|Year : 2017 | Volume
| Issue : 1 | Page : 1-8
Periodontal considerations during orthodontic treatment
Suma Shekar1, A Bhagyalakshmi1, BR Chandrashekar2, BS Avinash3
1 Department of Orthodontics, JSS Dental College and Hospital, Jagadguru Sri Shivarathreeshwara University, JSS Medical Institutions Campus, Mysore, Karnataka, India
2 Department of Public Health Dentistry, JSS Dental College and Hospital, Jagadguru Sri Shivarathreeshwara University, JSS Medical Institutions Campus, Mysore, Karnataka, India
3 Department of Periodontics, JSS Dental College and Hospital, Jagadguru Sri Shivarathreeshwara University, JSS Medical Institutions Campus, Mysore, Karnataka, India
|Date of Web Publication||17-Jul-2017|
Department of Orthodontics, JSS Dental College and Hospital, Jagadguru Sri Shivarathreeshwara University, JSS Medical Institutions Campus, Mysore, Karnataka
Source of Support: None, Conflict of Interest: None
Orthodontic treatment aims at providing an acceptable functional and esthetic occlusion. Tooth movements are strongly related to interactions of teeth with their supportive periodontal tissues. In recent years, due to the increased number of adult patients seeking orthodontic treatment, orthodontists frequently face patients with periodontal problems. Esthetic considerations, such as uneven gingival margins or functional problems resulting from inflammatory periodontal diseases, should be considered in the orthodontic treatment planning. The purpose of this article is to provide a dental practitioner with basic understanding of the interrelationship between periodontics and orthodontics and also to highlight the orthodontics and periodontics interface in clinical practice for optimized treatment outcomes.
Keywords: Orthodontic treatment, periodontal considerations, review
|How to cite this article:|
Shekar S, Bhagyalakshmi A, Chandrashekar B R, Avinash B S. Periodontal considerations during orthodontic treatment. Indian J Oral Health Res 2017;3:1-8
|How to cite this URL:|
Shekar S, Bhagyalakshmi A, Chandrashekar B R, Avinash B S. Periodontal considerations during orthodontic treatment. Indian J Oral Health Res [serial online] 2017 [cited 2018 Apr 24];3:1-8. Available from: http://www.ijohr.org/text.asp?2017/3/1/1/210924
| Introduction|| |
The goal of orthodontic treatment is not only to improve facial esthetics and function but also to address the health of supporting structures and how teeth are placed in them. No matter how talented an orthodontist is, a magnificent orthodontic correction can be destroyed by failure to recognize periodontal susceptibility. Both the short- and long-term successful outcomes of orthodontic treatment are influenced by the patient's periodontal status before, during, and after active orthodontic therapy, which also includes posttreatment maintenance by the patient.
Periodontal pathogenesis is a multifactorial etiologic process, and the orthodontist must recognize the clinical forms of inflammatory periodontal diseases. Cooperation between different specialties in dentistry is extremely important in establishing diagnosis as well as in treatment planning. One such interaction exists between orthodontics and periodontics.
The interrelationship between orthodontics and periodontics often resembles symbiosis. In many cases, periodontal health is improved by orthodontic tooth movement, whereas orthodontic tooth movement is often facilitated by periodontal therapy. The purpose of this article is to provide a dental practitioner with basic understanding of the interrelationship between periodontics and orthodontics and also to highlight the orthodontics and periodontics interface in clinical practice for optimized treatment outcomes.
| Gingival and Periodontal Problems|| |
Accumulation of microorganisms around teeth can cause gingival redness, bleeding and edema, changes in gingival morphology, reduced tissue adaptation to the teeth, increase in the flow of crevicular fluid, and other clinical signs of inflammation. Mechanical removal of plaque reduces gingivitis, but many orthodontic patients are not motivated to remove plaque. Removal of supragingival plaque has been shown to have an inhibitory effect on the formation of subgingival plaque.
Gingivitis has been classified as given below.
- Established lesions.
Only the established lesion can be observed as clinical gingivitis. The important point is that alveolar bone loss has not yet occurred and it is hoped that the lesion can be prevented from spreading onto the surrounding structures. It is therefore crucial to determine the appropriate plaque control intervals for the patient which will prevent bone loss. Pseudopockets or gingival overgrowth or enlargement of the gingival margin and the papilla, whether it is drug induced or primary plaque related, are exacerbated by poor hygiene.
The risk factors for development of gingivitis include uncontrolled diabetes, pregnancy, systemic illness, and poor oral hygiene. Malaligned teeth, rough edges of fillings, and unclean oral appliances can irritate the gingiva and increase the risk of gingivitis. Medications such as phenytoin, oral contraceptive pills, and ingestion of heavy metals such as lead and bismuth can also be considered as risk factors.
