Orthodontic-periodontic interactions are mutually beneficial. Orthodontic treatment can be justified as a part of periodontal therapy if it is used to reduce plaque accumulation, correct abnormal gingival and osseous forms, improve aesthetics, and facilitate prosthetic replacement.

1. -DR. OINAM MONICA DEVI
Periodontic Orthodontic relationship

2. CONTENTS
• Introduction
• Effect of Orthodontic Forces on Periodontal Tissues
• Protective Role of Orthodontic Treatment against Periodontal Breakdown
• Benefits of Orthodontic Therapy
• Orthodontic Treatment as an Adjunct to Periodontal Therapy
• Factors to be Considered during Orthodontic Treatment
• Periodontal Conditions which requires Orthodontic Treatment
• Orthodontic Treatment in Adults
• Tooth Movement and Implant Aesthetics
• Periodontal Surgical Procedure in Orthodontic Patient
• Adverse effects of orthodontic treatment on periodontium
• Conclusion

3. Introduction
• Orthodontic-periodontic interactions are mutually beneficial.
• The main aim of periodontal therapy is to restore and maintain the health and
integrity of the attachment apparatus of teeth.
• Orthodontic treatment aims at providing acceptable functional occlusion and
aesthetic occlusion with appropriate tooth movements.
• Orthodontic treatment can be justified as a part of periodontal therapy if it is
used to reduce plaque accumulation, correct abnormal gingival and osseous
forms, improve aesthetics, and facilitate prosthetic replacement.

4. • Orthodontic tooth movement may be of substantial benefit to the adult
periorestorative patient.
• If these individuals also are susceptible to periodontal disease, tooth
malposition may be an exacerbating factor that could cause premature loss
of specific teeth.

5. Effect of Orthodontic Forces on Periodontal Tissues
• During orthodontic therapy, the various forces are applied. Tooth moves as the
bone surrounding the tooth responds.
• The tooth responds in following manner:
1. Bone resorption is seen where the pressure is applied.
2. Bone formation is seen where the tension occurs.

6. Protective Role of Orthodontic Treatment against Periodontal
Breakdown
• There is an increased number of periodontal pathogens in the anterior crowded
teeth compared to the aligned teeth.
• Correcting the crowded teeth with orthodontic therapy may help in reducing the
development of periodontal breakdown.
• After initiating orthodontic therapy at a mesially tipped molar; there is reduction
in pocket depth at upright molar.
• Moreover, less plaque accumulation and improved gingival architecture on the
upright molar may be noticed.

7. Benefits of Orthodontic Therapy
• Orthodontic therapy can provide several benefits to adult periodontal
patients.
1. Aligning crowded or malpositioned maxillary or mandibular anterior teeth
permits adult patients better access to clean all surfaces of their teeth.
2. Vertical orthodontic tooth repositioning can improve certain types of
osseous defects in periodontal patients. Often, moving the tooth eliminates
the need for resective osseous surgery.

8. 3. Orthodontic treatment can improve the aesthetic relationship of the maxillary
gingival margins before restorative dentistry.
• Aligning the gingival margins orthodontically avoids gingival recontouring,
which could also entail bone removal and exposure of the roots of the teeth.
4. Orthodontic therapy also benefits the patient with a severe fracture of a
maxillary anterior tooth that requires forced eruption to permit adequate
restoration of the root.
• Erupting the root allows the crown preparation to have sufficient resistance
form and retention for the final restoration.

9. 5. Orthodontic treatment allows open gingival embrasures to be corrected to regain
lost papillae.
• Open gingival embrasures located in the maxillary anterior areas can be corrected
with a combination of orthodontic root movement, tooth reshaping, and
restoration.
6. Orthodontic treatment could improve adjacent tooth positioning before implant
placement or tooth replacement.
7. A common tooth malalignment problem that results in periodontal pockets is the
mesially tipped molar.
• Orthodontic uprighting of tipped molars corrects the deep gingival contours and
eliminates or reduces the mesial periodontal pocket.

