A successfully treated case of severe periodontitis using interdisciplinary approach: Report of a case.

Treatment options for severely misaligned teeth with advanced bone loss are limited. We report the management of a case of advanced periodontitis in a labially placed extruded maxillary canine. A 24 years old male reported to the periodontal clinic to preserve his mobile and misaligned upper left lateral incisor. Clinical and radiographic examination revealed advanced attachment loss with bone resorption around the affected tooth. The decision was taken to reconstruct the lost periodontal tissues in coordination with orthodontic intervention to align the tooth in a functionally esthetic position. At the end of the combined periodontal and orthodontic treatment, the tooth was preserved and was well-aligned in the arch; the patient was satisfied with the treatment outcome. It can be concluded that severely misaligned teeth with advanced bone loss can be salvaged with a combined and meticulously planned Periodontal Orthodontic treatment approach.

INTRODUCTION

Misaligned teeth are more prone to periodontal disease as compared to normally aligned teeth as they act as nidus for plaque accumulation and maintaining oral hygiene around them is a difficult task. Also, studies have shown that the number of pathological microorganisms is much higher around misaligned teeth as compared to well-aligned teeth.[1] It is advocated that preventive orthodontic treatment should be delivered in such cases to prevent the occurrence of periodontal diseases and studies have shown that orthodontic treatment can positively affect the periodontal health.[234] On the other hand, severely misaligned teeth with advanced periodontitis are difficult to treat with a guarded long-term prognosis. The presence of inadequate bone support results in pathological tooth migration and mobility, which further deteriorates the condition resulting in both esthetic as well as functional problems to the patients as the success of orthodontic therapy in periodontally compromised teeth is limited. Most often, the result of such cases, failure of both periodontal as well as orthodontic treatment causing loss of affected tooth. We report an interesting case of a severely misaligned maxillary lateral incisor having the poor periodontal support that was treated successfully by meticulous periodontal treatment with orthodontic intervention.

CASE REPORT

A 24-year-old male reported to the Department of Periodontology, HPGDC, Shimla, HP with a chief complaint of extruded and badly positioned mobile upper left front tooth. On examination the upper left lateral incisor was found to be below the level of the occlusal plane of adjacent teeth, was buccally drifted and had Grade II mobility with a 10 mm deep periodontal pocket. Radiographic evaluation revealed vertical bone defect extending until the middle one-third of root, there was no bone defects or loss of attachment in the rest of the dentition [Figure 1]. Endodontic consultation was taken to rule out any pulpal pathology. There was no medical history associated. A primary diagnosis of severe localized chronic periodontitis resulting in extrusion and misalignment of the affected tooth was made based on the clinical findings. A two-pronged treatment plan was devised with the main aim to preserve the tooth by treating the periodontal disease and promoting the regeneration, followed by orthodontic treatment to align the tooth in the arch for long-term maintenance and esthetic reasons. Clinical pictures and cast (models) were made and decision was taken to start the Phase I periodontal therapy which included SRP and oral hygiene instructions. Once the Phase I periodontal therapy was completed, it was noticed that vertical bone defects and clinical attachment loss were still persistent, therefore the decision to initiate Phase II periodontal therapy was taken to reconstruct the lost periodontal support. Open flap debridement using Kirkland flap was done under local anesthesia and the bone defect was filled using bio-oss* (Bone graft material). The flap was re-approximated and sutured. The sutures were removed after a week, and the patient was placed on a maintenance and recall program, which included a recall visit every 2 weeks for first 1-month, followed by every 3 weeks for 6 months postoperatively. At the end of 6 months, there was a gain in clinical attachment gain by 7 mm, reduction in pocket depth by 2 mm, and there was no mobility. Intraoral periapical radiographs also showed evidence of bone formation. At this stage, the patient was referred to the Department of Orthodontics for alignment of the tooth to its original position.

Figure 1

Severe periodontitis in relation to maxillary left lateral incisor resulting in extrusion and unesthetic appearance

A full 0.22” preadjusted edgewise appliance was bonded to the maxillary arch and special attention was taken in using light force to achieve alignment and leveling with 0.14” NiTi archwire. Step by step ligation of 0.14” NiTi archwire was performed before inserting the archwire into the bracket slot that took 4 months. 0.16 × 0.22 NiTi archwire was ligated for 3 months for perfect slot leveling before space closure. After achieving the slot leveling, space closure was performed with 0.19 × 0.25 SS archwire and the wire was left passive for 3 months before debonding. A bonded retainer was given for 6 months after debonding the case. During the whole period of orthodontic treatment, the patient was put on supportive periodontal therapy [Figure 2].

Figure 2

Patient's condition at the initiation of orthodontic therapy (6 months)

At the end of orthodontic treatment (i.e., 1-year after initiating the orthodontic treatment), the tooth was aligned properly, and a retention appliance was given to maintain its position in the arch. The patient was satisfied with the treatment outcome [Figure 3].

Figure 3

Well-aligned maxillary leftt lateral incisor and a satisfied patient at the end of the treatment

DISCUSSION

The ultimate aim of periodontal therapy is to regenerate the lost periodontal tissue and attain a sustainable environment for good long-term maintenance and health of the periodontal tissue. Orthodontic treatment plays a vital role in achieving the goal by positioning the misaligned tooth properly in the arch and achieving adequate contacts with the tooth in the adjacent and opposing arch, which in turn prevents any undue trauma from occlusion and plaque accumulation. Although the treatment results are predictable in most of the cases of mild periodontitis requiring orthodontic corrections, the prognosis is questionable in cases of moderate to severe periodontitis cases and most of the orthodontists are reluctant to provide orthodontic therapy suggesting inadequate periodontal support. A predictable treatment outcome in such “Perio-ortho” cases demands a well-coordinated approach between the orthodontist and the periodontist. The present case report shows successful treatment outcome in severe periodontitis with pathologic tooth migration by combined periodontal-orthodontic effort.

After properly assessing the case, a meticulous treatment plan was made which included thorough periodontal management along with orthodontic correction for better long-term prognosis. The decision was taken first to remove the cause for pathologic migration that is periodontitis and stabilize the tooth to achieve periodontal regeneration. Six months after attaining the desired results, orthodontic treatment was initiated to manage the pathologic migration and subsequently attain the desired dentofacial appearance of the patient as studies have shown that after proper periodontal therapy, orthodontic treatment can positively improve both alveolar bone and the soft periodontal tissues.[5] Since the case was dentoskeletal class 1 with mild spacing in upper anterior and extruded left lateral incisor due to pathological migration, the orthodontic treatment was planned for intrusion and alignment of the extruded lateral incisor. At the end of the orthodontic therapy, the tooth was moved back to its original position successfully with the evidence of bone formation. Based on the current evidence suggested in the literature, permanent retention was given to eliminate the risk of relapse and secondary occlusal trauma.[6] The above case report supports the fact that periodontal therapy in combination with adjuvant orthodontic treatment can definitely improve periodontal health and overall physical appearance and self-esteem of the patient.[789] This case report also underscores the fact that an adequate maintenance program and a good patient motivation are very important for achieving the desired treatment outcomes and even severe periodontitis cases with limited bone support can be treated successfully by a well-coordinated periodontal-orthodontic management.[10]

SUMMARY

Declaration of patient consent

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Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.