Periodontitis has been defined as an inflammatory disease of specific bacterial origin that progresses with the episodic attachment loss of periodontium. Although gingival inflammation may be a prerequisite, the actual mechanism for conversion of gingivitis to periodontitis is still being debated. Adult periodontitis is the most common form of periodontitis. The organisms most often reported to be associated with adult periodontitis are Porphryomonas gingivalis, Prevotella intermedia, and Bacteroides forsythus. The periodontitis is of different types and few important ones are briefly explained.
It is a rare form that appears soon after eruption of primary teeth. It can occur in either the localized or the generalized form.
Localized or generalized juvenile periodontitis
It occurs in the circumpubertal period. These patients have little plaque and calculus and they respond well to local debridement and supplemental tetracycline therapy. Juvenile periodontitis is characterized by a rapid loss of alveolar bone and periodontal attachment in otherwise healthy adolescents, with onset thought to occur after puberty. It is generally localized to the permanent first molars and incisors, with little gingival inflammation. The correction of malocclusion in juvenile periodontitis patients after periodontal therapy is a problem if increasing clinical concern since many teeth with severe alveolar bone loss in these patients can now be treated successfully without extractions.
These findings have led to a general consensus that orthodontic treatment has the potential to aggravate preexisting plaque-induced periodontal diseases and cause further loss of alveolar bone and attachment. However, it has been demonstrated that if excellent plaque control is achieved during orthodontic treatment, including uprighting and intrusion procedures, then periodontally compromised teeth can be successfully repositioned without further loss of periodontal attachment. The orthodontic patient may be at a greater risk of attachment loss after teeth have become mobile because of tooth movement. The clinical signs of inflammation and tooth mobility must be recognized and controlled during treatment to prevent extensive bone loss. Periodic monitoring of the periodontal status with probing, microbiologic assessment with immunologic assays, DNA probes, and culturing, as well as clinical findings are useful in determining scaling intervals and detecting potential sites for increased risk of attachment loss. These methods may be used to assess the endpoint of the effectiveness of scaling and root planing before orthodontic treatment to ensure that no putative pathogen exists.
Rapidly progressive periodontitis
This occurs commonly in young adults, and the cause of pathogenesis appears to share many of the features of generalized juvenile periodontitis, such as rapid bone loss and depressed neutrophil functions.
This is a disease condition used to define sites present in patients who continue to be infected with periodontal pathogens and who have a high rate of loss of attachment and tooth loss, despite intensive treatment to prevent bone loss.
Mucogingival problems ,
It is suggested that some cases of potential or actual mucogingival deficiencies may be improved by tooth movement. Since orthodontic and conservative periodontal therapy may induce changes in the character and level of attached gingiva, surgical grafts may be unnecessary.
Mucogingival deformities in children and adults have been described as recession, gingival clefts, and localized pathologic recession. Inadequate keratinized gingiva, minimally attached gingiva, coronally attached frenal and muscle attachments, abnormal tooth position, fenestrations or bony dehiscence in the alveolus, and other factors have been predisposing and etiologically related pathosis.
Lang and Loe concluded that gingival health is compatible with a very narrow gingiva and that 2 mm of keratinized gingiva is adequate to maintain gingival health. Minimally attached gingiva, apically positioned gingival margins, and apparently high muscle attachments have been treated surgically to prevent development of localized gingival recession. A localized pathologic recession may be identified when the gingival attachment is apical to the cementoenamel junction (CEJ). Factors that may be etiologic or predisposing to mucogingival problems of the mandibular incisors may be developmental or acquired.
Abnormal frenal and muscle attachments 
Abnormal frenum and muscle pull has been considered detrimental to periodontal health by pulling away the gingival margin from the tooth, contributing to accumulation of plaque and calculus and leading to inflammation and pocket formation. Adequate depth of the vestibule has been similarly held significant. Several surgical procedures to deepen the vestibule as well as to reduce the height of frenal attachments have been developed as preventive therapeutic measures.
Occasionally, in the developing dentition, abnormal frenal or muscle attachments may extend onto the crest of the alveolar ridge. The erupting tooth may pass through the alveolar gingiva and be deficient in keratinized tissue. Surgical recession will ensure normal eruption of the tooth with adequately attached gingiva.
Interdental recession ,,,
Causes of open gingival embrasures
- Severely malaligned maxillary incisors
- Dimensional changes in the interdental papilla
- Location and size of interproximal contact
- Divergent root angulations
- Triangular-shaped crowns.
Interdental recessions manifest as dark triangles between teeth. Main indication of correction of interdental recession is esthetics.
Options available for treatment of interdental recessions are
- Mucogingival surgeries with coronally positioned grafts and guided tissue regeneration
- Provision of gingival prosthesis
- Orthodontic paralleling of the roots of neighboring teeth
- Mesiodistal enamel reduction.
