Treatment of Periodontally Compromised Teeth using Adjunctive Orthodontic Therapy

JIOS

The Journal of Indian Orthodontic Society, October-December 2010;44(4):115-118 115

Treatment of Periodontally Compromised Teethusing Adjunctive Orthodontic Therapy:

A Multidisciplinary Approach1Ratna Padmanabhan, 2Sailesh Deviah, 3Suchindran, 4Piush Kumar, 5Gagan Deep Singh

CASE REPORT

Received on: 5/10//10

Accepted after Revision: 13/12/10

ABSTRACT

Periodontal disease and its sequelae often lead to an unesthetic appearance and functional problems which may be also associated withrestorative problems. Adult orthodontic therapy has a role in providing a complete rehabilitation in terms of both appearance and functionwith a satisfactory long-term prognosis, if the patient is reasonably motivated and responds well to the initial periodontal therapy. In thisarticle, we have shown two case reports to aptly describe the benefits of adjunctive orthodontic treatment for restoration of esthetics as wellas function in a compromised patient.Keywords: Periodontics, Esthetics, Multidisciplinary treatment, Compromised teeth.

How to cite this article: Padmanabhan R, Deviah S, Suchindran, Kumar P, Singh GD. Treatment of Periodontally Compromised Teethusing Adjunctive Orthodontic Therapy: A Multidisciplinary Approach. J of Ind Ortho Soc 2010;44(4):115-118.

INTRODUCTION

Today with more and more emphasis on multidisciplinaryapproach for the complete rehabilitation of patients we areseeing an ever increase in periodontally compromised patientsrequiring adjunctive orthodontic treatment. The long-termsuccessful outcome of orthodontic treatment in these patientsis influenced by the patient’s periodontal status before, duringand after active orthodontic therapy, which also includes post-treatment maintenance by the patient. Periodontal pathogenesisis a multifactorial etiologic process and it is imperative for usto recognize the clinical forms of inflammatory periodontaldiseases. Cooperation between different specialties in dentistryis extremely important in establishing diagnosis as well as intreatment planning. The most commonly encountered problemsin periodontally compromised patients are migration, extrusion,

flaring of teeth or missing teeth which may further cause tippingof adjacent teeth. It is important for the clinician to differentiatebetween what is possible in an adult and to what extent theproblem can be corrected.

Different types of tooth movements generate different forcedistributions. The force magnitude is often the only parameterto be considered by the operating clinician while treatingperiodontally compromised teeth. One of the most debatablemovements in these patients is intrusion of teeth. Extrusion ofteeth due to severe periodontal damage of teeth can be correctedby aligning them using light orthodontic forces. This may becalled as “intrusion” but not “true intrusion”.1

The two case reports discussed here describe the benefitsof using adjunctive orthodontic therapy, for unestheticappearance due to extruded anterior teeth as a result of severeperiodontal damage. The treatment outcome revealed areduction in clinical crown length and better bone support ofthe intruded teeth and good esthetics.

CASE REPORTS

Case 1

A female aged 24 years, complained of migration of upper frontteeth for the past 2 years. She complained of discoloration,mobility and compromised esthetics due to extrusion andslanting of left upper central incisor and extruded right uppercentral incisor. On examination, the patient was in good healthand had no history of any medical problems. She had a historyof trauma at 9 years of age in maxillary right central incisor androot canal treatment had been done for the same. On clinicalexamination (Fig. 1A), brownish discoloration was seen in that

1,2,5Professor, 3Senior Lecturer, 4Reader1,3Department of Orthodontics, Meenakshi Ammal Dental College andHospital, Chennai, Tamil Nadu, India2,4Department of Orthodontics, ITS Centre for Dental Studies andResearch, Muradnagar, Ghaziabad, Uttar Pradesh, India5Department of Prosthodontics, Eklavya Dental College, KotputliRajasthan, India

Corresponding Author: Ratna Padmanabhan, ProfessorDepartment of Orthodontics, Meenakshi Ammal DentalCollege and Hospital, Alapakkam Main Road, MaduravoyalChennai-600095, Tamil Nadu, India

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tooth. Marginal and papillary gingival inflammation was seenin relation to maxillary central incisors and left lateral incisor.Grade II mobility was observed in the central incisors.

On periodontal examination, the maxillary central incisorswere extruded and found to have deep pockets mesially anddistally. A probing depth of 6 mm, 5 mm and 5 mm was foundin relation with right central, left central and left lateralrespectively. There was no evident pus discharge, thoughbleeding on probing was present.

Radiographic examination (Fig. 1B) revealed localizedsevere bone loss with deep angular bony defect associated withdistal aspect of left central incisor and mesial aspect of rightcentral incisor, horizontal bone loss in relation to left lateraland periodontal widening in relation to right central incisor.Periapical radiolucency was also seen in relation to the rightlateral incisor.

