This seminar clarify the inter relationship between two major dentistry branch and highlights treatment strategies

1. SOHINI
Periodontic-Orthodontic
Interrelationship

2. 1. Introduction
2. Factors affecting Perio - Ortho Outcomes
3. Biological and biomechanical considerations for ortho treatment
4. Benefits of orthodontics in periodontal health
5. Clinical response to various orthodontic movements
6. Periodontal surgeries associated with orthodontic correction
7. Perioesthetics
8. Periodontally accelerated osteogenic orthodontics [PAOO]
9. Sequence of periodontal/orthodontic treatment
10. Conclusion

4.  Often periodontal health is improved by orthodontic
tooth movement, whereas orthodontic tooth movement
is often facilitated by periodontal therapy.
 Co-operation, coordination, and interaction between
different specialties in dentistry are extremely important
in establishing diagnosis and an effective treatment
planning.

5.  Reducing plaque retention
 Crowded teeth
 Tipped teeth
 Malposed teeth
 Teeth in linguoversion
 Vertical tooth positioning improves certain types of osseous defects.
 Facilitating prosthetic replacements
 Improving esthetics – allows open gingival embrasures…regain lost
papilla
Implant
placement
Benefits of orthodontics for a periodontally compromised patient

6. Factors affecting Perio - Ortho
Outcomes

7. Some factors have to be evaluated to prevent negative
periodontal sequelae during orthodontic treatment.
GENERAL FACTORS:
 Family history of premature tooth loss (indication of
immune system deficiency)
 Systemic history (e.g. diabetes)
 Nutritional status
 Stress

8. LOCAL FACTORS:
 Tooth alignment (e.g. marginal ridge, cementoenamel
junction relationship)
 Plaque indices, oral hygiene maintenance
 Occlusal loading, TFO
 Periodontal biotype
 Crown-to-root ratio
 Grinding, clenching habits (parafunctional activity)
 Restorative status

9. Biological and biomechanical
considerations for orthodontic
treatment

10.  Apical displacement of the center of resistance in
teeth with marginal bone loss (Melsen, 1980) results
in greater moments created at force application.

11.  It is important to understand that the loss of alveolar
bone results in the center of resistance, of involved teeth,
moving apically with the net effect being that the teeth
are more prone to tipping instead of bodily movement
[Williams et al, 1982].
COMPROMISED PERIODONTIUM

12. ROLE OF OCCLUSAL TRAUMA
 In healthy but reduced periodontium, normal occlusal
forces may become traumatic (Bernal et al., 2002).
 Traumatic occlusal forces worsen an active
periodontal defect and lead to loss of attachment and
bone (Ericsson and Thilander, 1978).

13. The basic principles used in the treatment of patients
with reduced bone support
• Lighter forces

14.  Longer time intervals between reactivation
 Increasing number of teeth in the anchorage unit
 Simple mechanics --- Segmental arch mechanics
(Melsen, 1991; Proffit,
1993)

15. Use of implants as anchorage (Ong & Wang, 2002).
Oral hygiene, control of infection, periodic recalls
(Zachrisson, 1996).
Space may be created by extracting single tooth
rather than routine premolar extraction.

16. Clinical response to various
orthodontic movements

17. • Orthodontic correction of
malposed teeth creates gingival
contours that are more
conducive to periodontal
health.
Alignment of malposed teeth

18. Case : Alignment of crowding resulting healthy periodontal status

19. Extrusion
Least hazardous type of movement to
solve osseous morphology defects.
Result :
In areas of one- and two-wall bony
pockets coronal (favorable) positioning of
intact connective tissue attachment
reduction in pocket depth
shallowing of the bony defect
(van Venroy and Yukna, 1985)

20. Forced Eruption
Slow Fast
Bone and gingiva follows tooth
Crown lengthening before final
restoration
Bone temporarily left
behind

21. Criteria to determine forced extrusion of teeth:
1. Root length & Root form : a short root or an unusual
root shape 
2. Level of fracture :
3. Esthetics (peri-implant)
4. Periodontal-endodontic prognosis

22.  Conflicting evidence has been
reported regarding the benefits of
intrusion of individual teeth.
 It requires careful control of force
magnitude.
 Light force is advocated because the
force is concentrated in a small area at
the tooth apex.
Intrusion

23.  Ericson et al (1987) have demonstrated in
experimental animals that orthodontic intrusion of
teeth can shift supragingivally located plaque to a
subgingival location, leading to formation of
infrabony pockets and loss of connective tissue
attachment.