The principle involved in stripping is to recontour the teeth which have an abnormal shape. By this procedure, a good occlusion with optimal tooth contact point relationships and normal interdental gingival papillary contours will be achieved. When crowding is unraveled in orthodontic patients, the contact points are located in the incisal thirds. The amount of tooth material to be removed by enamel reduction will be around 0.5–0.75 mm. After diastema is created, space is closed orthodontically. As this takes place, roots of neighboring teeth come closer and the contact point is lengthened and the reduced papilla can fill the embrasure.
Missing interdental papilla,,
Usually, when the papilla is lost as a result of advanced periodontal disease which involves loss of interdental alveolar crest, the esthetic improvement in the situation requires a combination of enameloplasty (interproximal reduction), tooth movement, and selective addition of composite resin. If this is not enough for the remodeled tissue to cover the area of the papilla, direct bonding resin can be added to lower the contact point and create the illusion of a healthier papilla. Interproximal enamel reduction along with the closure of the resultant diastema is sufficient in most cases to restore the missing papilla.
| Basic Tooth Movements and Periodontal Changes|| |
Orthodontic treatment is based on the premise that when force is applied to a tooth, it is transmitted to the adjacent investing tissues, and certain structural alterations take place within these tissues which allow for and contribute to tooth movement.
Intrusion alters the CEJ and angular crest relationships and creates only epithelial root attachment. therefore, a periodontally susceptible patient is at greater risk of future periodontal breakdown. Tooth movement, when properly executed, improves periodontal condition and is beneficial to periodontal health. Orthodontic forces, when kept within biological limits, do not induce tissue alterations leading to loss of connective tissue attachment and periodontal pocket formation. The gingiva moves in the same direction as that of tooth intrusion, but it moves only by about 60%. Gingival sulcus gets deepened by about 40% of tooth intrusion.
- Teeth with horizontal bone loss
- To increase clinical crown length.
Clark et al. studied the effect of intrusion on the microvascular bed and fenestrae in the apical periodontal ligament (PDL) of rat molar. They found that the decrease in fenestrae numbers per square micrometer of endothelium was most marked in the venous capillaries, which had the greatest density of fenestrae per square micrometer of endothelial surface. With intrusive loading, the small arterial fenestrae population was unchanged.
Zachrisson et al. measured the gingival pocket depth during treatment and retention in orthodontic patients treated with edgewise appliance and found that pocket depth increased during the tooth movement. They reported that the increase was caused by edematous swelling in the gingiva and by tissue accumulation during tooth movement, not by deepening of the pocket. Gingival sulcus deepened with tooth intrusion. Further, dentoperiosteal and dentogingival fibers were parted from the cementum gradually as tooth intrusion increased.
Melsen et al. studied the tissue reaction related to orthodontic intrusion of teeth and the influence of oral hygiene on this reaction. They found that alveolar bone height was gained through forced eruption and that this bone may be maintained even during an intrusion applied following extrusion. Intrusion can therefore constitute a reliable therapeutic method in the orthodontic treatment of adult patients with a healthy periodontal condition. Intrusion of teeth does not result in a decrease in marginal bone level in periodontally healthy patients provided gingival inflammation is controlled.
Nanda et al. studied the extent of root resorption due to intrusion. Results indicated that intrusion with low forces can be effective in reducing overbite while causing only a negligible amount of apical root resorption. McFadden et al. found an average root shortening of 1.8 mm per tooth, irrespective of the amount of intrusion.
Since orthodontic movement of teeth into inflamed infrabony pockets may create an additional periodontal destruction, and because infrabony pockets are frequently found at teeth that have been tipped or elongated as a result of periodontal disease, it is essential that periodontal treatment with elimination of the plaque-induced lesion should be performed before the initiation of orthodontic treatment. Maintenance of excellent oral hygiene during the treatment is equally important.
Extrusion or eruption of a tooth or several teeth, along with reduction of the clinical crown height, is reported to reduce infrabony defects and decrease pocket depth. Extrusion of an individual tooth is used specifically for correction of isolated periodontal osseous lesions. Studies have shown that extrusion in the absence of gingival inflammation reduces bleeding on probing, decreases pocket depth, and even causes formation of new bone at the alveolar crest as the tooth erupts, with no occlusal factor present.
Raymond Yukna et al. in animal experiments studied the effects of extrusion of single-rooted teeth with advanced periodontal disease. Extruded teeth had shallower pocket depths, less gingival inflammation, and no bleeding on probing. Early in the extrusion process, the teeth appeared to be avulsed, with more than three-fourths of the root coronal to the alveolar crest. After stabilization, approximately 2 mm of new bone was seen coronal to the original alveolar crest, and the periapical areas had filled in with bone. The extruded teeth had an intact attachment apparatus.