10. Periodontal Tissue Response and Orthodontic Forces
• Tooth movement induced by orthodontic force is the result of placing
controlled forces on teeth.
• The applied force causes remodeling changes in the dental and periodontal
tissues.
• Orthodontic force application results in compression of the alveolar bone and
the periodontal ligament on one side while the periodontal ligament is stretched
on the opposite side.
• The bone is selectively resorbed on the compressed side and deposited on the
tension side.

11. • Periodontal fiber bundles are arranged such that it opposes the dislodging of the
tooth from the forces during normal function.The applied force causes remodeling
changes in the dental and periodontal tissues.
• Moderate orthodontic forces, i.e., forces exceeding capillary blood pressure lead to
periodontal ligament strangulation resulting in delayed bone resorption.

12. Orthodontic Treatment as an Adjunct to Periodontal Therapy
• Various orthodontic treatments such as uprighting, intrusion, and rotation are
performed to correct the pathologically migrated teeth that control further
periodontal breakdown, improve oral function, and provide acceptable
aesthetics.
• Orthodontic uprighting of the tilted molars has several advantages:
1. The distal movement tooth allows the deposition of alveolar bone on the
mesial defect.
2. It also eliminates the gingival folding and plaque retentive area on the
mesial side.

13. • Orthodontic extrusion of teeth may be indicated for shallowing out intraosseous
defects and for increasing the clinical crown length of single teeth.
• Extrusion results in coronal positioning of intact connective tissue attachment
along the tooth and also the bone deposition.
• Orthodontic intrusion has been recommended for teeth with horizontal bone
defect or infrabony pockets, and for increasing the crown length of a single
tooth.
• Furcation defects require special attention during orthodontic treatment as they
are difficult to maintain and can worsen during orthodontic treatment.
• The hemiseptal defects can be eliminated using uprighting, extrusion, and
leveling of the bone defect.

14. Factors to be Considered during Orthodontic Treatment
Oral hygiene maintenance
• Orthodontic treatment does not damage the periodontal attachment if the
level of gingival inflammation is kept under control.
• The combination of orthodontic forces and inflammation sustained from
plaque cause the uncontrolled breakdown of periodontal attachment.
• The presence of plaque is the considered as one of the main factors in the
development of gingivitis.
• Orthodontic brackets and elastics might interfere with effective removal of
dental plaque, thereby increasing the risk of gingivitis.

15. • Position of Brackets and Molar bands Orthodontic bands placed subgingivally
may encroach on alveolar bone.
• The periodontal effects of banded appliances may differ from those of bonded
appliances, with banding being associated with increased inflammation and loss
of attachment when compared with bonding.
• Gingival hyperplasia can be a potential problem around orthodontic bands,
leading to pseudo-pocketing , which usually resolves within weeks of debanding.
• Care must be taken to ensure that the bracket slots are perpendicular to the long
axis of the tooth and not parallel to the incisal edges.
• If brackets placement is done based on incisal edges, greater root divergence
may cause an open gingival embrasure, which is esthetically unappealing.

16. Force Magnitude
• Human and animal studies agree that there is an increase in severity of root
resorption with increasing force magnitude.
Force Duration
• Debate exists as to whether more root resorption is associated with continuous or
intermittent forces.
• Many believe that discontinuous forces produce less root resorption because the
pause in tooth movement allows the resorbed cementum to heal.

17. Gingival recession
• Orthodontic treatment itself does not lead to gingival recession; it depends on the
type of tooth movement.
• Certain type of tooth movement which occurs outside bone envelope, acts as
predisposing factor for gingival recession.
• Factors affecting gingival recession in orthodontic patients are:
1. Thickness of cortical plate and Type of load distribution
2. Thin tissue and thin cortical plate are more prone to gingival recession compared
to normal or thick tissue.
• It is widely accepted that at least 2 mm of keratinized gingiva should be present
to withstand orthodontic force and prevent recession.
• Most commonly lower anteriors are prone for gingival recession.

18. • Tipping is considered to be one of the types of force causing gingival
recession.
• Wennstrom et al (1987) in animal studies observed that there is no
relationship between width of keratinized tissue and gingival recession
occurrence during orthodontic treatment. Instead it is the buccolingual
thickness which may be the determining factor for development of gingival
recession and attachment loss at sites with gingivitis during orthodontic
treatment.

