilibration and creative bracket
placement is to provide a more favorable bony
architecture as well as a more favorable crown-to-root
ratio.

83. Furcation
defects
Furcation lesions require special
attention in patients undergoing
orthodontic treatment.
Often, the molars require bands with
tubes and other attachments that
impede the patient’s access to the
buccal furcation for home care and
instrumentation at the time of recall.
Furcation

84.  Furcation lesions require special consideration
because they are the most difficult lesions to
maintain and can worsen during orthodontic
therapy.
 These patient needs to be maintained on a 2-3
month recall schedule. Proper instrumentation of
these furcation helps to minimize further
periodontal breakdown.
84

85.  If a patient with Class III furcation defect will be
undergoing orthodontic treatment, possible method for
treating the furcation is to eliminate it by hemisecting
crown and root of the tooth.
 If the patient will be undergoing orthodontic
treatment, it is advisable to perform the orthodontic
treatment first if the roots of the teeth will not be
moved apart. In these patients, the molar to be
hemisected remains intact during orthodontics .

86. In some patients requiring hemisection of a mandibular
molar with a class III furcation, pushing the roots apart
during orthodontic treatment may be advantageous if
the hemisected molars will be used as an abutment for a
bridge after orthodontics.
Moving the roots apart orthodontically permits a
favorable restoration and splinting across the edentulous
spaces.

87. About 7 or 8 mm may be
created between the
roots of the hemisected
molar. This process
eliminates the original
furcation problem and
allows the patient to
clean the area with
greater efficiency.
87

88. Fractured Teeth/Forced Eruption :
• If the fracture is extending beneath the level of the
gingival margin and terminating at the level of the
alveolar ridges---- restoration of the fractured crown is
impossible because the tooth preparation would extend
to the level of the bone.

89. The overextension of the crown margin could result in
an invasion of the biologic width of the tooth and cause
persistent inflammation of the marginal gingiva.
These type of cases are best treated by forced eruption
of the fractured root out of the bone and moving the
fracture margin coronally so that it can be properly
restored.
However, if the fracture extends too far apically, it
may be better to extract the tooth and replace it with an
implant or bridge.

90. 1. Root length
2. Root form
3. Level of the fracture
4. Relative importance of the tooth
5. Esthetics
6. Endo/Perio prognosis
Six criteria must be considered before
forceful extrusion of a tooth

91. If all these factors are favorable, then forced
eruption of the fractured root is indicated.
After the tooth root has been erupted, it must be
stabilized to prevent it from intruding back into
alveolus.

92. As the root erupts, the
gingiva moves
coronally with the
tooth. As a result, the
clinical crown length
becomes shorter after
extrusion. This can be
corrected by gingival
surgery either by simple
gingivectomy or flap
with osseous surgery.

93. Orthodontic tooth movement in
adults with periodontal tissue
breakdown

94.  Boyd et al described 10 adults with generalized
periodontitis who received pre-orthodontic
periodontal treatment including surgery, and then
regular maintenance at 3 month intervals during a
2-year orthodontic treatment period.
 They were compared with 10 control adults who
had normal periodontal tissues, and 20 adolescents
orthodontic patients.

95. Results:
Adults were more effective then adolescents in removing
plaque, especially late in orthodontic treatment period.
Tooth movement in adults with reduced but healthy
periodontium did not result in significant further loss of
attachment.
Adults with teeth that did not have healthy periodontium
may experience further breakdown and tooth loss due to
abscesses during orthodontic treatment.

96. More studies on much larger groups(350-400 patients)
of consecutively treated adult patients from different
practices (Nelson & Artun 1997, Re et al 2000) have
confirmed that-
1. Pre-treatment evidence of periodontal tissue destruction is no
contraindication for orthodontic therapy.
2. Orthodontic therapy improves the possibilities of saving and
restoring a deteriorated dentition,
3. The risk of recurrence of an active disease process is not
increased during appliance therapy.

97. Tooth movement into infrabony
pockets

98. Orthodontic forces per se are unlikely to convert gingivitis
into destructive periodontitis.
Infrabony pockets may also be created by orthodontic tipping
and/or intruding movements of teeth harbouring plaque.
(Ericsson et al)
Angular bony defect can be eliminated by orthodontic
movement, but no coronal gain of attachment was found and a
thin epithelial lining covered the root surface corresponding to
its pre-treatment position.
The only thing to be taken care is that excellent oral hygiene
should be maintained throughout the course of orthodontic
treatment.
Polson et al,
Wennstrom et al

99. Tooth movement into compromised
bone areas

100. Experimental reports (Lindskog, Stokland et al)
and clinical studies (Stepovich, Hom & Turley,
Thilander et al) have shown that a reduction in
vertical bone height is not contraindication for
orthodontic tooth movement towards or into
constricted area.
For orthodontic tooth movement into markedly
atrophied alveolar ridges, the possibility to acquire
new bone by, for example, GBR procedures should
be considered.

