Restorative Dentistry

Adjunctive orthodontic treatment of periodontailyinvolved teeth: Case reportsA-Bakr M. Rabie, MS. Cert Orth. PhD^VYti Meni: Deng. DDS. PhD PDipDS**/Li Jian Jin. DDS. PhD, M M d S *

Elongated and spaced incisors are common in patients .suffering from severe periodontal di.wise. Intrusion anduprighting of incisors might be the logical solution for this problem. This article describes a team appivach totreatment planning for adult patients with .severe localized periodontitis accompanied hv marginal bone lossand spacing and elongation of incisors. The treatment involves the combination of periodontal treatment, ortho-dontic intrusion, and prosthetic therapy. Controlled intrusion in t\vo patients led to a decrease in the clinicalcmwn length, better access for oral hygiene procedures, better gingival form, and a more suitable distributionof occlusatforces. (Quintessence Int 1998:27:13-19)

Key words: elongated incisors, murginal bone loss, ortliodoniii: intrusion, periodontally involved teeth.periodotititis. spaced ineisors. team approach

Orthodontic tooth movement in periodontallyinvolved patients constitutes a problem distinct

from routine orthodontics.' Patients with advanced peri-odontal disease may experience tooth migrationinvolving single or multiple teeth. The most commonsymptoms may include tipping and extrusion of one orseveral incisors and development of single or multiplediasîemas of the anterior teeth.- Correction of theseproblems demands advanced techniques and an under-standing of the biologic situation present in thosepatients.' Judicious interiiiseiplinary treaiment planningshould involve a periodontist. an orthodontist, and ageneral dentist to achieve a satisfactory result. The com-bination of periodontal treatment and orthodontic intru-sion of elongated and migrated incisors seems to be anecessary and benellcial pan of the total treatment plan,provided that both the biomechanical force system andoral hygiene are kept under control.••-"

'Assofiiilc Pr(il"cs-..'r. Dcp.irliiiL'iil nl ChiliJri;n\ IDijiiiiMrv and Orlh-ixinmÍL-s. Faculty .il Dtnlislr>'. Univiirsily ol Hong Kon;!. Hung Kong

"-ViMiing SL-hulür, DcpíiriineTii iir Children'.s DciiUMiy ;indOrihiidiinlics. Faculiy iiT DL'nii^iry. Univcrsily oT Hong Koni;^LcL-iurer. Dt-pjrliiiuni of Orlhiiilantit.s. Schim! iit" Sliimiiuilogy.Beijing Medical LJniversiiy. Btijiny, Peoples Republic ulChinü.

'*"• Assi .Slam Prolcssiir. Dcpiinmcnl ni Periiiijonlokiçy und Public Heíillh.Faculiy ol" Denlislry. Llmvtrsity iit Hiing Kon^, Honu Kiinj;.

Reprinl requests: Dr A. M. Ríihie. Dcparlmenl cil' Children s Denlislryund Oriliiidonlii\s. Facully iif Denlistry. tjniversily iiT Honj; Kiin;;.Princo Philip Dinlal Hospilill. .'4 Hospilül Road. Hung Kong. E-tiuiil:rabie (nhkiisua.bk 11.hk

In a recent report, it was suggested that in situationswhere tooth movement is indicated as an adjunct toperiodontal therapy, vigorous preparation of root sur-laces and gingival tissues should precede placement ofthe orthodontic appliance.' Deep pockets must be elimi-nated before orthodontic treaiment is initiated, so as toprevent apical displacement of plaque that could estab-lish progressi\e periodontal lesions.** Results of a longi-tudinal study of adults with reduced gingi\ al height anda healthy periodontium showed that orthodontic treat-ment did not result in significant further loss of attach-ment." This finding depended on the prerequisite thatperiodonial treatment was provided to arrest active dis-ease before orthodontic treatment was begun. Further-more, these patients received monthly reintbrccment ofplaque remoxal and also received subgingival debride-mcnt at .1-month intervals during orthodontic treatmentto maintain healthy gingival tissues."