The improved periodontal condition resulting from extrusion may have been due to both physiologic and microbiologic changes in the local environment. The subgingival microbial plaque may have been converted to a supragingival plaque by the extrusive tooth movement, thereby lessening its pathogenicity and effect on gingival tissues. This is the reverse finding of Ericsson et al., who reported that orthodontic treatment which involves intrusion of a tooth in a plaque-infected dentition may shift a supragingivally located plaque into a subgingival location.
Marc Quirynen et al. studied the periodontal health of orthodontically extruded impacted teeth. Most impacted teeth were extruded after minor periodontal surgery. They found no difference between test and control teeth, except gingival width, which was 1 mm larger for the spontaneously erupted teeth. This study demonstrated that orthodontic extrusion of impacted teeth does not jeopardize their periodontal health
Forced eruption ,
- It helps save an isolated tooth in which caries, trauma, or iatrogenesis has destroyed the clinical crown by bringing the fractured, diseased, or prepared margins of the neck of the tooth more coronally to reestablish biological width
- Although forced eruption is associated with an increase in the width of attached gingiva, mucogingival junction remains unaltered
- Fiberotomy, which is done before active eruption, is essential for success of the procedure
- For shallowing out of isolated intraosseous defects
- Increase clinical crown length of single teeth.
Forced eruption was first introduced by Ingber in 1974 for the treatment of one-walled and two-walled defects. Extrusion results in a coronal position of the connective tissue attachment and the bony defect are shallowed out. Because of extrusion, the tooth is in supraocclusion and will need to be shortened. During the elimination of an intraosseous defect by means of extrusion, the relationship between CEJ and the crest of alveolar bone is maintained. When the goal of treatment is to extrude the tooth out of periodontium as required during crown fractures, extrusion has to be combined with fiberotomy.
The supporting soft tissue structures will also follow the bone during extrusion without fiberotomy. Kajiyama et al. found that in experimental animals, the free gingiva moved about 90% and the attached gingiva about 80% of the extruded distance. The width of the attached gingiva and the clinical crown length increased significantly, whereas the position of the mucogingival junction remained unaltered.
Relapse tendencies exist in a fairly high percentage of treated malocclusion and it is greatest for rotation corrections. The fibrous elements of the PDL adapt to tooth movement in possibly three mechanisms:
- Progressive osteogenic and cementogenic activity plays an active role in the shortening of the extended fibers during tooth movement
- The stretching of the wavy collagen fibers and reorientation of their directional morphology permit a certain amount of tooth movement
- The existence of a type of intermediate plexus might allow an elongation of fiber bundles by slippage of the fibers over one another and a subsequent reorientation of the fibers in a new position.
Brauer et al. found that transsecting the supracrestal fibers with vertical incisions mesial and distal to the rotated teeth may reduce the danger of relapse. They reported a significant reduction in relapse after an initial retention of 4–8 weeks. Edwards et al. concluded that a simple surgical method of severing all supracrestal fibers attachment of a rotated tooth can significantly alleviate relapse following rotation, without apparent damage to supporting structures of the tooth.
Space closure ,
Wennstrom et al. 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 pockets may enhance the rate of connective tissue loss. They found that orthodontic movement of teeth into infrabony pockets may be detrimental for the periodontal attachment when realignment of teeth that have been tipped and/or elongated as a result of periodontal disease being considered. Hence, periodontal treatment directed at elimination of the plaque-induced lesion should precede the initiation of orthodontic therapy and proper oral hygiene maintained during the orthodontic treatment.
Studies demonstrate that provided periodontal health and a proper oral hygiene standard are maintained during the phase of orthodontic therapy, no injuries, or only clinically insignificant injuries will occur. If oral hygiene is less effective and periodontal inflammation is present during tooth movement, an increased risk for attachment loss was found.
Camilla Tulloch et al. undertook a study to determine the incidence and possible association of gingival invaginations seen during space closure with gingival health and stability of extraction space closure. An infolding or invagination of gingival tissue commonly forms during the orthodontic approximation of teeth. The clinical appearance of these invaginations ranges from a minor one-surface crease in the attached gingiva to a deep cleft that extends across the interdental papilla from the buccal to the lingual alveolar surface. The precise cause of these invaginations remains unclear.
The study revealed that:
- Gingival invaginations occur commonly during orthodontic treatment that involves first premolar extraction and space closure. Although they may decrease in size or even resolve, many invaginations persist for years after treatment
- Invaginations are more common, complex, severe, and persistent in the mandibular arch than in the maxillary arch
- Their formation is not related to the width of the attached gingiva, canine inclination, or overall gingival health
- Gingival invaginations do not seem to be associated with extraction space reopening
- The presence, severity, and complexity of invaginations appear to impair the patient's ability to maintain adequate gingival health in the extraction area.
Traumatic occlusion and orthodontic treatment 
Studies indicate that traumatic occlusion forces:
- Do not produce gingival inflammation or loss of attachment in patients with healthy periodontium
- Do not aggravate and cause spread of gingivitis
- May aggravate an active periodontitis lesion, i.e., may be a co-destructive factor
- May lead to less gain of attachment after periodontal treatment.