19. Tooth mobility
• Radiographically, it can be observed that the periodontal ligament space widens
during orthodontic tooth movement.
• Heavier the orthodontic force, greater the amount of undermining resorption
expected, leading to greater mobility.
• If a tooth becomes extremely mobile during orthodontic treatment, all forces
should be discontinued until the mobility decreases to moderate level.

20. Periodontal Conditions which requires Orthodontic Treatment
Midline diastema and correction of black triangles
• Adult patients previously affected by periodontal disease often present with “black
triangles” due to missed interdental papillae height.
• By means of orthodontics, it is possible to correct teeth position and to improve soft
tissue aesthetics.
• It was suggested that orthodontic teeth approximation might change the topography
of the interproximal alveolar crest level and enhance the position of the interdental
papilla.
• Depending on the anatomy of the patient’s frenum, there may be excess fibrotic
tissue in the area that will prevent space closure or cause the space to open up after
it has been closed.
• The second condition that needs correction is when the labial frenum is positioned
near the edge of the gingival tissue in a way that produces tension that without
correction will lead to recession or loss of gingiva in that area.

21. Pathological migration with infrabony defects
• Patients with pathologically migrated anterior teeth could cause unaesthetic
appearance to the patient which is often associated with intrabony defect ,
which needs the use of OFD before the application of orthodontic forces.
• Various orthodontic tooth movements such as intrusion, extrusion, rotation, and
uprighting are needed to achieve an esthetically acceptable outcome that helps
in the control of periodontal breakdown and restoration of good oral function.

22. • Intrusion is a type of tooth movement which has been recommended for teeth
with horizontal bone loss or infrabony defects, provided that both the
biomechanical force system and the oral hygiene are kept under control.
• If the oral hygiene maintainence is not proper, it might worsen the periodontal
breakdown by shifting supragingival deposits into subgingival deposits.
• On other hand, if the tooth is supraerupted with osseous defect, intrusion and
leveling of the bone defect can help to eliminate these problems.
• An osseous crater is an interproximal, two-wall defect that does not improve
with orthodontic treatment.

23. Tilted molars
• Molar uprighting may be accomplished with the use of removable or fixed
orthodontic appliances.
• Pocket depth on the mesial aspect of a mesially tipped molar will be a
combination of both relative and absolute pocket formation, which requires
initial therapy (SRP) along with consultation with an orthodontist.
• The treatment period for molar uprighting, ranges from 3 to 6 months. When the
tooth is uprighted, the mesial angular defect will widen, allowing the gingiva a
more physiologic contour.
• It is believed that after molar uprighting, the periodontal defect will usually be
less, due to the formation of bone when the tooth is bodily moved.
• Osteoplasty/ostectomy with a gradual mesial sloping of the osseous defect can
be used to contour the tissue in the edentulous space.

24. • One should pay special attention towards furcation defects, because during
orthodontic treatment it can remain same or may worsen especially in the
presence of inflammation.
• In case of class III furcation involvement in mandibular molars, hemisection is
the possible option followed by separating the roots apart by using orthodontic
forces.
• The amount of separation is determined by the size of the adjacent edentulous
spaces and the occlusion in the opposing arch. About 7 or 8 mm may be created
between the roots of the hemisected molar.
• After the completion of orthodontic treatment, these teeth should be stabilized
for at least 6 months and reassessed periodontally.

25. Gummy smile or A high smile line
• It is described as one having more than 2 mm of maxillary gingival display.
• Several conditions may result in the excessive display of gingiva, including
pseudopockets caused by gingivitis, drug-induced gingival enlargement and altered
passive eruption of teeth, a high lip line, a hypermobile upper lip or vertical
maxillary excess.
• If the origin of the excessive gingival display is a skeletal abnormality, then
orthognathic surgery and orthodontic treatment should be considered.
• If there is a dental reason for the excessive gingival display, then correction of the
gingival and osseous architecture is indicated.