When periodontal treatment alone cannot correct orcontrol the damage produced by a pathologic occlu-sion, then orthodontic tooth movement becomes animportant step in the overall treatment plan.'" In thesepatients, orthodontic goals and mechanics must bemodified to keep orthodontic forces to an absoluteminimum.'"" This is necessary when bone has beenlost because the periodontal ligament area decreases.and the same force against the crown produces greaterpressure in the periodontal ligament of a periodontallycompromised tooth than a normally supported one.'- '̂

Quintessence International 13

Rabie et al

Fig la Case 1. Appearanoe of a 39-year-old Ctiinese man withadull periodontitis after initial periodontal preparation. The incisorsare spaced and extruded, and deep overbite and overjet arepresent.

Fig 1b Complete-mouth radiograpfiio series before orthodontictfierapy, revealing horizontal bone loss around one thirt) to onehalf of the roof length and vertical bohe loss ai the maxillary rightiirst premolar.

The aims of the present article are to illustrate anddiscuss, by meatis of case reports, the interrelationshipof orthodontics, periodontics, and prosthetic dentistry tofulfill the needs of periodontal I y involved patients and tohighlight the benefits of the team approach.

Case report.s

Case 1

A 36-year-old Chinese man presented with the chiefcomplaint of drifting and spacing of the maxillaryincisors (Fig la). Clinical examination revealed incom-petent lips. Class II malocclusion, increased overjet (9mm), and overbite (4 mm). Periodontal charting demon-strated that probing depths ranged from 4 to 9 mm. Themesial aspect of the ma.\illary right premolar exhibited aprobing depth of 9 mm. Radiographie examinationrevealed generahzed horizontal bone loss in both arche.s.

Treatment planning involved a team that consistedof a periodontist, an orthodontist, and a general dentist.

Treatment plan1. Periodontal treatment: Thorough oral hygiene in-

structions, scaling, and root planing in deep pocketsites before orthodontic treatment

2, Periodontal maintenance: Carried out during and afterorthodontic treatment

3, Orthodontie treatment: Intrusion and letroclination ofprochned and spaced maxillary incisors and intrusionof mandibular incisors

4. Retention: Fixed lingual retainers and regular reviewof the periodontal condition

5. Restorative treatment: Prosthetic replacement ofmaxillary left first molar

Periodontal treatment. This patient had been undera periodontist's care for nearly 2 years. Intensive peri-odontal treatment involved oral hygiene instructions,scaling, and root planing. The maxillary left secondmolar was extracted because of poor response to treat-ment. Before the commencement of the orthodontictreatment, plaque control was good, periodontal dis-ease was arrested, and the gingiva was clinicallyhealthy. No deep pockets were identified, and only a4-mm probing depth was measured at the maxillaryright first premolar. Radiographic examination re-vealed generalized horizontal bone loss around onethird to one half of the root (Fig lb¡.

Periodontal maintenance. Periodontal maintenancewas carried out at regular intervals during orthodontictreatment and home care was emphasized.

Orthodontic treatment. Treatment included a fixedappliance with bonded brackets on the first molars andincisors. The initial leveling wire was a 0.014-inchstainless steel arch wire with intrusion loops mesial tothe first molars. These intrusion loops were bent insuch a way that, when the wire was not engaged in thebracket, the anterior segment of the wire rested at thevestibule (Fig Ic). This wire is called an intrusionarch because, when it is engaged into the incisorbrackets, it applie,s force on the teeth in an apicaldirection, thus intruding the incisors (Fig i^^ .^^^force used in this case was light and ranged |>,.,̂ .|j j^jto 15 g per tooth , to avoid damugjj^^ ^^^periodontium.

14

Fig 1c Incisor-intrusive mechanism Initial lignt leveling wireswere 2 x 4 0.014-inch stainless steel arch wire. Simultaneousintrusion was achieved with the mesial lirsi molar omega loop.

Fig Id Maxillary intrusion arch wire witn a power cnain is used toconsolidatB spaces in the incisor region.

Fig 1e Postorttioöontic appearance. The maxillary incisors havebeen intruded and retracted to contact with the mandibularincisors. Residual spaces have been eliminated by resin compos-ite buildup ot the lateral incisors.

Fig I t Compiete-mouth radiographie series atter orthodontietherapy, demonstrating positive bone remodeling around the alve-olar orest.

Residual spaces remaining after retroclination andintrusion of inc isors were e l imina ted by resincomposite buildup of the maxillary lateral incisorsI Fig lel-

Releiitioii. Retention was achieved with a fixed lin-gual splint from canine to canine. Total active treatmenttime was 7 months.