Some studies conclude that occlusal adjustments should be carried out in the evidence of trauma after the control of inflammation. Burgett et al. have demonstrated that there is a significant gain in attachment in patients who received occlusal adjustment as part of treatment plan.
Periodontal considerations in surgical exposure ,
It is often seen that teeth have a delayed eruption and at times do not erupt at all. In such conditions, management of the periodontal tissues is very much vital. According to the current concepts, electrosurgery or lasers should be avoided for such cases, but their use could be restricted toward removing the overlying tissue.
Prato et al. compared the width of keratinized gingiva after orthodontic therapy for buccally erupting premolars that had been pretreated by extraction of deciduous teeth alone versus interceptive mucogingival surgery. It was noted that there was no significant difference in the mean width of keratinized tissue at the start of treatment. By the end of treatment, mean width at the site where mucogingival surgery was performed was found to be significantly higher (2.3 mm) than the site where extraction alone was performed (1.3 mm). This proved conclusively that mucogingival surgery was an effective technique to maintain keratinized tissue in correspondence with buccally erupted teeth. Mucogingival interceptive therapy in patients with buccally erupting teeth is performed to prevent the ectopic permanent tooth from developing periodontal lesions.
Christina Hansson reviewed the periodontal status of patients who had unilateral palatal impacted canines and their adjacent incisors 1–18 years post treatment. The results showed greater mesial probing depth of the canines on the treated side, on the adjacent lateral incisors distolingually, and on the first premolars mesiolingually. In general, the results showed a good gingival and periodontal status with slight differences between treated and untreated sides.
Orthodontic force and labial recession ,
Teeth having adequately attached gingiva occasionally develop localized recession during treatment. It has generally been assumed that such destruction has been associated with excessive force that has not permitted repair and remodeling of alveolar bone. It is more likely that the direction and extent of tooth movement have forced the tooth through the cortical plate. This concept is supported in cases of severe gingival recession consequent to tooth movement, in which remaining gingival attachment appears relatively free of inflammation. Such sequelae may be readily explained if the direction of tooth movement has been toward areas of attachment deficiency. When adverse forces and local factors do not exist, however, the prior presence of an unseen dehiscence should be suspected. Chronic marginal gingivitis may rapidly destroy the marginal alveolar bone and gingival attachment during the application of modest forces normally well tolerated by the periodontium.
Mandibular incisors with minimally attached gingiva may be particularly susceptible to the adverse effect of a cross bite or an edge to edge occlusion. If the resulting occlusal forces are in the direction of the inadequate gingival attachment, they may accentuate the destructive capacity of the inflammatory process and crestal alveolar bone may be lost. Orthodontic correction of malaligned teeth may induce a spontaneous improvement in periodontal health. Inflammation and mobility decrease with the improvement in hygiene and occlusal function. Such changes can occur with minimally attached gingiva or localized recession, regardless of the age of the patient.
Sabine Ruf et al. studied the effect of orthodontic proclination of lower incisors in children and adolescents on the possible development on gingival recession. In all patients, Herbst treatment resulted in varying degrees of lower incisor proclination. Either no recession developed or preexisting recession remained unchanged during Herbst therapy. No interrelationship was found between the amount of incisor proclination and recession.
Artun and Kronstad found that gingival recession in adults developed mostly during the active phase of orthodontics and the first 3 years after appliance removal of only negligible recession took place.
Handelmann et al. in a review of nonsurgical rapid palatal expansion cases have shown that buccal attachment loss was not statistically significant for males when the adult expansion group was compared to the adult control group. The average increase in crown length was 0.5 mm. They suggested that patients who demonstrated the largest increase in gingival recession following RME would be the oldest, those who had the greatest maxillary transarch deficiency, those with the greatest amount of transarch expansion, and those who initially had the longest crown heights.
Orthodontic uprighting of mesially tipped molars is accompanied by the elimination of osseous defects and improvement in pocket probing depth and in crown-root ratio. However, in molars with furcation involvement, there is an increased risk of aggravation of the periodontal problem during the orthodontic uprighting procedure. Orthodontic movement of teeth in edentulous areas with reduced alveolar ridge height is, usually, possible with minimal loss of alveolar bone. The movement should be parallel and performed with low orthodontic forces.
In conformity to the present esthetic standards, maxillary gingival display in an attractive adult smile will range between 1 and 2 mm. Increased gingival exposure may be attributed to different causes, which designate the appropriate management: vertical growth of the maxilla, retardation of the physiological apical migration of gingival margins, extrusion of maxillary anterior teeth and anatomical considerations.
