|Year : 2014 | Volume
| Issue : 2 | Page : 77-85
The orthodontic periodontal interface: A narrative review
Gurkeerat Singh1, Puneet Batra2
1 Vice Principal, Professor and Head, Department of Orthodontics and Dentofacial Orthopedics, Sudha Rustagi College of Dental, Sciences and Research, Faridabad, Haryana, India
2 Vice Principal, Professor and Head in Orthodontics and PG guide at Institute of Dental Studies and Technologies, Modinagar, Ghaziabad, Uttar Pradesh, India
|Date of Web Publication||28-Oct-2014|
Department of Orthodontics and Dentofacial Orthopedics, Sudha Rustagi College of Dental, Sciences and Research, Faridabad, Haryana
Source of Support: None, Conflict of Interest: None
| Abstract|| |
The purpose of this review is to highlight the orthodontics and periodontics interface in clinical practice for optimized treatment outcomes. 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, like uneven gingival margins or functional problems resulting from inflammatory periodontal diseases, should be considered in orthodontic treatment planning. Potentials and limitations that derive from the interdisciplinary approach of complex orthodontic-periodontal clinical problems are discussed along with the role of light forces and self-ligating brackets.
Keywords: Ortho Perio interface, self ligation, regional accelerated tooth movement
|How to cite this article:|
Singh G, Batra P. The orthodontic periodontal interface: A narrative review
. J Int Clin Dent Res Organ 2014;6:77-85
| Introduction|| |
The purpose of this review is to highlight the orthodontics and periodontics interface in clinical practice for optimized treatment outcomes. 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, like uneven gingival margins or functional problems resulting from inflammatory periodontal diseases, should be considered in orthodontic treatment planning. Potentials and limitations that derive from the interdisciplinary approach of complex orthodontic-periodontal clinical problems are discussed along with the role of light forces and self-ligating brackets.
Orthodontic treatment ensures proper alignment of the teeth and improves the occlusal and jaw relationship, which aids in better mastication, speech, facial esthetics, which contributes to general and oral health, thereby improving the quality - of-life. Orthodontic treatment, in addition to its benefits, has also associated risks and complications. Periodontal health is an important factor that may be used to evaluate the success of orthodontic therapy. Periodontal complications are reported to be one of the most common side-effects linked to orthodontics.  Aligned teeth are easier to clean, and perhaps correct occlusion may promote healthier periodontium. It is equally important to recognize that a number of orthodontic procedures, such as the judicial use of dental extractions, interproximal enamel reduction, correct root torque, selective grinding and if indicated treatment in the mixed dentition can act to retain the roots within the alveolar bone and thereby reduce root prominence and the risk of gingival recession. They may also allow creeping attachment and if planned, a better future surgical site. The reported benefits of orthodontic treatment in relation to gingival recession are as follows: Self-maintaining oral hygiene, crown alignment within the dento-alveolar envelope, removal of occlusal trauma, root alignment within the bone, A hopeless tooth is not a useless tooth-the value of a periodontal opinion is important, as such teeth can be utilized to enhance bone and/or soft tissue anatomy before insertion of implants.
The most common orthodontic problems found in a periodontally compromised patient include proclination of the maxillary anterior teeth, irregular interdental spacing, rotation, overeruption, migration, loss of teeth or traumatic occlusion. Those changes in the dentition are a consequence of the diminished support provided by the compromised periodontium, and they can sometimes hinder periodontal treatment by reducing the conditions for good oral hygiene and impairing function and aesthetics of the stomatognathic system. The periodontal complications associated with orthodontic therapy mainly include gingivitis, periodontitis, gingival recession or hypertrophy, alveolar bone loss, dehiscences, fenestrations, interdental fold, and dark triangles. ,,, Presence of microbial plaque is reported to be the most important factor in the initiation, progression, and recurrence of periodontal disease in a reduced periodontium.  The presence of plaque is the considered as one of the main factors in the development of gingivitis. , Orthodontic brackets and elastics might interfere with effective removal of dental plaque, thereby increasing the risk of gingivitis. As a result of the orthodontic treatment, a shift in the composition and type of bacteria can be expected.  Orthodontic treatment is known to affect the equilibrium of oral microflora by increasing bacteria retention. Furthermore, in patients with active periodontal disease, the presence of traumatic occlusion may inhibit bone apposition that can occur following periodontal treatment. ,
Orthodontic treatment may inhibit complete oral hygiene procedures ,, and create the possibility of transition of the subgingival plaque to a more aggressive periopathogenic flora , (converting gingivitis into periodontitis). If a thorough oral hygiene regime is applied before and during orthodontic treatment, minimal or no increase in gingival bleeding index  or a plaque quantity will be evident.  After appliance removal, there is a significant improvement on plaque index and bleeding index.  With adequate plaque control, patients with reduced but healthy periodontium can undergo orthodontic treatment without aggravating their periodontal conditions. , However, when inflammation is not fully controlled orthodontic treatment may trigger inflammatory processes and accelerate the progression of periodontal destruction leading to further loss of attachment, even in patients with sound oral hygiene. ,, Specific long-term clinical and radiographic findings support the fact that periodontal disease develops in regions where orthodontic bands are placed and leads to statistically significant loss of attachment. 