Restorative treatment. The patient was referred forprosthetic replacement of missing posterior teeth.

Results. Evaluation after the orthodontic treatmentrevealed satisfactory oral hygiene except for plaque

accumulation at the distogingival margin of the maxil-lary left first molar. No probing depth was in excess of 3mm, and no further recession was noted. The clinicalcrown length decreased by 0.5 to 1.0 mm. Posttreatmentradiographie evaluation revealed positive bone remodel-ing around the alveolar crest (Eig If).

The aims of the orthodontic treatment were achieved.The maxillary incisors were intruded and retracted anddisplayed proper overjct and acceptable o\crbitc. Exam-ination of the patient 13 tnonlhs later revealed a stableocclusion and acceptable functional and esthetic results.

Quintessence International 15

Rabie et a

Fig 2a Appeataiice of a 30-year-olcl Chínese woman afler inifiaiperiodontal therapy Gingival recession oí the mandibular ieftincisors is associated with antetior crossbite, and the manûibuiarlefl incisors are mobile.

Fig 2b CoiT.plete-tTioulh radiographie series belore orihodontictherapy. Note the spacing of the teelh, horizontal bone lossaround one third to one half of the root length, and vertical boneioss at the mandibuiar incisors and first moiars.

Case 2

A 27-year-old Chitiese woman presented with mild mar-ginal gingival inflammation, limited largely to themandibtilar anterior teeth. Gingival receiíKion wasobserved at the lahial surfaces of the mandibularincisors, particularly the right lateral incisor (Fig 2a).Deep probing depths were detected on tiie maxillaryright first molar, mandibular first molars, and maxil-lary central and lateral incisors, consi.stent with a diag-nosis of localized juvenile pcriodontitli,. This was con-firmed in radiographie examination where markedbone loss was evident on anterior teeth and lirsi molars(Fig 2b). Also, a mesioden.s was observed between ihi;maxillary iticisors.

On clinical examinatitin, a slight anterior displace-ment of tbe mandible was detected. The displacementwas caused by an anterior crossbite of the maxillaryleft central and lateral incisors. Molars and caninesexbibited Class I relationships, and space analysisrevealed excess space in both arches.

Treatment planning involved a team tbat consisted ofa periodonti.st. an orthodontist, and a general denti.sl.

Treatment pian1. Periodonial treatment: Oral hygiene instruction,

scaling, and 'iubgingival instrutnentation2. Periodonml maintenance; Carried out during and

after orthodontic treatmetit3. Orthodontic treatment: Correction of anteritjr cross-

bite, alignment of anterior teeth, and elimination ofanterior tnandibuiar displacement

4. Retention: Fixed lingual retainers and regularreview of the peritjdontal condition

5, Prosthetic treatment: Porceiain veneers to improvethe esthetics of the maxillary incisors

Periodontal treatment. The patient was tinder theperiodontisi's care lor 2 years for management of herlocalized juvenile periodontiiis. Before the start ofortbodontic treatment, the oral hygiene status was wellmaintained and the gingival condition was registered assound with no bleeding on probing. Gingival recessionwas evident at the mandibttlar incisors. Probing depthsmeasured 4 to 5 mm at the po.sterior teetb. Generalizedhorizontal bone loss around one tbird to one ball' theroot lengtb was evident. Mild tootb mobility was detect-ed at the maxillary incisor region, and severe tootbmobility was noted at the mandibular incisor region.

Periodontal maintenance. Tbrougbout the ortbodon-tic treatment period, ilie patient was under regular peri-odontal care and underwent subgingival curettage wbenit was considered necessary.

Ortliodontic treatment. Treatment included the useof fixed appliances with bonded brackets on the secondmolars and ineisors. The tnitial wires were 0.014-inchstainles.s steel arch wire, used for leveling and aligningtbe incisors. The mandibular incisors wete retracted ona rectangular wire with a closing loop distal to the rightlateral incisor ¡Fig 2c). The use of rectangular wire withadded lingual root torque prevented the retroclination ofthe mandibular incisors during space closure. Closure ol'the spaces in ihe mandibular anterior region resulted inpositive overjet (Fig 2c). which led to the elimination ofthe traumatic occlusion.