Patients with excessive vertical growth of the maxilla, generally, present normal clinical crowns dimensions and healthy gingiva. In growing patients, growth modification should be considered to inhibit vertical growth with orthopedic forces, while management of this condition in adults possibly demands orthognathic surgery including LeFort I osteotomy and maxillary impaction.
Certain patients present a significant retardation of the physiological apical migration of gingival margins, with thick gingival biotype or fibroid gingival tissues and probing depth of gingival sulcus of approximately 3–4 mm, sometimes even without clinical signs of inflammation. Main clinical features of this type of a gummy smile are the short clinical crowns and the apparently increased labiolingual thickness of gingival tissues. This condition is an indication for mucogingival esthetic surgery.
[TAG:2]Periodontal Surgical Procedures Commonly Required during Orthodontic Procedure ,,,,[/TAG:2]
Curettage means scraping of the gingival wall of a periodontal pocket to remove infected and necrotic tooth substance. It removes the inflamed soft tissue lateral to the pocket wall. The aim of curettage is to reduce pocket depth by enhancing gingival shrinkage and new connective tissue attachment.
- It can be performed as part of new attachment attempts in moderately deep infrabony pockets located in accessible areas where a type of closed surgery is deemed advisable
- It can be done as a nondefinitive procedure to reduce inflammation before pocket elimination using other methods or in patients in whom more aggressive techniques are contraindicated
- It is also performed on recall visits as a method of maintenance treatment for areas of recurrent inflammation and pocket deepening.
Gingivectomy means excision of the gingiva. By removing diseased tissue and local irritants, it creates a favorable environment for gingival healing and the restoration of a physiological gingival contour.
- Elimination of suprabony pockets if the pocket wall is firm and fibrous
- Elimination of gingival enlargements.
- When osseous surgery is needed
- Bottom of pocket located apical to the mucogingival location
- Esthetic considerations particularly in the anterior maxilla.
According to Kokich et al. in SEM Orthod 1996, the relationship of the gingival margin of the six maxillary anterior teeth plays an important role in esthetic appearance of teeth. In some instances, it may be necessary to increase the clinical crown length of one or several teeth during or after orthodontic treatment. If a gingival margin discrepancy exists and the patient's lip does not move to expose the discrepancy, then no treatment is required. If the discrepancy is apparent, one of the four possible treatment modalities may be undertaken:
- Intrusion and incisal restoration
- Extrusion with fiberotomy and porcelain crown
- Surgical crown lengthening.
Gingivoplasty is the reshaping of gingiva to create physiologic gingival contours, for the sole purpose of recontouring the gingiva in the absence of pockets. Gingival and periodontal diseases often produce deformities in the gingiva that interferes with normal food excursion, collect plaque and food debris, and aggravate the disease process.
Methods to reduce of relapse of orthodontically treated teeth, especially rotated teeth, include:
- Complete correction or over correction of rotated teeth
- Stable long-term retention with bonded lingual retainers
- Use of fiberotomy.
Periodontal fiber bundles that influence stability are the principal fibers of PDL and the supraalveolar fibers. Fibers of PDL remodel completely only after 2–3 months. The supraalveolar fibers are stable and have a slower turnover. The supracrestal gingival tissues contribute to rotational relapse and hence the technique of “circumferential supracrestal fiberotomy.” The transseptal fibers are cut interdentally by entering the PDL space. Clinical healing occurs in 7–10 days. The fiberotomy procedure is not indicated during active tooth movement or in the presence of gingival inflammation. When performed in healthy tissues after orthodontics, there is minimal attachment loss.
Edwards studied the long-term effect of fiberotomy. It was found that cerebrospinal fluid was more effective in the maxillary anterior than the mandibular arch. It was more effective in alleviating rotational than labiolingual relapse. There was no clinically significant increase in sulcus depth nor any gingival recession that was observed.
Hyperplastic types of frenum with fan-shaped attachment may obstruct diastema closure and hence surgical intervention is desirable. In the past, frenectomy was undertaken. The complication with frenectomy is that the complete removal of the frenum may result in gingival recession between the central incisors. Hence, frenotomy with only partial removal of the frenum with the purpose of relocating the attachment in a more apical direction is currently undertaken. Tissue healing is uneventful although some scarring may occur.
Removal of gingival clefts
Incomplete adaptation of supporting tissues during space closure may result in invaginations or infolding or clefts in the gingiva. A simple removal of only the excess gingiva in the buccal and lingual areas would be sufficient to alleviate the tendency of teeth to separate after space closure.
A simple localized gingivectomy to the bottom of the clinical gingival sulcus will increase the crown length. As shown in a human experimental model, nearly 50% of the excised tissue will regenerate and become clinically and histologically indistinguishable from normal gingiva. This means that if a labial probing pocket depth of 4 mm is recorded on the cuspid, a gain of 2 mm in crown length can be anticipated. Electrosurgery can be used but is no more effective than a scalpel. Even if the excision is extended into the alveolar mucosa, the coronal part of the regenerated gingiva will still become keratinized. Careful oral hygiene procedures, using single-tufted brushes, are required for 2 months after the gingivectomy so that the regenerated gingiva will appear entirely normal.