101. Orthodontic treatment of gingival
discrepancies

102. The relationship of the gingival margins of the six
maxillary anterior teeth plays an important role in the
appearance of the crowns. Four factors contribute to
ideal gingival form.
 The gingival margins of the two central incisors
should be at the same level.
 The gingival margins of the central incisors should be
positioned more apically than the lateral incisors and
at the same level as the canines.
Uneven Gingival Margins

103.  The contour of the labial gingival margins should
mimic the CEJs of the teeth.
 A papilla should exist between each tooth, and the
height of the tip of the papilla is usually halfway
between the incisal edge and the labial gingival height
of contour over the center of each anterior tooth.
 Therefore the gingival papilla occupies half of the
interproximal contact, and the adjacent teeth form the
other half of the contact.
103

104. When gingival margin discrepancies, are present,
the proper solution for the problem must be
determined;
-orthodontic movement to reposition the gingival
margins or
-surgical correction of gingival margin
discrepancies.

105.  First, the relationship between the gingival margin of the
maxillary central incisors and the patient’s lip line should
be assessed when the patient smiles. If a gingival margin
discrepancy is present but the discrepancy is not exposed,
it does not require correction.
 If a gingival margin discrepancy is apparent, the second
step is to evaluate the labial sulcular depth over the two
central incisors.
If the shorter tooth has a deeper sulcus, excisional
gingivectomy may be appropriate to move the gingival
margin of the shorter tooth apically.
However, if the sulcular depths of the short and
long incisors are equivalent, gingival surgery does not
correct the problem.
105

106. The third step is to evaluate the relationship between
the shortest central incisor and the adjacent lateral
incisors.
• If the shortest central is still longer than the
lateral incisors, the other possibility is to extrude
the longer central incisor and equilibrate the
incisal edge. This moves the gingival margin
coronally and eliminates the gingival margin
discrepancy.
• If the shortest central is shorter than the
laterals, this technique would produce an
unaesthetic relationship between the gingival
margins of the central and lateral incisors.

107.  The fourth step is to determine whether the incisal
edges have been abraded.
This is best accomplished by evaluating the teeth from
an incisal perspective. If one incisal edge is thicker
labiolingually than the adjacent tooth, this may indicate
that it has been abraded and the tooth has overerupted.
107

108.  In such cases, the best method of correcting the
gingival margin discrepancy is to intrude the short
central incisor. This method moves the gingival
margin apically and permits restoration of the
incisal edges.
 The intrusion should be accomplished at least 6
months before appliance removal. This allows
reorientation of the principal fibers of the
periodontium and avoids reextrusion of the central
incisor(s) after appliance removal,
108

109. The presence of a papilla between the maxillary
central incisors is a key esthetic factor .
Open Gingival Embrasures may be due to one of
three causes:
1. tooth shape,
2. root angulations, or
3. periodontal bone loss.
Open Gingival Embrasures
Gingival embrassure

110.  The interproximal contact between the maxillary
central incisors consists of two parts.
One portion is the tooth contact and another is the
papilla.
 The ratio of papilla to contact is 1:1.
 If the patient has an open embrasure, the first aspect
that must be evaluated is whether the problem is due to
the papilla or the tooth contact.
 If the papilla is the problem, then the cause is usually a
lack of bone support due to an underlying periodontal
problem.
110

111.  In some situations, a deficient papilla can be improved
with orthodontic treatment.
 By closing open contacts, the interproximal gingiva
can be squeezed and moved incisally. This type of
movement may help create a more esthetic papilla
between two teeth despite alveolar bone loss.
 Another possibility is to erupt adjacent teeth when the
interproximal bone level is positioned apically.
111

112. Most open embrasures between the central incisors
are due to problems with tooth contact.
•The first step in the diagnosis of this problem is
to evaluate a periapical radiograph of the central
incisors.
•If the root angulation is divergent, then the
brackets should be repositioned so the root
position can be corrected.
•If the periapical radiograph shows that the roots
are in their correct relationship, then the open
gingival embrasure is due to a triangular tooth
shape.

113. If the shape of the tooth is the problem, treatment
is:
-by restoring the open gingival embrasure or
-reshape the tooth by flattening the incisal
contact and closing the space.
113

114. Diastema
A common esthetic challenge is a diastema between
central incisors.
A narrow diastema (1-3mm wide) is eliminated either by
closing the space orthodontically or restoring the mesial
surfaces of the central incisors.
Closure of a diastema by restoration is limited by the
length and width of the anterior teeth and the width of the
diastema.
 When the restored central incisors are esthetically too
wide, orthodontic closure of the space may be preferred.