Retention. Retention was achieved with a fixed lin-gual splint from canine to canine. Total active fixedappliance therapy was 12 months.

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Rabie et al

Fig 2c Brackets bonded on the second molars and inciso's.Initial lighi leveling wnes were 2 x 4 0 014-inch stainless sleel archwire to derotate the maxillary lelt central incisor, redistribute spacelor orown buildup, and correct the anterior crossbite In Ihe linalleveling stage, in the mandible, the first molars were bonded and2 x 6 0.016 X 0022-inch TMA rectangular arch wire with closingloop, step ups/step downs, and lingual root torque was used toclose spaoe and upright and intrude the inoisors.

Fig 2d Appearance alter orlhodontic treatment Note the esthet-ic appearance ol the porcelain veneers lor the maxillary inoiscrs

Fig 2e Cornpiete-mouin raüioyraphic series aitei orifiooontictherapy The bone remained at pretieatment levels.

Restorative treatment. Porcelaiti veneers were usedto build up ihe size of the maxillary lulerui iticisors andimprove the esthetics ot the central inci,sor,s (Fig 2d).

Results. Evulttatioti after urlhodontic treatmentrevealed tio increase in probing depth and no increase ingingival recession. The hone remained at pretreatmentlevels (Fig 2e). The orthodotitif goals and objectiveswere achieved, beeause the crossbite was eliminatedand the overjet and overbite were corrected. Porcelainveneers on the tnaxillary ineisors improved estheticsand triLisked the residual spaces produced as a result olsmall maxillary lateral incisors.

Discussion

This paper describes a team approach toward treatmentplanning tor adult patients with severe localized peri-odontitis accompanied by marginal bone loss and spac-ing and elongation ol" the incisors. The relationship

between periodontal disease and maioeelusion has beena controversial subject. Tooth ma!po,sitioning has beenrecognized as both an etiologic factor contributing toperiodontal destruction as well as a result of chronicdestructive periodontal disease.'•* Malposed or rotatedteeth may be predisposed to more rapid breakdown oftbe periodontium when the roots are too close to oneanother, resulting in a thin interproximal septum.^Klassman and Zaeher" reported that correction of the.semalposed teeth may be therapeutic and/or prophylactic.

At the present titne. there ha\e been no significantstudies tbat confirm a definite relationsbip between mal-occlusion and periodontal disease,'"'' On the contrary.the consensus of the majority of studies i,s that tbere isno relation between various types of malocclusion andperiodontal diseases.'-"''" In a study of IÍÍ8 persons withperiodontal di.sease, no relationship was found betweenperiodontal di.sease and Angle's classification, overbile.overjet. open bite, rotation, or inclination of the man-

Ouintessenoe International

Rabie et al

dibniar incisors. Grewe and associates'" reported thaiplaque retention based on oral hygiene habits may bethe major lactcn- in periodontal disease, while irregular-ities of tooth position may play another minor compli-cating role.

The only exceptions to this appear to be extremelysevere overbite, in which there is direct impingement olthe teeth on the soft tissues, and localized crossbite withtraumatic oeclusion.'" The patient in case 2 exhibited thedestructive effects of traumatic occlusion, caused bylocalized crossbite, on ihe periodonial supporting struc-ture (see Figs 2a and 2b). Gingival recession and mobili-ty affecting isolated mandibular incisors are not uncom-mon in association with lingually positioned incisors.-"In such cases, the risk of accelerated loss of attachmentappears likely.-" Beeause traumatic occlusion may havebeen a predisposing factor for the gingival recessiím andmobility of the mandibular incisors of the patient in case2, elimination of the anicrior crossbite became a majorobjective of the treatment planning.

This type of orthodontic ireatment is consideredadjunctive orthodontic treatment.' By definition, it istooth movement carried out to facilitate other dental pro-cedures necessary to control disease and restore func-tion.' During the treatment planning for this adjunctiveorthodontic treatment, special biomechanical considera-tions were emphasized. The design of the appliance useddepended on ihe number of teeth to be moved, the avail-ability of anchorage, and the desired direction andamount of crown or tooth movement.' Thus in case 2.fixed appliances were used only on the maxillary andmandibular incisors and second molars. Second molarswere used as anchorage units instead of first molarsbecause of the poor periodontal condition of the latter.Mandibular incisors were retracted bodily on rectangularwires to prevent lingual tipping of the crowns while iheroots were being moved lingually.

