Ortho-perio integrated approach in periodontally compromised patients.

It is an undisputed fact that sound and strong periodontal health is a must in patients seeking orthodontic treatment. Does this mean that we are going to deny orthodontic treatment for those adults whose number is rising, more often secondary to periodontal deterioration and pathological migration of teeth resulting in aesthetic and functional problems? Need of the hour is to have an integrated approach where in periodontal treatment precedes orthodontic treatment to restore periodontal health. Orthodontic treatment should be performed under strict plaque control measures to place the teeth in a structurally balanced and functionally efficient position. Aim of this article is to familiarize the practicing clinicians both in the field of orthodontics and periodontics with current thoughts and successful clinical techniques used in the field of periodontology to regenerate lost periodontal structures. Furthermore, it aims to integrate such techniques into the orthodontic treatment of patients with severe bone loss.

INTRODUCTION

Multidisciplinary approach is often necessary to treat complex dental problems in our patients and there cannot be a better example than ortho perio interaction. Orthodontic treatment is based on the principle that if prolonged pressure is applied to a tooth, it will move as the surrounding bone remodels. Bone is selectively removed in some areas and added in others. In essence, the tooth moves through the bone carrying its attachment apparatus with it, as the socket of the tooth migrates. Since this response is mediated by the periodontal ligament, tooth movement is primarily a periodontal ligament phenomenon.[1]

This being the situation, it is mandatory to see that good periodontal health prevails before, during, and after orthodontic treatment. It could be an oral prophylactic procedure in adolescent patients or advanced periodontal treatment in adults so as to eliminate the presence of inflammation in the presence of which carrying out orthodontic treatment will have deleterious effect. The orthodontic literature has presented different treatment modalities for the management of adult orthodontic patients with mild to moderate bone loss. However, the management of adult orthodontic patients with severe bone loss continues to present a challenge. All the experienced clinicians would agree that a well aligned dentition may be more conducive to periodontal health than a crowded dentition. The most important factor in the initiation, progression, and recurrence of periodontal problems is the presence of microbial plaque. Inadequate maintenance of oral hygiene during orthodontic treatment increases the risk of developing gingival inflammation. There is evidence of increase in the lactobacillus count in saliva after appliance placement.[2]

Many adult patients seek orthodontic treatment for aesthetic improvement due to the mal-alignment of the anterior teeth secondary to periodontal breakdown. But the aesthetics may not be the only concern for the clinician as malocclusion more often than not leads to trauma from occlusion, which would aggravate the deterioration of the dentition.

In a follow-up study on 22 patients with up righted mandibular molars after an average of 3.5 years, it was reported that pockets on the mesial surfaces were shallower on the up righted teeth than on the control teeth.[3] Some case reports have reported that a reduction of probing depths in bony defects following tooth extrusion can also be achieved.[4] The combination of orthodontic intrusion and periodontal treatment has also been shown to improve periodontal conditions in animals provided oral hygiene is maintained and tissues are healthy.[5]

Intrusion of incisors in adult patients with marginal bone loss and deep overbite has been reported to cause root resorption varying from one to three mm. It is suggested that intrusion is best performed with low forces (5-15 g/tooth) to minimize root resorption.[6] Studies have also shown that moving teeth into adjacent osseous defects, orthodontic extrusion with or without fiberotomy, and labial tipping of anterior teeth can be successfully accomplished without jeopardizing the periodontal support in the presence of adequate plaque control.[7]

Guided tissue regeneration (GTR), demineralized freeze-dried bone allograft, or a combination of these are considered to be the most predictable regenerative procedures for achieving favorable treatment outcomes. These findings were further supported by several researchers who established a large body of clinical evidence that clearly indicated periodontal bone grafts consistently led to better bone fill of the defect than the non grafted controls. Histological analyses of cementum regeneration in experimental animals have conclusively demonstrated that regenerative treatment with bone grafting leads to some degree of regenerated bone, cementum, and periodontal ligament.[8]

General factors, such as the morphology of the defect, plaque control, and patient compliance can directly affect the predictability of periodontal regeneration. Defect selection is critical to achieve a successful outcome. Deep and narrow defects show the most predictable positive response to regenerative procedures where as shallow defects show poor results. In such a scenario, orthodontic intrusion can change a horizontal bone defect into a deep and narrow defect that is more favorable for regeneration of the periodontium through grafting procedures[8] [Figure 1].

Figure 1

(a) Severe bone loss, spacing and extrusion of incisors. Horizontal defect (H) around maxillary left central incisor. (b) Orthodontic intrusion changes the topography of the defect into a vertical (V) defect and narrow defect. (c) Orthodontic intrusion in the presented case changing the topography of the original horizontal defect. (d) One wall defect in relation to right central incisor prior to periodontal regenerative surgery

Therefore, the field of orthodontics should consider the combined regenerative and periodontal surgical treatments an invaluable addition to the armamentarium available for the orthodontic treatment of adult patients with severe loss of periodontal tissues. Similarly, the field of periodontics should recognize the importance of orthodontic intervention in achieving results unattainable with periodontal treatment alone.