There is no contraindication for orthodontic treatment in adults with severe periodontal condition. On the contrary, sometimes orthodontics may be necessary to improve the possibilities of restoring a deteriorated dentition.  In periodontally compromised teeth, the center of resistance is displaced apically following the anatomical elements of the periodontium, thus resulting in the expression of greater moments during force application and an increase in the extrusion component of the applied force  [Figure 1] and [Figure 2]. Skeletal anchorage devices such as orthodontic mini-screws, mini-plates or even dental implants that serve as anchorage units are used especially when the present teeth are inappropriate. The use of occlusal forces (e.g., bite plates or occlusal splints) may sometimes be a valuable help for vertical control of the position of teeth, as well as for anchorage enhancement or for dissocclusion of selected teeth facilitating planned tooth movement. One precaution is to avoid using wire loops and elastomeric ligatures and remove immediately the excess of bonding material during bracket placement. Self-ligating brackets or wire ligatures are considered preferable, instead of elastomeric ligatures, as the latter favor plaque accumulation.  Despite the inconclusive results presented in the literature, bonding instead of banding the molars appears to be a safer solution for reasons previously stated. In patients with an intact periodontium, treatment with the aligners seems to be more favorable for periodontal reasons compared to labially or lingually fixed appliances.  Movement of teeth with infrabony defects can be successfully accomplished in the absence of inflammation and adequate control of the bacterial plaque. Although there is little evidence in humans, a well-designed recent clinical trial has shown that orthodontic tooth movement (OTM) toward the infrabony defect combined with intrusion and surgical periodontal therapy results in significant clinical attachment gain and in radiographic bone fill. Appliance of orthodontic forces was almost immediate 10 days after surgical periodontal treatment. 
|Figure 1: Normal versus teeth which are periodontally compromised with altered anteæs law (altered crown root clinical ratio)|
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|Figure 2: The different location of the center of resistance for periodontally compromised teeth|
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| Gingival recession in orthodontics|| |
The development of gingival recession during or after orthodontic treatment would be a significant clinical problem. A number of predisposing and precipitating factors include anatomical and morphological characteristics, such as alveolar bone dehiscence, gingival biotype, skeletal pattern, narrow symphysis and ectopic tooth eruption or morphology. Precipitating factors lead to an acceleration of the defect, such as traumatic tooth brushing, traumatic overbite, age, smoking, parafunctional habits, pregnancy and piercing. In addition and perhaps equally important are inappropriate treatment mechanics, such as arch expansion, with excessive proclination and the use of RME in adult patients. Care should also be taken when decompensating a class III incisor relationship in preparation for surgery and aligning ectopic/transposed teeth. One could consider the acronym ABEF to help take into account the risk factors: A: Anatomy of the alveolar bone and proximity of the root to the cortical plates B: Biotype E: Environment (oral hygiene, habits, poor brushing, poor orthodontic mechanics, active lingual retainers) F: Functional matrix.