26. Gingival margin discrepencies
• Uneven gingival margins can be due to various reasons like tilted tooth,short clinical
crown etc.
• It is necessary to evaluate four criteria to decide the type of treatment:
1. The relationship between the gingival margin of the maxillary central incisors and the
patient’s lip line.
2. To evaluate the labial sulcular depth over the two central incisors.
3. To evaluate the relationship between the shortest central incisor and the adjacent lateral
incisors.
4. Whether the incisal edges have been abraded-In such cases intrusion moves the gingival
margin apically and permits restoration of the incisal edges.
• The intrusion should be accomplished at least 6 months before appliance removal which
allows reorientation of the principal fibers of the periodontium and avoids reextrusion of
the central incisor(s) after appliance removal.

27. Periodontal Treatment as an Adjunct to Orthodontic Therapy
• To maintain proper gingival health, a 2-mm width of keratinized gingiva is
adequate.
• Tension on the gingival margin during orthodontic force application also results
in gingival recession.
• High frenal attachment prevents mesial migration of the central incisor and the
aberrant fiber increases the relapse tendency after orthodontic space closure.
• Surgical removal of the frenum is usually advised in these situations and it
should be performed after the completion of orthodontic treatment unless the
frenum prevents space closure or become painful or traumatized.

28. • Forced eruption of an impacted tooth is a common orthodontic treatment
procedure.
• Proper exposure of the impacted tooth and preservation of the keratinized tissue
are important to avoid loss of attachment after orthodontic treatment.
• Apically or laterally positioned pedicle graft is usually advised in this situation.
• Circumferential supracrestal fiberotomy is usually advised to reduce this relapse
tendency.
• Fiberotomy is usually performed toward the end of the active orthodontic therapy,
i.e., a few weeks before the removal of the orthodontic appliance.

29. • Crown lengthening is usually performed in teeth with shorter clinical crown to
facilitate proper placement of orthodontic appliance.
• Crown lengthening is usually performed by gingivectomy or an apically
repositioned flap in combination with gingivectomy prior to orthodontic bonding
procedures.
• If the result of periodontal therapy is stable, orthodontic treatment can be initiated
3-6 months after periodontal surgery in three-wall defects.
• Alveolar ridge augmentation and placement of implants for orthodontic retention
are other adjunctive procedures performed to achieve orthodontic treatment goals.

30. Orthodontic Treatment in Adults
• Adult orthodontics need special consideration in several aspects such as
psychosocial, biological, mechanical, and age-related considerations such as the
aging of tissues, lack of growth potential, vulnerability to temporomandibular
joint (TMJ) disorder, and root resorption.
• Compared to children and teenagers, the tissue response to orthodontic force,
especially cell mobilization and conversion of collagen fibers, is much slower in
adults.
• Adult bone is less reactive to orthodontic force.
• Compared to the elderly, there is a greater risk of marginal bone loss and loss of
attachment with mild gingival infection.

31. • Lindhe (1989) recommended the use of an interrupted force of 20-30 g in adults
during the initial stage of orthodontic treatment.
• The force might be increased up to 50-80 g in bodily movement and 30-50 g in
tipping, corresponding to a distance of movement of 0.5-1.0 mm per month,
depending on the amount of the remaining alveolar bone and the degree of
marginal bone loss.

32. Tooth Movement and Implant Aesthetics
• The lack of adequate space for implant can be managed by orthodontic
movement of the neighboring teeth to an optimal position, which will allow
redistribution of the available space in the dental arch and provide space for
implant placement.
• Selective orthodontic extrusion of a hopeless incisor or molar may be useful
to improve the placement of a single tooth implant by vertically increasing the
height of the ridge upon extrusion.

33. • Both the alveolar bone and periodontal tissues follow the extruded tooth,
leading to bone formation in the direction of tooth movement.
• The reduced buccolingual ridge thickness associated with extraction space
can be managed by orthodontic movement of the adjacent tooth to the
edentulous space, resulting in bone deposition along the tension side and
the implant can be placed at the site of the orthodontically moved tooth.

35. Periodontal Surgical Procedure in Orthodontic Patient
Corticotomy-Assisted Orthodontics
• It 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.

36. • 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.
• 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.