It has been proposed that orthodontic treatmeni maybe used to attain more favorable bone levels and con-tours around periodontally involved teeth.^'•' Kessler'-'propased that changes in osseous topography could beaccomplished by moving teeth into an area of the archthat has a greater volume of bone and by repositioningperiodontally involved anterior teeth.

On the one hand, traumatic occlusion may con-tribute to destructive periodontal disease, but. on iheother hand, advanced periodontal disease with the los.sof periodontal supporting structure can cause migra-tion, extrusion, flaring, and loss of teeth,'-' This isbecause a secondary occiusal trauma may further com-plicate an already difficult problem. This pattern ofocclusion was manifested by the patienl in case I. Thepatient presented with the chief complaint of migration

of his teeih with resultani spaces. The same biome-chanical considerations discussed earlier were imple-mented for this patient. Fixed appliance therapy waslimited to tbe incisors and tbe first molars. Buccal seg-ments were not involved in the fixed appliance therapybecause of their poor periodontal condit ion.Orthodontic treatment resulted in successful intrusiotiand space closure. Meisen et aP*' concluded that intru-sion of incisors in adult patients with marginal boneioss offers a beneficial effect on the periodonta! condi-tion at the clinical and radiographie levels. Sueh aresult was seen in Case I, where Fig I f demonstratespositive bone remodeling when compared to pretreat-ment radiographs IKig lb).

Summary

The efficacy of intrusion and uprighting of pathologi-cally migrated anterior teeth with deep overbite and ananterior crossbite has been discussed. Intrusion is areliable therapeutic meihod for orthodontic treatmentof periodontally involved palients. A multidisciplinaryapproach can better serve the needs of periodontallyinvolved patients with malposed teeth.

References

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Thilanddr B. The mlc of the ontiiidiiiilist in llic niiillidisi.ipliiiuiy•H'P"i;^li w periodontiil iherapy. Im Dem J 1986;36:12-17.B,.\J RL, Leggolt PJ, Qiiiiin RS, Eiikk WS, CllLUllbcr^ D.Periüdonlal implkaüoiis of orthodonlic liealment in udull.̂ withr^Jucid or normal periodonlal tissue versus those ol adolescents.Am J Oiihod Dciitotac Orlhop I989:g{i:l<)l-iyy.Kiisv RP, Tiilloch JFC. An;ilysi> of moment-lorie imios in IhonieL-h:inics iif tooth movement. Am J Orthod DenlofLR- Orfhopl')S6;yO: 127-131.Miller BH. OrllloJontics for the ;idijU palicni. Purl 2 The orlh-iidontic role in periodontal. oi;i;liisal Lind reslurative problems.BrDentJ l9Si);14K: 128-132,Kessler M. tnlerrelalionships between orthodontics and peri-uddniics, .^m J Onhod I y76:70:154-172,

Klassmiin B. Zacher HW. Treatment of a periodontal defeetresulting trom improper tooLh alignment and local facinrs.J Periodontol 1969:4(1:401.

Ericsson t, Thitander B. Orthodonlic relapse in dentitions withredueod periodontal support. An e.\peiimenlal study in dogs. EurJ Orthod 1980:2:51-57.

Ânun J. Urbye KS. The effect of orthodontic trealment on peii-(idonlal bi>ne support in puiienls wiih Lidvanced loss ..f marginalperiodoniiiim. Am J Orthod Deniofac Onhop 1988:0?: 143-148.Geiger .\M. Occlusion in periodontal disease. J Periodnntol1495:36:387-392.GreweJM.ChadhaJM. Hagan D,ZLTmeno JA OrLiI hygiene LindocclusLiI disharmony in Me'iKjn-.Aineriean uhildrcinJ PeriodontRes l%Çl;4:189-192,Shaw w e . Risk-benefit appraisal in orthodontics. In: Shaw WCledl. Orthodonlics and Occlusal Management, ed I, Cambridjie:Oxford, I9'3?:l,34-I5.i.Wagenbcrg BD. Eskow RN. Langer B. Orthodontic proceduresihat improve the periodontal prognosis. J Am Dent Assoc 1980:

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