To minimize the risk of gingival recession and maximize the benefit of the orthodontic treatment, the orthodontist must take some universal precautions as tabulated in [Table 1]. 
|Table 1: Universal precautions to minimise risk of periodontic implications during orthodontic treatment|
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In patients requiring pre-surgical decompensation, preprosthetic preparation or where a non-extraction approach is judged as necessary: The importance of ensuring optimal oral hygiene and using a free gingival graft prior to the planned OTM should be considered. The preferred approach in these susceptible patients should be to again ensure optimal oral hygiene, align the roots within the alveolar envelope, avoiding proclination and to re-evaluate the need for a mucogingival graft after treatment.
| Orthodontic extrusion and intrusion|| |
A recent clinical study on orthodontically treated patients with intact periodontium concluded that extrusion of mandibular incisors resulted in displacement of the gingival margin and the mucogingival junction by 80% and 52.5%, respectively, of the total amount of extrusion.  Thus, in cases where movement of bone margin and attachment along with the tooth is not desirable (as in crown-root fractures), there is a need for periodical circumferential supracrestal fiberotomy at the start and every 2 weeks during orthodontic extrusion.  According to experimental studies and clinical reports, orthodontic extrusion of teeth with one or two wall-infrabony defects results in a more favorable position of the connective tissue attachment and reduction in the defect. , Orthodontic extrusion of non-restorable teeth prior to implant placement appears to be a viable alternative for conventional bone augmentation procedures in implant recipient sites.
During orthodontic intrusion of lower incisors in patients with an intact periodontium, the gingival margin and the mucogingival junction moves apically 79% and 62% of total intrusion, respectively.  Regarding periodontally affected teeth, sufficient clinical data suggest that the intrusion of teeth can considerably improve the level of attachment when there is absolute control of inflammation and bacterial biofilms. , The use of light forces is recommended to move teeth efficiently and probably reduce the amount of root resorption.  This is of capital importance in teeth with a reduced periodontium as the specific implication results in further loss of periodontal support and increase in crown-root ratio.
| Molar uprighting|| |
Orthodontic uprighting of mesially tipped molars is accompanied by the elimination of osseous defects, 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.
| Labial Tooth Movement/Proclination|| |
These movements represent the most viable method to resolve crowding and are frequently considered to produce gingival recession especially in the region of lower incisors.  The most important predisposing factor for the development of gingival recession during or following orthodontic treatment is the reduced thickness of soft tissue and bone in the region.  No correlation was found between the orthodontic labial inclination of mandibular central incisors and age with gingival recession (except in excessive proclination >10 mm of mandibular incisors).
| Missing interdental papilla|| |
Usually, when the papilla is lost as a result of advanced periodontal disease which involves loss of interdental alveolar crest, the aesthetic 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. 
| Gummy smile|| |
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, usually, present clinical crowns with normal 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 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 aesthetic surgery. 
Sometimes a gummy smile may be attributed to extrusion of maxillary anterior teeth. It frequently happens in Angle class II, division 2 malocclusions. The indicated treatment, usually, includes orthodontic intrusion of maxillary incisors, which is expected to eliminate the gummy smile.  According to Sarver and Ackerman  gummy smile caused by decreased philtrum height of the upper lip may be effectively corrected by V-Y cheiloplasty, practically covering the gummy smile with the upper lip. Polo  recommends the use of Botox for the neuromuscular correction of excessive gingival display on smiling achieving satisfactory, but transitory results.
| Prevention of relapse|| |
Remodeling of supra-alveolar fibers continues to take place even after a period of 4-6 months.  It seems that after the end of orthodontic treatment, the retention period should exceed 12 months to provide appropriate time for remodeling of the periodontal fibers.  Relapse can be prevented by orthodontic overcorrection, adjunctive periodontal surgery  and long-term fixed retention.
Surgical removal of the stressed interdental soft tissues after closure of the diastema seems to prevent relapse.  In cases of maxillary midline diastema, it is often advisable to perform a frenectomy after the orthodontic closure to alleviate relapse. The circumferential fiberotomy of supracrestal gingival fibers has been proposed for preventing relapse of teeth that were severely rotated prior to treatment. This procedure alleviates relapse without harmful long term effects in periodontal health.  Permanent retention of the result of orthodontic treatment is indispensable in patients with significantly reduced periodontal support. Probably, the most appropriate method for retention is the coaxial multistranded stainless steel wire retainer bonded to the lingual side of each tooth. This retainer is easy to fabricate, not visible, and it allows teeth to retain their physiological mobility. There is a possibility of gingival recession due to active multistranded lingual retainers. ,
| Periodontal treatment schedule|| |
When planning orthodontic treatment in adults with a history of periodontal disease, it is suggested to allow 2-6 months from the end of periodontal therapy until bracket placement, for periodontal tissue remodeling, restoration of health and evaluation of patient's compliance. The patient should fully understand the potential risks in case of noncompliance.  It should be kept in mind that the critical pocket depth for maintaining periodontal health with ordinary oral hygiene is 5-6 mm.  If the presence of dehiscence or fenestration is suspected; two potential options exist: Avoid over-expansion of the arch, that is, attempt to maintain the teeth within the dentoalveolar envelope by considering dental extractions or interproximal enamel reduction. In situations where we absolutely need to expand orthodontically out of the envelope, it would be wise to ask for soft tissue augmentation prior to treatment.