The patient was advised root canal treatment in relation tothe right lateral incisor followed by periodontal therapy. Initialtreatment consisted of scaling, root planing and surgicalcurettage in relation to the centrals and left lateral incisors,followed by adjunctive orthodontic therapy. After the activeperiodontal treatment, 6 weeks of healing time was advisedbefore commencement of orthodontic treatment. The probingpocket depth reduced to 4 mm in relation to mesial of rightcentral incisor and 3 mm in relation to distal of left central andlateral incisors. No evidence of periodontal inflammation andbleeding on probing was observed.

Adjunctive orthodontic treatment was done using Beggappliance. The teeth were aligned using 0.014 NiTi wiresectionally engaged onto a 0.016 inch SS arch wire. The force

levels were kept to a minimum so as to prevent furtherperiodontal damage. It took 14 months to complete theorthodontic treatment where in the extrusion, axial inclinationand the spacing were reasonably corrected (Fig. 1C).

Mobility reduced to grade I. Lingual bonded retainer wasgiven to provide permanent retention until the completion ofhealing and new bone formation. Radiographic examinationrevealed good bone support in relation to the anteriors. Theangular bony defect had considerably reduced. Periodontalwidening was still evident in relation to right central incisordue to the orthodontic movement (Fig. 1D).

Case 2

A female aged 22 years reported with a complaint of migrationand mobility of her front upper teeth. She had a history ofpregnancy gingivitis 18 months back which was not treated.She was in good health and had no medical ailment.

On examination, teeth showed discoloration due to fluorosis(Fig. 2A). The central incisors were proclined, extruded andwere rotated mesiolabially (Fig. 2C). An unesthetic blacktriangular space due to papillary recession was seen betweenthe central incisors. Blunt papilla was observed between thecentrals and left central and lateral incisors due to loss of contact.Grade II mobility and gingival recession (Fig. 2A) was observedin central incisors. Cementoenamel junction was exposedlabially and lingually. Probing pocket depth was 3 mm inrelation with the central incisors but loss of attachment was5 mm on the distal and palatal surfaces and 3 mm on mesialand labial surfaces of all the incisors. No evidence of pusdischarge.

Figs 1A to D: Pretreatment and Post-treatment photographs and radiographs. (A) Pretreatment intraoral view, (B) pretreatment OPG,(C) post-treatment intraoral view, (D) post-treatment OPG

Treatment of Periodontally Compromised Teeth using Adjunctive Orthodontic Therapy

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The Journal of Indian Orthodontic Society, October-December 2010;44(4):115-118 117

Figs 2A to F: Pretreatment and Post-treatment photographs and radiographs: (A) Pretreatment intraoral view, (B) post-treatment intraoralview, (C) pretreatment occlusal view, (D) post-treatment occlusal view, (E) pretreatment OPG, (F) post-treatment OPG

Radiographic finding showed furcation involvement withangular bone defects in relation to maxillary and mandibularright first molar. Angular bone defects were also seen in rightupper and lower second premolars (Fig 2E). Horizontal boneloss in relation to all the maxillary incisors and widening ofperiodontal ligament space in relation to the central incisorswas seen. The periodontal treatment included scaling and rootplanning. Around 4 weeks of good oral hygiene maintenanceand frequent recalls were followed by the orthodontic treatment.

Adjunct orthodontic treatment was done using preadjustededgewise appliance. A 0.014 inch NiTi was used for initialalignment for minimal orthodontic force followed by 0.014 inchSS wire. Right maxillary first molar was not included inorthodontic treatment due to reduced periodontal support. Theanchorage was derived from the second molar in the maxillary

right quadrant. A good alignment (Fig. 2F) was achieved in 9months and fixed lingual bonded retainer was given forretention. Acceptable esthetics was achieved by this adjunctivetherapy.

DISCUSSION

The goal of orthodontic treatment is not only to improve facialesthetics and function but also to address the health of supportingstructures and how teeth are placed in them. The inter-relationship between orthodontics and periodontics oftenresembles symbiosis. In many cases, periodontal health isimproved by orthodontic tooth movement, whereas orthodontictooth movement is often facilitated by periodontal therapy.

Elongated and spaced incisors are common problems inpatients suffering from severe periodontal disease. Intrusion

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alters the cementoenamel junction and angular crest relation-ships, and creates only epithelial root attachment, therefore, aperiodontally susceptible patient is at greater risk of futureperiodontal breakdown, if the patient does not maintain properoral hygiene. Tooth movement, when properly executed,improves periodontal condition and is beneficial to periodontalhealth. Orthodontic forces, when kept within biological limits,do not induce tissue alterations leading to loss of connectivetissue attachment and periodontal pocket formation. The gingivamoves in the same direction as that of tooth intrusion but itmoves only by about 60%. Gingival sulcus gets deepened byabout 40% of tooth intrusion.

