Periodontal Consideration Before and After ... - Dr. Frank Hsieh

Periodontal Consideration Before and AfterOrthodontic TreatmentTsung-Ju Hsieh, D.D.S., M.S.D.1

Potential periodontal problems• Before Orthodontic Treatment• During Orthodontic Treatment• After Orthodontic Treatment2

Before Orthodontic Treatment• Malocclusion vs. Periodontitis• Sequence of Treatment?– Periodontal surgery?• Gingival Recession?– Prevention?3

Malocclusion vs. Periodontitis• Malocclusion has little if any impact ondiseases of the teeth (caries) or supportingstructures (periodontitis).– Helm S. Acta Odontol Scand 1989• Motivation determine oral hygiene muchmore than how well the teeth are aligned.• Plaque is the major determinant.4

Malocclusion vs. Periodontitis• Comparison of periodontal status 10-20 years afterortho treatment: orthodontic treated patient =untreated individuals → no benefit of orthodontictreatment on future periodontal health → untreatedmalocclusion doesn’t have a major role in thecause of periodontal problems.• Long-term studies showed no indication thatorthodontic treatment increased the chance of laterperiodontal problems5

Adult orthodontics with periodontitis• >75% have periodontitis by age 40• Beginning gor even advanced periodontalbreakdown does not contraindicate orthodontictreatment• 2 major types of periodontal findings in orthopatients:– Mucogingival problems: inadequate attached gingiva– Inflammatory lesions of the gingiva or periodontium6

• The prevalence of periodontal disease is afunction of age.•The prevalence of mucogingival g problemspeaks in their twenties.7

• Persistent bleeding on probing is the bestindicator of active and presumablyprogressive periodontal disease.8

• Tooth movement in adults with reduced buthealthy periodontium did not result infurther significant loss of attachment (noneof the adults had mean loss of attachment ofmore than 0.3mm)– Boyd, 198910

Ortho vs. Perio• Orthodontic tooth movement + poorlycontrolled periodontal health → rapid andirreversible breakdown of the periodontalsupport apparatus.• Initiate ortho tx at least 6 months after fullperio tx to allow healing and resolution ofinflammation.11

Positive architecture13

Periodontal Surgery before orafter Orthodontic Treatment?• A nondefinitive open flap curettage prior toorthodontic intervention– eliminate gross inflammation– enhance attachment at a more coronal level14

Periodontal Surgery before orafter Orthodontic Treatment?• Guided-tissue regenerative (GTR) surgery– May result in spontaneous realignment ofmaxillary incisors.– This suggests that GTR should be performedwell in advance of orthodontic ti treatment, t t andthe need for tooth movement reassessed whenhealing is complete• Periodontal surgery for pocket eliminationshould follow orthodontic treatment15

Gingival Recession16

Gingival recession•Cause:– Toothbrush trauma– Plaque-induced inflammation– The stretching and thinning of the gingiva thatmight be created by labial tooth movement.• Gingival thickness is more important thansurface quality (keratinized or non-keratinized)17

Root coverage needed?• An abrasion defect is evident in theroot surface. The tooth brushingtechnique was adjusted to minimizethe trauma to the tissue.• Because the tooth was planned tobe moved in disto-lingual direction,surgical correction of the recessiondefect was postponed untilcompletion of the tooth movement.• The reduction in the recession andthe increase of the gingiva zone thathas taken place as a consequence ofthe changed position of the tooth.18

Gingival Recession• The gingival dimensions will increase because ofgrowth in the alveolar process and that teeth willoften change their position in a bucco-lingualdirection in the developing dentition,mucogingival problems such as recession typedefects will often be eliminated spontaneously inthe growing child, provided adequate plaquecontrol is established and maintained.– Powell, 1982; Persson 1986; Andlin-Sobocki 199119

Gingival Recession• Reparative surgical treatment of recessiontype defects in the developing dentition maynot be necessary and should therefore bepostponed p until growth is completed.20

Adequate Attached Gingiva?• 2 mm of keratinized gingiva (corresponding to 1mm attached gingiva) is adequate to maintaingingival health (not correct any more)– Lang and Loe, 1972• A certain quantity of gingiva does not seem to beessential for the maintenance of periodontal healthand the preclusion of recession.– Wennstrom, 199421

Adequate Attached Gingiva?• the incidence of recession in areas withoutan attached portion of gingiva g was notgreater than that observed in areas with awide area of attached gingivag– Schoo, 1985; Kisch, 1986; Wennstrom, 1987;Freedman, 199222

Surgical treatment toprevent recession?• Surgical treatment with the sole purpose ofincreasing the apico-coronal width of thegingiva to maintain periodontal health andprevent the development of soft tissuerecession cannot be considered justified.– The European Workshop op on Periodontology,ogy,199323

Potential periodontal problems• Before Orthodontic Treatment• During Orthodontic Treatment• After Orthodontic Treatment24

Periodontal Problems DuringOrthodontic Treatment• Hyperplastic gingivitis: developed 1-2months after orthodontic appliance is placed• Hyperplastic and inflammatory tissues mayalso interfere with completion oforthodontic treatment and be implicated inrelapse tendencies.25

Periodontal Problems DuringOrthodontic Treatment• The use of steel ligatures is recommended on allbrackets, even the tooth-colored brackets, becauseelastomeric rings have been shown to attractsignificantly more plaque than steel ties.– Forsberg 199126