Regenerative periodontal techniques (periodontal therapy with guided tissue regeneration or enamel matrix derivatives [EMDs]) are usually implemented before orthodontic treatment (10 days-4 months) to create favorable preorthodontic conditions in complex clinical scenarios. In case of thin periodontal tissues, the width of soft periodontal tissues must be enhanced prior to labial OTM, when it is estimated that otherwise the planned movement will result in the development of bone dehiscence.  During orthodontic treatment, professional cleaning and examination of periodontal tissues should be performed routinely. If the patient fails to maintain a high level of oral hygiene, orthodontic treatment should be interrupted. Elective periodontal treatment should be implemented during the final stages of orthodontic treatment or even later, when the final position of hard and soft tissues can be safely determined. After the end of active orthodontic treatment and appliance removal, the patient should receive renewed oral hygiene instructions for reducing the risk of recession because plaque removal and tooth cleaning will be more easily performed. The importance of re-educating the patient in respect of their brushing technique in conjunction to considering adjunct interdental cleaning aids, such as an oral irrigator, dental floss and interdental toothbrushes.
| Treatment of gingival recession|| |
A number of specific surgical considerations were also identified as being important to success: flap thickness (≥1.1 mm), post-surgical position of the gingival margin (the higher the better) and maintaining a stable flap under low tension provided optimal wound healing. The importance of using biological agents (e.g., EMD) in conjunction with flap surgery is shown to be beneficial. , The use of a modified coronally advanced tunnel flap approach in treating gingival recession was demonstrated, with the advantage of optimizing tissue blending and aesthetics. 
In terms of what is the best method(s) for recession coverage, there is a need to distinguish between single and multiple recessions. In respect of single gingival recession, a number of options exist for recession coverage, an EMD (Emdogain) with or without a connective tissue graft in conjunction with a coronally positioned flap. , Good long-term (5 years) outcomes have been reported with connective tissue grafts and a coronally advanced flap.  Alternative methods include the envelope technique with connective tissue graft  or the laterally positioned flap with or without connective tissue graft. In the case of multiple recessions, the modified coronal advancement flap with or without graft is preferred in the maxilla,  whilst in the mandible, its use in conjunction to a connective tissue graft should be considered.  In regard to the Miller's class III defect, the modified coronal advancement tunnel technique with connective tissue graft should be considered. Whilst a free gingival graft can be used in both single and multiple gingival recessions, it is associated with high morbidity due to graft removal from the palate and sometimes necrosis of the graft.
| Possible combined future researches in the field of orthodontics and periodontics|| |
Orthodontic tooth movement is a process of paradental remodeling mediated by inflammatory mediators like PGE2s, cytokines, neuropeptides, MMPs, etc. These inflammatory mediators are also present in periodontitis and periodontal diseases. Hence the detection of these inflammatory mediators is of paramount importance in detection and screening of periodontal diseases as well as demonstrating OTM. GCF markers have several shortcomings like long collection times, easily prone to contamination, thick viscosity, questionable accuracy, etc. Salivary biomarkers are rapidly gaining increasing popularity over GCF markers these days.
- Inexpensive, non-invasive and easy-to-use.
- Ease of collection, storing and shipping.
- Easier handling as it does not clot.
- Informative analytes generally present in lower amounts than in serum.
- Dilution of biomarkers common.