Distraction osteogenesis of the periodontal ligament
Distraction osteogenesis is the process of growing new bone by mechanical stretching of preexisting bone tissue. A new concept of distracting the PDL is proposed to elicit canine retraction in 3 weeks. This is called dental distraction. The PDL acts as a suture between the bone and the tooth.
Liou and Hang studied patients who needed canine retraction and first premolar extractions in the maxilla and mandible. At the time of first premolar extraction, the interseptal bone distal to canine is undermined grooving vertically inside the extraction socket both buccally and lingually. Activation of 0.5–1 mm/day can be carried out immediately after extraction. Although some tipping was seen, most of the canines were moved bodily. Apical and lateral root resorption of the canine was minimal and there were no periodontal or endodontic complications by this method. It was observed from this study that the PDL can be rapidly distracted without complications.
Changes in the PDL on the mesial side of the canine can be classified into:
- Stretching and widening of the PDL
- Active growth of new bone spicules in the distracted PDL during the 2nd week
- Recovery of the distracted PDL during the 4th week
- Remodeling of striated bone from the 4th week to the 3rd month after distraction
- Maturation of the striated bone.
| Conclusion|| |
The main objective of periodontal therapy is to restore and maintain the health and integrity of the attachment apparatus of teeth. Orthodontic treatment can often correct these problems, or at least prevent them from progressing. In addition, orthodontic therapy can facilitate management of several restorative and aesthetic problems relating to fractured teeth, tipped abutment teeth, excess spacing, inadequate pontic space, malformed teeth, and diastema. Orthodontic treatment may improve periodontal health in these circumstances, but it also holds some potential for harm to the periodontal tissues. Thus, orthodontic treatment can be referred to as a two-edged sword, which may be sometimes very meaningful in increasing the periodontal health status and may be sometimes a harmful procedure, which can be followed by several types of periodontal complications.
We extend our sincere thanks to all college authorities for permitting us to undertake this project and volunteers for extending their valuable support in completing the questionnaire.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Ashley FP, Usiskin LA, Wilson RF, Wagaiyu E. The relationship between irregularity of the incisor teeth, plaque, and gingivitis: A study in a group of schoolchildren aged 11-14 years. Eur J Orthod 1998;20:65-72.
Brown IS. The effect of orthodontic therapy on certain types of periodontal defects. I. Clinical findings. J Periodontol 1973;44:742-56.
Bjørnaas T, Rygh P, Bøe OE. Severe overjet and overbite reduced alveolar bone height in 19-year-old men. Am J Orthod Dentofacial Orthop 1994;106:139-45.
Lindhe J. Textbook of Clinical Periodontology. 2nd
ed. Copenhagen: Munksgaard; 1989.
Proffit WR, Fields HW. Contemporary Orthodontics. 2nd
ed. St. Louis: CV Mosby; 1993.
Reitan K. Biomechanical principles and reactions. In: Graber X, Swain BF, editors. Current Orthodontic Concepts and Techniques. St. Louis: CV Mosby; 1985. p. 92-10.
Folio J, Rams TE, Keyes PH. Orthodontic therapy in patients with juvenile periodontitis: Clinical and microbiologic effects. Am J Orthod 1985;87:421-31.
Melsen B, Agerbaek N, Eriksen J, Terp S. New attachment through periodontal treatment and orthodontic intrusion. Am J Orthod Dentofacial Orthop 1988;94:104-16.
Kozlovsky A, Tal H, Lieberman M. Forced eruption combined with gingival fiberotomy. A technique for clinical crown lengthening. J Clin Periodontol 1988;15:534-8.
Lang NP, Löe H. The relationship between the width of keratinized gingiva and gingival health. J Periodontol 1972;43:623-7.
Wennstrom J, Lindhe J, Nyman S. Role of keratinized gingiva for gingival health. Clinical and histologic study of normal and regenerated gingival tissue in dogs. J Clin Periodontol 1981;8:311-28.
Coatoam GW, Behrents RG, Bissada NF. The width of keratinized gingiva during orthodontic treatment: Its significance and impact on periodontal status. J Periodontol 1981;52:307-13.
Dorfman HS. Mucogingival changes resulting from mandibular incisor tooth movement. Am J Orthod 1978;74:286-97.
Foushee DG, Moriarty JD, Simpson DM. Effects of mandibular orthognathic treatment on mucogingival tissues. J Periodontol 1985;56:727-33.
Maynard JG. The rationale for mucogingival therapy in the child and adolescent. Int J Periodontics Restorative Dent 1987;7:36-51.