24. • Birte Melsen et al (1989) found that incisor intrusion
through the long axis of the tooth in adult patients with
marginal bone loss had a beneficial effect on the
attachment level, as long as bacterial plaque is properly
controlled all along the course of movement.
 New connective tissue attachment can
also be formed
 Thus, SRP should be done during
active intrusion.

25. CASE : Intrusion Of Central Incisor

26.  Experiments in beagle dog demonstrated
that with tipping and intruding movements,
forces were capable of causing a gingival
lesion to be converted to a lesion associated
with attachment loss.
 In tipping movements, the force should be
light and the area kept clean to prevent the
formation of angular bony defects.
Tipping

27.  It has been suggested that movement into infrabony defects can
result in healing and regeneration of the attachment apparatus.
 Wide osseous defect adjacent to a tooth → the teeth were
moved in order to narrow the defect → better healing potential
may be possible.
Bodily movement into a defect

28.  Wennstrom et al (1993) evaluated in animal experiments
the effect of orthodontic tooth movement on the level of
the connective tissue attachment in sites with infrabony
pockets.
 Orthodontic therapy involving bodily movement of teeth
with inflamed, infrabony pocket may enhance the rate of
connective tissue loss.

29. Implants for replacing missing teeth:
Implants remain positionally stable
under orthodontic/orthopedic forces.
They should be stable for 4-6 mnths
before use as orthodontic anchor
[Shapiro & Kokich, 1988].
If implant is not being used for
anchorage, to be placed after the
orthodontic therapy.

30. Orthodontic implants
 Easy to insert and remove
 Immediate loading
Diameter: 1.2-2.3
Length: 6-14 mm

31.  The dimension of the alveolar ridge is an important
consideration prior to orthodontics movement.
Alveolar Ridge
Narrow
buccolingually
Fenestration &
dehiscence
Movement into edentulous spaces

32. •Movement into vertically reduced bone is not a
contraindication for tooth movement [Thilander, 1996].
•When tooth is moved through cortical plate: no bone
formation (Steiner et al, 1981)
•Light forces are applied to move teeth bodily into area with
reduced bone height having cancellous bone,
↓
Recreate a thin bone plate ahead of the moving tooth
[Lindskog-Stokland et al, 1993].

33. [Lindskog-Stokland et al, 1993]
CASE: Bodily movement of tooth before implant placement

34. Periodontal surgery associated with
orthodontic therapy

35. Evaluation of an aberrant frenum:
1.Vestibular depth
2.Width of attached gingiva
3.Tension test
4.Marginal tissue recession
5.Midline diastema (controversial)
Aberrant frenum

36.  FRENECTOMY: complete removal of the frenum
including it’s attachment to underlying bone.
 FRENOTOMY: incision of the frenum relocating the
frenal attachment so as to create a zone of attached
gingiva between gingival margin and frenum.

37. CASE : Frenectomy irt 11 21

38. Gingival Invaginations
 Incomplete adaptation of supporting structures during
orthodontic closure of extraction spaces in adults may
result in infolding or invagination of the gingiva.

39. Removal of gingival invagination
Edwards, 1971

40. Perioesthetics

41. Gummy smile
CAUSES:
1. Vertical maxillary excess
2. Delayed apical migration
of gingival margins
[Kokich,
1996]
3. Over-eruption of the
upper anteriors

42. GINGIVAL DISPLAY TREATMENT
 Gingivectomy
 Flap surgery with or without ostectomy
 Apical positioning of flap with or without osseous
resection

43. CASE : Correction of
gummy smile

44. Gingival margin discrepancy
According to Kokich et al (1996), the relationship of
gingival margin of the six maxillary anterior teeth plays an
important role in esthetic appearance of teeth.

45. Gingival marginal
discrepancy
Inapparent Apparent
No treatment required
Gingivectomy
Intrusion
and incisal
restoration
Extrusion,
fiberotomy &
incisal edge
equilibration
Surgical
crown
lengthening
If deep sulcus If short CI >LI
If incisal edge
is abraded
Encroachment of
biologic width

46. CASE : Gingivectomy done for crown lengthening

47. Orthodontic intrusion to correct gingival
marginal discrepancy & short clinical crown

48. Orthodontic extrusion

49. Surgical exposure of unerrupted teeth
Excision of gingival tissue over the embedded tooth is
done to achieve crown exposure.

50. CASE :
Surgical
exposure of
unerrupted
teeth

51. Gingival augmentation
Thin gingival biotype prone
to recession

52.  If thick gingival tissue is present, gingival recession is
less likely to occur.
 In areas of a labially positioned tooth with
dehiscence, bone may re-form and gingival thickness
and keratinized tissue may increase when the tooth is
moved lingually.
[Busschop et al, 1985]

53.  Other clinical studies (Dorfman 1978, Coatoam et al.
1981) have shown that → a narrow band of gingiva is
capable of withstanding the stress caused by orthodontic
forces.
 Results from an experimental study (Wennstrom et al.
1987) 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.