• Professional scaling may be particularly indicatedduring active intrusion of elongated maxillaryincisors, and when new attachment attempts aremade, because orthodontic intrusion may shiftsupragingival g plaque to a subgingival g location.– Ericsson, 1977&1978; Melsen 1988&199227

Treatment for orthodonticallyinduced gingival hyperplasia• Electrosurgical treatment:– contraindicated because of the proximity tometal which would conduct electrosurgicalcurrent and cause irreversible destruction andextreme pain.• Laser treatment:– Carbon dioxide (CO 2 )– Neodymium: yttrium aluminum garnet (Nd:YAG)28

Laser Treatment• Advantages:– Superior hemostasis– Less postoperative discomfort– Better acceptance by patients– Superior esthetic results (gingival architecture)– Decreased posttreatment bacteremia29

CO 2 Laser treatmentABCD30

Interval of Perio maintenance• S/RP on an accelerated schedule, typicallyat twice the frequency they would requirewithout orthodontic treatment.• e.g.: Perio maintenance every 3 monthsprior to ortho tx → perio maintenance every6 weeks.31

Effects of Reduced Perio Support• ↓ Periodontal support → the same forceagainst the crown produces greater pressurein the PDL → lighter orthodontic force tomove teeth with reduced perio support.32

• Unwise to move a tooth into an area where bonehas been destroyed by periodontal disease,because of the risk that normal bone formationwill not occur as the tooth moves into the defect.• Move away from this area and prepare forprosthetic replacement.• Exception: localized li aggressive periodontitis33

Reasons for favorable response• Relative young age of the patients• The original attack was almost entirely onthe first molars• The disappearance of the specific bacterialflora.34

Black triangle• Interproximalstripping and closespace• Converge rootangulations• Perio surgery toaugment tinterdentalt papilla35

Black triangleBob Woodin20 Rexhame st.Billerica, MA 01862United States36

Perio surgery37

Molar uprighting39

Tx options of missing lower 1stmolar• Upright 2 nd and 3 rd molars and open spacefor 1 st molar pontic• Extract 3 rd molar and upright 2 nd molar andopen space for 1 st molar pontic• Upright 2 nd and 3 rd molars but close spaceto eliminate the cost of prosthesis– p62040

ABC48

• Cut off crown topreserve ridge width• Endodontic treatmentwith calciumhydroxide• Wait until the growthis complete• Root resorption occur• Implant placement49

Potential periodontal problems• Before Orthodontic Treatment• During Orthodontic Treatment• After Orthodontic Treatment50

Periodontal Consideration after• Mobility• RelapseOrthodontic Treatment– Circumferential Supracrestal Fiberotomy (CSF)51

Mobility• Greater mobility in the adult after theorthodontic treatment than prior totreatment.• Because of this mobility, adults need alonger period of retention than would achild52

Retention in Adult• Lower rate of ossification: longer retention• If there has been significant periodontal lossprior to orthodontic treatment, the necessityfor permanent splinting is almost alwaysassured.53

Retention for Adults• Permanent Retention: bonded retainer ispreferred• removable plate or spring retainer :– ongoing jiggling of the teeth because of therelapse tendency during the day.– Jiggling forces may facilitate the progress ofattachment loss in periodontitis in the presenceof plaque54

Relapse• Transseptal fibers stretches elasticallyduring orthodontic treatment and trends topull the teeth back toward their originalposition.55

Buccal viewBuccal viewBuccal viewOcclusal view56

Circumferential SupracrestalFiberotomy (CSF)• supra-alveolar fibers do notadapt to new tooth th positionsand are in part responsible forrelapse–Thompson57

Circumferential SupracrestalFiberotomy (CSF)• the term “circumferential supracrestalfiberotomy” was first introduced• Not only transect free gingival fibers butalso transseptal ones– Campbell and associates, 197558

Indications• Rotated tooth• Crowded mandibular teeth• Median diastemas: recommended byCampbell and associates• Palatally blocked maxillary lateral incisors:relieve possible fiber tension, which h couldproduce palatal relapse59

Contraindications• Gingival recession or lack of attached gingiva• Poor oral hygiene, gingivitis, or any periodontalpocketing• Excessive labial root prominence with the distinctpossibility of a dehiscence should not have anylbili labial incision. ii• Incising the midportion of the labial gingiva ofmandibular incisors and canines: this mightprecipitate gingival recession.• Incising the gingiva g while the tooth is beingrotated.60– Campbell

Procedures of CSF• Anesthesia• Surgical technique• Timing of the procedure• Idi Indications i• Contraindications61

Anesthesia• intrapapillary injection• inserted from the facialaspect of the papilla tothe lingual aspect, and ananesthetic solutiondeposited as the needle iswithdrawn62

Surgical Procedures63

Timing• A few weeks before debonding or at thesame time of debonding• Obstacles: orthodontic bands that extendsubgingivally, coupled with plaqueaccumulation• If the gingival condition is unsatisfactory,the procedure can be delayed until sufficientresolution has occurred.64

CSF• Placement of retainers immediately aftersurgery:– mandibular arch: a canine-to-canine retainer– maxillary arch: a removable Hawley appliancewith palatal acrylic resin cut away from themarginal gingiva of the teeth in which surgerywas performed.65

Summary• Before Orthodontic Treatment– Sequence of Treatment?• Periodontal surgery?– Gingival Recession?• Preventive graft?• During Orthodontic Treatment– Treatment of hyperplastic gingivitis• After Orthodontic Treatment– Retention in Adults– CSF66