Steiner GG, Pearson JK, Ainamo J. Changes of the marginal periodontium as a result of labial tooth movement in monkeys. J Periodontol 1981;52:314-20.
Ericsson I, Thilander B. Orthodontic forces and recurrence of periodontal disease. An experimental study in the dog. Am J Orthod 1978;74:41-50.
Ericsson I, Thilander B. Orthodontic relapse in dentitions with reduced periodontal support: An experimental study in dogs. Eur J Orthod 1980;2:51-7.
Ericsson I, Thilander B, Lindhe J. Periodontal conditions after orthodontic tooth movements in the dog. Angle Orthod 1978;48:210-8.
Ericsson I, Thilander B, Lindhe J, Okamoto H. The effect of orthodontic tilting movements on the periodontal tissues of infected and non-infected dentitions in dogs. J Clin Periodontol 1977;4:278-93.
Zachrisson BU, Zachrisson S. Gingival condition associated with partial orthodontic treatment. Acta Odontol Scand 1972;30:127-36.
Melsen B, Agerbaek N, Markenstam G. Intrusion of incisors in adult patients with marginal bone loss. Am J Orthod Dentofacial Orthop 1989;96:232-41.
Melsen B. Tissue reaction following application of extrusive and intrusive forces to teeth in adult monkeys. Am J Orthod 1986;89:469-75.
Batenhorst KF, Bowers GM, Williams JE Jr. Tissue changes resulting from facial tipping and extrusion of incisors in monkeys. J Periodontol 1974;45:660-8.
Pontoriero R, Celenza F
Jr., Ricci G, Carnevale G. Rapid extrusion with fiber resection: A combined orthodontic-periodontic treatment modality. Int J Periodontics Restorative Dent 1987;7:30-43.
Ingber JS. Forced eruption. I. A method of treating isolated one and two wall infrabony osseous defects-rationale and case report. J Periodontol 1974;45:199-206.
Ingber JS. Forced eruption: Part II. A method of treating nonrestorable teeth – Periodontal and restorative considerations. J Periodontol 1976;47:203-16.
van Venrooy JR, Yukna RA. Orthodontic extrusion of single-rooted teeth affected with advanced periodontal disease. Am J Orthod 1985;87:67-74.
Wehrbein H, Bauer W, Diedrich PR. Gingival invagination area after space closure: A histologic study. Am J Orthod Dentofacial Orthop 1995;108:593-8.
Rönnerman A, Thilander B, Heyden G. Gingival tissue reactions to orthodontic closure of extraction sites. Histologic and histochemical studies. Am J Orthod 1980;77:620-5.
Lindhe J, Svanberg G. Influence of trauma from occlusion on progression of experimental periodontitis in the beagle dog. J Clin Periodontol 1974;1:3-14.
Edwards JG. The prevention of relapse in extraction cases. Am J Orthod 1971;60:128-44.
Robertson PB, Schultz LD, Levy BM. Occurrence and distribution of interdental gingival clefts following orthodontic movement into bicuspid extraction sites. J Periodontol 1977;48:232-5.
Allais D, Melsen B. Does labial movement of lower incisors influence the level of the gingival margin? A case-control study of adult orthodontic patients. Eur J Orthod 2003;25:343-52.
Djeu G, Hayes C, Zawaideh S. Correlation between mandibular central incisor proclination and gingival recession during fixed appliance therapy. Angle Orthod 2002;72:238-45.
Kraal JH, Digiancinto JJ, Dail RA, Lemmerman K, Peden JW. Periodontal conditions in patients after molar uprighting. J Prosthet Dent 1980;43:156-62.
Pontoriero R, Carnevale G. Surgical crown lengthening: A 12-month clinical wound healing study. J Periodontol 2001;72:841-8.
Oliveira MT, Molina GO, Furtado A, Ghizoni JS, Pereira JR. Gummy smile: A contemporary and multidisciplinary overview. Dent Hypotheses 2013;4:55-60. [Full text]
Sanders NL. Evidence-based care in orthodontics and periodontics: A review of the literature. J Am Dent Assoc 1999;130:521-7.
Bollen AM. Effects of malocclusions and orthodontics on periodontal health: Evidence from a systematic review. J Dent Educ 2008;72:912-8.
Bollen AM, Cunha-Cruz J, Bakko DW, Huang GJ, Hujoel PP. The effects of orthodontic therapy on periodontal health: A systematic review of controlled evidence. J Am Dent Assoc 2008;139:413-22.
Gray D, McIntyre G. Does oral health promotion influence the oral hygiene and gingival health of patients undergoing fixed appliance orthodontic treatment? A systematic literature review. J Orthod 2008;35:262-9.
van Gastel J, Quirynen M, Teughels W, Carels C. The relationships between malocclusion, fixed orthodontic appliances and periodontal disease. A review of the literature. Aust Orthod J 2007;23:121-9.