The intrusion of periodontally damaged teeth is considereda logical approach in clinical practice. The concept has,however, been highly debatable among the clinicians. Bringingthe teeth closer to the palatal bone may convert suprabonypockets to infrabony defects, thereby enhancing potential forreattachment of periodontium, if inflammation of the overlyingtissue could be controlled.2,5 However, the outcome of thisapproach is highly dependent on the oral hygiene maintenance.Melsen et al (1989)3 found that incisor intrusion in adult patientswith marginal bone loss had a beneficial effect where the posttreatment radiographs showed positive bone remodeling. Theyalso reported that a new connective tissue attachment can beformed during the intrusion of periodontally involved teeth, ifgingival inflammation is eliminated and root surfaces areadequately scaled.

Since orthodontic movement of teeth into inflamedinfrabony pockets may create an additional periodontaldestruction, and because infrabony pockets are frequently foundin teeth that have been tipped or elongated as a result ofperiodontal disease. It is essential that periodontal treatmentwith elimination of the plaque induced lesion be performedbefore the initiation of orthodontic treatment. Maintenance ofexcellent oral hygiene during the course of treatment is equallyimportant.

Vardimon et al ( 2001) found that orthodontic toothmovement is a stimulating factor of bone apposition. Conversionin repair pattern was seen which supported the link betweentooth movement and enhanced bone deposition. Clinicalimplication suggests incorporation of orthodontic toothmovement in regenerative therapy. Nelson and Artun (1997)4

found a close relation between age and cumulative loss ofattachment. Adult orthodontic patients are more likely to presentwith periodontal pockets than adolescents. Mean bone loss inadults not undergoing orthodontic therapy was found to be 0.07to 0.11 mm. Bone loss for the average orthodontic patient wasfound to be 0.31 mm suggesting that adults have an increaserate of periodontal breakdown. On further analysis, they foundthat even though the bone loss is more the risk of severegeneralized attachment loss was very low. They concluded thatorthodontic treatment of adults may not be associated withincreased periodontal breakdown.

The finding that resorption comprised only the periodontalside of the alveolar bone indicates that a cone-shaped bonedefect is created along with the intrusion, which according tosome authors is conducive for reattachment procedure. Nandaet al (1996)6 studied the extent of root resorption due tointrusion. Results indicated that intrusion with low forces canbe effective in reducing overbite while causing only a negligibleamount of apical root resorption. McFadden et al (1989)7 foundan average root shortening of 1.8 mm per tooth irrespective ofthe amount of intrusion.

Schwarz postulated that forces of about 25 gm/cm2 equalto blood pressure of PLD terminal capillaries should be optimalfor tooth movement, while larger forces would block PDL bloodflow, leading to tissue necrosis at compressed areas. Hence,necrosis caused is not due to the direct destructive effect oflarge orthodontic force but rather to stagnation of blood supplyto the area. Due to the low force of 10 to 25 gm that was used inthe patients there were no detrimental effects in the pulp.

CONCLUSION

Intrusion constitutes a reliable therapeutic method in orthodontictreatment of adult patients with heavy periodontal condition. Itcan be concluded that intrusion of teeth with a reducedperiodontium should only be carried out in patients with ahealthy periodontium without pathologically increased pockets.In both patients, the treatment proved beneficial on theperiodontal condition of the patients when judged at the clinicaland radiographic levels. Acceptable esthetic was achieved whichhad a positive effect on their confidence levels. The treatmentoutcome also proved to be a good motivational factor tomaintain good oral hygiene.

REFERENCES

1. Melsen B. Tissue reaction to orthodontic tooth movement: Anew paradigm. EurJ Orthod 2001;23:671-81.

2. Melsen B. Tissue reaction following application of extrusiveand intrusive forces to teeth in adult monkeys. Am J Orthod1986;89:469-75.

3. Melsen B, Agerbaek N, Markenstam G. Intrusion of incisors inadult patients with marginal bone loss. Am J Orthod1989;96:232-41.

4. Nelson PA, Artun J. Alveolar bone loss of maxillary anteriorteeth in adult orthodontic patients. Am J Orthod Dentofac Orthop1997;111:328-34.

5. Melson B, Agerbaek N, Eriksen J, Terp S. New attachmentthrough periodontal treatment of orthodontic intrusion. Am JOrthod Dentofac Orthop 1988;94:104-16.

6. Nanda R, Costopoulos G. An evaluation of root resorptionincident to orthodontic intrusion. Am J Orthod Dentofac Orthop1996;109:543-48.

7. McFadden WM, Engstrom C, Engstrom H, Anholm JM. A studyof the relationship between incisor intrusion and root shortening.Am J Orthod Dentofac Orthop 1989; 96:390-96.