115.  After the diastema has been eliminated, the
maxillary labial frenum should be evaluated.
When the frenum attaches at or near the papilla , a
frenectomy may be indicated.
 Frenectomy should be performed after closure of
the diastema.
115

116. The position in which a tooth erupts through the
alveolar process and its eventual position in relation to
the bucco-lingual dimension of the alveolar process
influence the amount of gingiva that will be established
around the tooth.
Mucogingival And Esthetic Considerations

117. According to Lang and Loe, a minimum 2 mm of
gingiva, corresponding to 1 mm of attached gingiva is
necessary to maintain gingival health.
However,
Studies of MIYASATO showed that minimal
bands of gingiva could be maintained in periodontal
health without progressive recession if traumatic
toothbrushing and inflammation were controlled.

118.  A retrospective study of orthodontically treated adults
showed a low prevalence of mucogingival defects (5%).
 Results from an experimental study indicate that as long
as the tooth is moved within the envelope of the
alveolar process, the risk of harmful side effects on the
marginal soft tissue is minimal.
118

119. Gingival augmentation might be considered when
facial tooth movement with thin keratinized gingiva
could cause alveolar bone dehiscences with resultant
marginal tissue recession.
Mucogingival interceptive surgeries, including
double pedicle grafts, apically positioned flaps, and
free gingival grafts, have been shown to be effective
approaches to conserving the keratinized buccal
gingiva of ectopically erupting premolars over 7
years.

120. Canine exposure
120
 The stages involved in orthodontic guidance of impacted
canine include:
 Pre-surgical orthodontics –
placement of fixed orthodontic appliance, preparation of
anchorage, alignment of adjoining teeth/root and creation of
space for the erupting canine.
 Surgical stage –
exposure of the impacted canine and bonding an attachment
on the exposed surface.
 Post-surgical orthodontics –
application of light traction & guiding impacted canine into
occlusion.

121. 121
The techniques for surgical exposure of impacted canine
includes:
 Open eruption technique (excisional uncovering),
 apically positioned flap,
 closed eruption technique,
 Trap door approach

122. Orthodontic Traction of Impacted Upper Canines Using the
VISTA Technique
Closed-eruption procedures through keratinized gingival
tissue are recommended for traction of impacted canines.
One such method currently used for buccally impacted
canines is the vestibular incision subperiosteal tunnel access
(VISTA) technique, which was introduced by Dr.
Homayoun Zadeh and later modified and improved by Dr.
Chris Chang.
Bariani RC, Milani R, Guimaraes Junior CH, Moura WS, Ortolani CL J Clin
Orthod. 2017 Feb;51(2):76-85

123. Although orthodontic movement of an impacted tooth can create periodontal
problems such as gingival retraction and gingival attached deficiency, these
were not observed in the present case. Damage was likely avoided because
VISTA is a closed-eruption technique that requires minimal removal of bone
on the canine crown. Studies have found that a closed technique results in
exposed tooth edges with less attachment and bone loss,less gingival scarring,
and more esthetically pleasing gingival contours.

124. IMPLANTS AND ORTHODONTICS

125. Implants for orthodontic anchorage can be used
 in pre-prosthetic tooth alignment,
 retracting and realigning malpositioned teeth,
 closing edentulous spaces,
 correcting midline and anterior tooth spacing,
 intruding or extruding teeth,
 correcting a reverse occlusal relationship,
 correcting an anterior open occlusal relationship,
 protracting an arch or the entire dentition, and
providing stabilization for teeth with reduced bone
support.

126.  Acquiring adequate support for orthodontic tooth
movement is a major challenge in adult orthodontic
treatment, especially in areas of partial edentulism and
limited amounts of alveolar bone support.
 In addition, severely periodontally compromised teeth
might experience further periodontal breakdown and
might eventually be lost during treatment. In such
situations, the option of removing these teeth and using
implants for the needed orthodontic anchorage has
become a clinical reality.
126

127.  Implant-orthodontic anchorage has become a valid
treatment option for patients in whom conventional
orthodontic treatment might not be indicated
because of lack of proper anchorage (eg, a
periodontally compromised dentition that offers
inadequate anchorage for the necessary tooth
movement).

128. Corticotomy-Assisted Orthodontics
 Corticotomy-assisted orthodontics has been
employed in various forms to accelerate
orthodontic treatment. Rapid tooth movement
associated with corticotomy was first
introduced by Henry Kole in 1959.
 The cortical plates of the bone are believed to
be the main resistance to orthodontic tooth
movement.
 In corticotomy-assisted orthodontics, rapid
tooth movement is achieved by disrupting the
continuity of the cortical bone by a selective
cut and preserving the vitality of the teeth and
marginal periodontium.