The treatment consideration

Patients with advanced periodontal disease may experience tooth migration involving single or multiple teeth. The most common symptoms include tipping and extrusion of one or more incisors and the development of spaces between the anterior teeth. The management of such cases requires judicious interdisciplinary treatment planning by the periodontist and the orthodontist. In the present article, the critical role of the orthodontist in changing the topography of a bony defect to a more favorable shape is highlighted (i.e., a horizontal defect to a vertical, narrow, and deep defect) followed by regenerative procedure by the periodontist to restore the vertical defects towards favorable clinical outcome.

CASE REPORT

A patient aged 19 years reported to the department of Orthodontics and Dentofacial Orthopedics at AECS Maaruti Dental College, Bangalore, with forwardly placed front teeth. On examination, on the class 1 skeletal base, she had proclined maxillary and mandibular anterior teeth with spacing, deep bite, crowding in the posterior segment with scissor bite. On soft tissue examination, she had inflamed gingiva with deep periodontal pockets. The patient was referred to the department of periodontics for further investigation and opinion. They diagnosed her to be having chronic localized periodontitis compounded with trauma from occlusion. On clinical examination, grade III mobility of maxillary anterior teeth was seen [Figure 2].

Figure 2

Preoperative photographs and OPG

After inter departmental discussion on the treatment plan, it was decided to proceed with following steps in this case:

Phase I therapy comprising of scaling and root planing before orthodontic treatment.

Alignment of the teeth with light forces using copper NITI wires after extraction of 15, 24, 34, and 44.

Continuous monitoring of periodontal health with periodic scaling and root planing and administration of Gengigel™§ (0.8% hyaluronic acid) to improve the attachment was coordinated by the periodontist.

After evaluation, regenerative periodontal therapy comprising of GTR and bone graft for the osseous defect.

After the initial prophylactic treatment, we started with the orthodontic treatment. 022 slot PEA was used in this case. Special attention was taken in using light forces to achieve leveling and aligning. For the next phase of retraction and space closure in the mandibular arch, we used 19×25 SS wires and the same was achieved [Figure 3].

Figure 3

Mid treatment photographs and OPG, retraction and space closure

Continuous periodontal follow-up comprising of scaling and root planing with interventional Gengigel™ application in the anterior region was performed with favorable results [Figure 4, Table 1].

Figure 4

Effect of Gengigel™ (0.8% hyaluronic acid gel)

Table 1

Effect of gengigel™ probing depth and CAL

The challenge was in the maxillary arch where we had to achieve retraction and intrusion. We used 17×25 NITI arch wire with RCS design and light elastic chain to simultaneously intrude and retract the anterior teeth. At this juncture, we decided to do intentional root canal treatment for maxillary anterior teeth to avoid any endo-perio cross infection [Figure 5].

Figure 5

Post orthodontic treatment. Root canal therapy done with maxillary incisors

As the desired movements were achieved, we shifted to 19×25 stainless steel wire incorporated with curve of spee design. This helped us to intrude and retract the anterior segment as well as to convert the horizontal bone defect to a vertical defect which can receive and retain graft material [Figure 6].

Figure 6

Post orthodontic treatment

On achieving the short term orthodontic objectives such as alignment, good contacts, absence of rotations, class I occlusion with good cusp to fosse relation and good facial balance; periodontal regenerative surgery was performed for 12–21. GTR with bone graft [DuoPack™¥–collagen membrane and reinforced tri calcium phosphate bone graft] in region of vertical defect 12-11 [Figure 7].

Figure 7

(a) Vertical defect wrt 11-12. (b) Bone graft and guided tissue regeneration wrt 11-12 [DuoPack™]

Two weeks post surgically, we decided to remove the orthodontic appliance followed by lingual splinting [Figure 8].

Figure 8

Post Op

Prognosis

This depends on patient education and maintenance. Periodic follow-up after periodontal surgery is essential.

CONCLUSION

Orthodontic procedures in periodontally compromised patients require extensive periodontal care/consideration to maintain the periodontium in a healthy condition during and after treatment. Minor periodontal surgery may be required to prevent relapse after orthodontic treatment in addition to the lingual bonded retainers on a long term basis. Inter disciplinary approach complimented by patient education and continued care of good oral hygiene will transform patients with unattractive dentition due to migrated teeth secondary to periodontal breakdown and inflamed periodontium into individuals with attractive dentition and radiant smile.

Since there is a close relationship between orthodontic treatment and periodontal health and vice versa, an understanding of the ortho-perio relationship will help in bringing the best possible results in needy patients.