54.  Many researchers and clinicians agree that thin labial
tissues should be augmented before labial orthodontic
tooth movement is begun.
(Steiner et al. 1981, Foushee et al. 1985, Maynard
1987, Wennstrom et al. 1987).

55. CASE : Free Gingival Graft irt 31

56. Rapid maxillary expansion (RME ) and
gingival recession
Graber and Vanarsdall stated that if the maxillary
expansion is performed after the midpalatine suture begins
to fuse (after approximately 14 to 16 years of age), there is
a greater risk of recession of the buccal gingival tissue of
the maxillary premolars and molars later in life.

57. Fiberotomy
 Two soft-tissue
periodontal entities may
influence the stability:

1.Principal fibers of the
periodontal ligament,
and
2.Supra-alveolar fibers.

58. Gingival hyperplasia
Gingival
hyperplasia
Reversible
Gingivectomy/
plasty
Interfere with
tooth movement
Usually develops 1-2 months after
ortho appliance is placed

59. Periodontally accelerated
osteogenic orthodontics
[PAOO]

60.  Dr. Thomas Wilcko & Dr.William Wilcko → Accelerated
Osteogenic Orthodontics (AOO)
 In May 1998 the AOOTM
procedure was introduced at the
98th
Annual Session of the American Association of
Orthodontics.
 Patented by “Wilckodontics”

61. Technique

62. Fixed orthodontic treatment:
Bracket placement, archwire placement
 Incision: Intrasulcular incisions/1mm below marginal
gingiva
 Flap reflection: buccal and lingual full thickness flaps
 Decortication: bone bur No, ½, 2, 4
 Bone grafting: DFDBA alone or combined with bovine-
derived xenograft
 Fixed orthodontic treatment:
Heavy forces (0-18 Ni Ti) 1 week after surgery. More
frequent reactivation (force application every 1-3 weeks)

63. DECORTICATION
BONE GRAFTING

64. Treatment time: 7 months, 1week

65. PRETREATMENT POST TREATMENT
Treatment time: 6mos

66. Advantages
Reduced treatment time (60-70%)
Decreased tendency for relapse
Decreased root resorption
Improved retention
Prevents re - crowding of lower incisors
Reduced postoperative complications (devitalisation,
ankylosis)

67. Disadvantages
Risk of morbidity (surgical procedure)
Need for long-term peer-viewed data and more animal
studies
Coordination between orthodontist and surgeon

68. Sequence of periodontal/
orthodontic treatment

69. Before orthodontic treatment
 Increasing
keratinized tissue

70. (Zachrisson, 1996)
 In regenerative procedures, a follow up period of
four to six months, depending on disease severity,
should elapse before placement of fixed appliances.
 During this period the periodontal status is
evaluated and the patients oral hygiene is monitored.

71. During orthodontic treatment
 All adult patients should have thorough periodontal
maintenance every 3 months [Boyd et al, 1989].
 Soft-tissue periodontal surgery:
Frenectomy/Frenotomy

72. After orthodontic treatment
Depigme
ntation

73. Oral hygiene maintenance

74. Tooth brushing
Super floss

75. Interdental brushing
Chemical plaque control

76. CONCLUSION
• Adult orthodontic tooth movement can be performed on
both healthy and diseased periodontia with few
detrimental effects provided physiologic forces are used,
periodontal inflammation is controlled and meticulous oral
hygiene is maintained throughout active therapy.
• By combining the talents of the periodontist and the
orthodontist, we can have an optimal treatment result.

77. 1.Clinical Periodontology – 8th & 9th edition Carranza
2.Clinical Periodontology & Implantology – 3rd & 4th edition
Lindhe
3.Contemporary orthodontic: Profitt
4.Orthodontics & Periodontitis: B.U. Zachission and A.
Baldouf.
5.Evidence based care in orthodontic and Periodontics.
A review of literature: Noran Saunders (JADA, Vol. 130, April
1999)
6.Gingival response to orthodontic force:
Meir Redlier et al (AJODO 1999:116:152-8).
7.Quintessence Int. 1992; 23:509-513.
8.J. Periodontal 2001:72:858-869.
9.Australian Orthodontic journal Vol. 19 Nov.1 April 2003.
10.Eur J. of Orthodon. Vol. 25, No. 6, 579-584, 2003.

78. Thank you