An increase in salivary levels of Cathepsin G, Elastase, Elastase inhibitors and C-reactive proteins correlated with increased periodontal breakdown.  Salivary biomarkers Interleukin-1β and MMP-8 specific for three aspects of periodontitis that is inflammation, collagen degradation and bone turnover were significantly higher in subjects with periodontal breakdown.  The activity of creatine kinase, Lactate dehydrogenase, Aspartate aminotransferase, Alanine aminotransferase, Gamma glutamil transferase, acid phosphatase and alkaline phosphatase significantly increased in the saliva of patients with periodontal breakdown.  Elevated mean salivary levels of TNF-α in subjects having periodontal diseases.  The mean myeloperoxidase activity in both GCF and saliva increased 2 h after orthodontic appliance activation.  The salivary concentrations of deoxypyridinoline (DPD) and bone-specific alkaline phosphatase (BAP) as detected with four consecutive visits may be linked with different phases of tooth movement.  Results showed that although DPD values revealed an increasing nature after force application and BAP values showed a decreasing trend, only the former showed significant changes over time which implied that DPD dominates the earlier phases of tooth movement while BAP serves as an indicator of bone formation as soon as tooth movement stops. Thus, qualitative changes in the composition of saliva biomarkers used in estimating OTM mediated by paradental remodeling could have significance in diagnosis and treatment of periodontal disease as well.
| Periodontally Accelerated Osteogenic Orthodontics (PAOO)|| |
Surgically accelerated modalities like selective alveolar decortication (SAD) and periodontally accelerated osteogenesis orthodontics can be used as an adjunct to conventional approaches to accelerate OTM with fewer adverse effects. SAD is a procedure where linear and punctuate decortications are made after reflecting the flap. ,, The decortications should not impinge on root-PDL-cribriform plate complex and not extend to the alveolus crest. Accelerated OTM occurs due to inflammation and wound healing processes that are evoked by surgical trauma to the alveolar bone. In addition, alveolar bone surgery may also stimulate the production of MSCs in marrow cavities that function synergistically with neighboring PDL and alveolar bone cells resulting in accelerated OTM. Addition of bone graft to a teeth moving through a surgical wound increases bone mass and enhances long-term stability.  The term popular is the "regional acceleratory phenomenon" with normal metabolic rate of inflammation and wound healing process is accelerated [Figure 3], [Figure 4], [Figure 5]. ,,
|Figure 4: Buccal corticotomy initiated with round burs to do the initial scoring|
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|Figure 5: Buccal corticotomy cuts made joining the initial scoring points|
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| conclusion|| |
Harmonious cooperation between the periodontist and the orthodontist offers great possibilities for the treatment of combined orthodontic-periodontal problems. Orthodontic treatment along with patient's compliance and absence of periodontal inflammation can provide satisfactory results without causing irreversible damage to periodontal tissues. Orthodontic treatment can expand the possibilities of periodontal therapy in certain patients, contributing to better control of microbiota, reducing the potentially hazardous forces applied to teeth and finally improved the overall prognosis. Participation of the periodontist is also essential, either in management of orthodontic-periodontal problems or in specific interventions aiming to prevent orthodontic treatment's relapse.
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| Authors|| |
About the Authors
Dr. Gurkeerat Singh, is a graduate and postgraduate from the Mangalore College of Dental Surgery, a constituent of the Manipal Academy of Higher Education, Manipal. He did his M. Orth in 2001 and is registered with the Royal College of Surgeons, London as well as the Royal College of Physicians and Surgeons of Glasgow. He is a diplomate of the Indian Board of Orthodontics. Dr. Singh has over two dozen publications in various Indian and foreign journals to his credit as well as " The Textbook of Orthodontics", the first full-color textbook by an Indian author on the subject and a " Mini Atlas on Orthodontics". He is professor and head of the department of orthodontics and dentofacial orthopedics at Sudha Rustagi College of Dental Sciences and Research, Faridabad, Haryana. He is also the Editor of the Journal of the Indian Orthodontic Society.
Dr. Puneet Batra completed his BDS 1996 and did his MDS in Orthodontics from All India Institute of Medical Sciences New Delhi. He did his M. Orth from the Royal College of Surgeons in Edinburgh in the year 2003 and FFD Orth from the Royal College of Surgeons in Ireland in 2005. He was awarded DNB in Orthodontics from the ministry of health and family welfare. He has been awarded the prestigious commonwealth scholarship (Great Ormond Street London) and TC White award (Dunddee Dental School Scotland). He has been awarded the PP Jacob award and the JG Kannapan award by the Indian Orthodontic Society. He has more than 70 publications in peer reviewed national and international journals. He is the Vice Principal and Professor and Head in Orthodontics and PG guide at Institute of Dental Studies and Technologies Modinagar.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
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