37. • Corticotomy-assisted orthodontics has several advantages:
1. This procedure reduces the treatment time.
2. It facilitates expansion of the dental arch.
3. It produces less root resorption rate compared to normal tooth movement due
to decreased resistance from the cortical bone.
4. It also provides improved postorthodontic stability and slower relapse
tendency.

39. Periodontally Accelerated Osteogenic Orthodontics (PAOO)
• This technique was first introduced by Wilko et al. in 2001, which includes the
combination of corticotomy and bone grafting.
• It is a revised corticotomy-facilitated technique, which involves a full-thickness
labial and lingual flap elevation accompanied by selective surgical scarring of
the labial and lingual cortical bones (corticotomy) followed by placement of the
graft material, surgical closure, and orthodontic force application.
• Basically it was hypothesized that cortical plates are the one which inhibits tooth
movement so by disrupting the cortical plates, tooth movement can be achieved
in lesser time compared to conventional treatment.

40. Biology underlying PAOO:
• Localized areas of osteoporosis are created in the healing phase in corticotomy
sites known as regional acceleratory phenomenon . This is usually seen in
fracture sites, osteotomy sites or bone grafting areas.
• It is not different from normal healing event except that the cell recruitment and
cellular activity will be 2 to 10 folds faster than normal healing.
• RAP is a localized osteoporosis state, which occurs as a part of healing and
may be responsible for rapid tooth movement associated with PAOO.

42. • Timing of orthodontic treatment - placement of brackets and activation
of arch wires are done 1 week prior to the surgical treatment.
• After the flap repositioning heavy orthodontic forces can be applied
immediately and should not be delayed for more than 2 weeks after
surgery.
• The orthodontist has a limited amount of time about 4 to 6 months to
accomplish accelerated tooth movement.

43. Piezocision:
• Corticotomy combined with piezoelectric surgery was introduced in 2007 by
Vercelotti and Podesta. Although they recorded a significant reduction of
treatment time, this procedure was quite invasive since it required flap elevation
and excessive bone removal.
• In 2009, Dibart et al. developed Piezocision as a minimally invasive technique,
their procedure was based on small cuts in the buccal gingiva to allow the
piezosurgery knife to enter and perform cuts in the buccal cortical plate to
stimulate the RAP phenomenon, and it also could combine piezocison with
selective tunneling when soft or hard tissue grafting is required.

44. • Piezocision was performed by making a vertical incision mesial and distal to the
first molar using a microsurgical blade.
• Then BS1 insert of the Piezotome was inserted through that micro-opening to
create the alveolar bone injury.
• The cortical bone was penetrated to a depth of 0.5mm mesially and distally
(decortications) for which low-frequency ultrasonic waves (28–36kHz) are used.
• The microvibrations that were created in the piezoelectric handpiece caused the
inserts to vibrate linearly between 30 and 60 μm.

45. • Nelson et al in 1983 stated that it can be repeated more than once in the same
area to re-activate the RAP (after 5-6 months) and keep the area demineralized.
• The repeated procedure takes very little time and is so conservative that it
meets high patient‟s acceptance yet yielding great treatment outcomes.

46. Adverse effects of orthodontic treatment on periodontium
• Orthodontic brackets and elastics might interfere with effective removal of
dental plaque, thereby increasing the risk of gingivitis.
• Orthodontic treatment is known to affect the equilibrium of oral
microflora by increasing bacteria retention.
• Orthodontically induced inflammatory root resorption (OIIRR) is a sterile
inflammatory process that is extremely complex and composed of various
disparate components including forces, tooth roots, bone, cells, surrounding
matrix, and certain known biological messengers.

47. Conclusion
• Periodontal health is important for every type of dental treatment, specifically for
orthodontic treatment.
• Orthodontic treatment has its positive and negative effects on periodontium.
• Orthodontic treatment should not be performed in periodontitis which is in its active
stage, so regular checkup for the evaluation of periodontal parameters is necessary.
• For the success of treatment, one of the main factors is maintenance of periodontium
in healthy condition, good oral hygiene maintenance and regular follow-up which
would be required for achieving expected outcome.

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49. Thank you