129.  The biology behind corticotomy-assisted orthodontics is the
regional acceleratory phenomenon (RAP).
 It is a local response of the tissue to noxious stimuli, through
which the tissue regenerates at a faster rate than normal (without
corticotomy).
 The areas around the cuts are associated with intensified bone
response, i.e., increased osteoblastic-osteoclastic activity and
increased level of inflammatory mediators, which accelerate the
bone turnover and facilitate rapid orthodontic tooth movement.

130. 130
 Corticotomy-assisted orthodontics has several advantages
such as this procedure reduces the treatment time and
facilitates expansion of the dental arch and produces less
root resorption rate compared to normal tooth movement
due to decreased resistance from the cortical bone.
 It also provides improved postorthodontic stability and
slower relapse tendency.

131. Periodontally Accelerated Osteogenic
Orthodontics(PAOO)
 Periodontally accelerated osteogenic orthodontics (PAOO), also termed
Wilckodontics, was introduced by Wilcko et al. in 2001.
 Rapid tooth movement associated with PAOO is substantially different
from periodontal ligament cell-mediated tooth movement.
 Recent evidence suggests that RAP is a localized osteoporosis state,
which occurs as a part of healing and may be responsible for rapid
tooth movement associated with PAOO.

132.  The placement of orthodontic appliance and its activation are
typically done in the week before surgical procedure.
 However, in complex mucogingival procedures, the absence of
orthodontic appliance may enable easier soft tissue manipulation
and suturing.
 A heavy orthodontic force immediately after surgery is usually
recommended in this condition. The initiation of orthodontic
force should not be delayed more than 2 weeks after surgery.
 The time period for RAP usually lasts for 4-6 months. A delay in
activation of the orthodontic appliance will fail to take full
advantage of the regional acceleratory phenomenon.

133. Piezocision-Assisted Orthodontics
 Piezosurgery assisted orthodontics is a new
minimally invasive surgical procedure introduced
by Dibart et al. in 2009.
 In this technique microincision is performed on
the buccal gingiva that allows the piezoelectric
knife to give osseous cuts to the buccal cortical
plates and initiate RAP.
 This procedure provides rapid tooth movement
without an extensive traumatic surgical approach.
 This procedure also maintains the clinical benefit
of the bone or soft tissue grafting, along with
tunnel approach

134.  Piezosurgery works only on mineralized tissues, sparing
soft tissues and producing micrometric and selective
osteotomy cuts without any osteonecrosis.
 Compared to the classic decortication procedure,
piezosurgery has added advantages such as being
minimally invasive, safe, and less traumatic to the patients.
 Piezocision can also be combined with Invisalign in
selected cases to produce outcomes that are less time-
consuming as well as satisfy the patient's desire of aesthetic
appliance.

135.  Orthodontic treatment should not be started until the
inflammation of the gingiva has been reduced to a minimum
through adequate scaling, root planning & correcting other
irritational factors.
 Periodically during the orthodontic therapy, the periodontist
should check the condition of the tissues, remove all irritants and
reinforce the patient’s oral hygiene as needed. The frequency of
these examinations is usually every 8-12 weeks.
ORAL HYGIENE FOR ORTHODONTIC
PATIENT

136. Maintaining a good oral hygiene is a challenge to
everyone. But particularly for orthodontic patients
whose appliances make them more susceptible
to gingivitis, hyperplastic tissues, decalcification
and dental caries.
Fixed appliances make plaque removal more
difficult because of the increase in surfaces & the
inaccessibility in some areas .

137. Use of bi-bevel
bristles
Use of powered tooth
brush

138. Use of stimudent
to remove plaque
Use of floss threader

139. Use of interproximal
brush to clean around
the brackets
Rubber stimulator to
disrupt plaque and
massage the papilla

140. Additional adjuncts to personal plaque control
includes
 Use of oral irrigators to dislodge the food debris
 Use of chlorhexidene mouth wash
 Fluoride application to prevent caries
140

141. CONCLUSION
141

142. • Periodontal health is essential for any form of dental treatment,
especially for orthodontic treatment.
• The orthodontic treatment has two ways of action on the periodontal
tissues; it provides some degree of protection to the periodontium and
keeps the gingiva, the bone, and the periodontal ligament in a healthy
status but on the other hand, it produces negative effects on the
periodontium, mainly gingivitis, gingival recessions, and bone
dehiscences, etc.
• In the recent years, because of the increased number of adults seeking
orthodontic treatment, orthodontists frequently face patients with
periodontal disease.

143.  The combined orthodontic-periodontic interdisciplinary approach
could be effective in these situations.
 Adult patients must undergo regular oral hygiene performance
and periodontal maintenance in order to maintain healthy gingival
tissue during active orthodontic therapy.
 The development of new methods to accelerate orthodontic tooth
movement through periodontal surgical procedures, especially
PAOO and piezocision, has shortened the treatment time and
increased the quality of treatment.
 The harmonious cooperation of the periodontist and the
orthodontist offers great possibilities for the treatment of
combined orthodontic-periodontal problems.

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