Jan Lindhe. Clinical Periodontology

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ORTHODONTICS AND PERIODONTICS • 745

746 • CHAPTER

Fig. 31-2. Long-term radiographic

follow-up of the same patient as

in Fig. 31-1. Radiographs of maxil

lary and mandibular anterior re-

gions 7 years after the completion

of orthodontic therapy (b,d) show

reduced but healthy periodon-

tium, with no progression of peri-

odontal tissue destruction com-

pared with the initial situation

(a,

c).

may produce a more rapid destruction than would

occur with inflammation alone (Kessler 1976). How-

ever, with properly performed treatment, extensive

orthodontic tooth movement can be made in adults

with a reduced but healthy periodontium without

further periodontal deterioration. Figs. 31-1 to 31-6

show the pretreatment and post-treatment conditions

in four different adult orthodontic patients with ad-

vanced periodontitis. The findings of no significant

further periodontal tissue breakdown in these pa-

tients was the result of carefully controlled treatment

planning considerations.

Only a few well-controlled studies have been pub-

lished on groups of adults with advanced periodonti-

tis, who have received comprehensive orthodontic

fixed-appliance treatment. Boyd et al. (1989) described

10 adults with generalized periodontitis who received

preorthodontic periodontal treatment including sur-

gery, and then regular maintenance at 3-month inter

vals during a 2-year orthodontic treatment period.

They were compared with 10 control adults who had

normal periodontal tissues, and 20 adolescent ortho-

dontic patients.The results demonstrated that:

•

Adults were more effective than adolescents in re-

moving plaque, especially late in the orthodontic

treatment period

•

Tooth movement in adults with reduced, but

healthy, periodontium did not result in significant

further loss of attachment (none of the adults had

additional mean loss of attachment of more than 0.3

mm)

•

Adults with teeth that did

not

have healthy peri-

odontal tissues may experience further breakdown

and tooth loss due to abscesses during orthodontic

treatment.

In another study by Artun & Urbye (1988) 24 patients

with advanced loss of marginal bone and pathologic

tooth migration received active appliance therapy for

an average of 7 months, following periodontal treat-

ment. Bone level measurements on radiographs indi

cated that the majority of sites showed little or no

additional loss of bone support. However, a few sites

demonstrated pronounced additional bone loss.

More recent studies on much larger groups (350-400

patients) of consecutively treated adult patients from

different practices (Nelson & Artun 1997, Re et al.

ORTHODONTICS AND PERIODONTICS • 747

Fig. 31-3. Adult female periodontitis patient before (a-c), during (d), and after (e,f) periodontal and orthodontic

treatment. The initial extensive destruction of bone around the maxillary incisors had resulted in pathologic migra

tion (b,c), and the loss of the left first premolar. The right first premolar was extracted as part of the treatment

plan.

The treatment result is retained with a gold-coated maxillary retainer bonded lingually from canine to

canine, and

two short labial retainers in the closed extraction sites (e,f). The esthetic result is much improved,

even in the pres

ence of some interdental gingival recession post-treatment (f). No apparent further progression of

the periodontal

tissue breakdown occurred during the orthodontic space closure and levelling of the teeth.

2000) have confirmed that (1) pretreatment evidence

of periodontal tissue destruction is no contraindica-

tion for orthodontics, (2) orthodontic therapy im-

proves the possibilities of saving and restoring a dete-

riorated dentition, and (3) the risk of recurrence of an

active disease process is not increased during appli-

ance therapy. However, these larger samples have

indicated that adult orthodontic patients are at a

somewhat higher risk than adolescents for tissue

breakdown. The mean bone loss on radiographs of the

six anterior teeth in the study of Nelson & Artun

(1997)

was 0.54 mm (SD 0.62). Only 2.5% of the patients had

average bone loss of 2 mm or more, but as many as

748 • CHAPTER 31

Fig. 31-4. Adult female periodontitis patient with pathologic migration of the maxillary incisors before (a,b), during

(c-

e) and after (f) periodontal and orthodontic treatment. An attempt had been made by the periodontist to grind

and

splint the overextruded right central incisor with composite resin (b) before orthodontic treatment was started.

Due to

extensive mesial and distal recontouring of the incisors (stripping) during the treatment (c,d), it was possible to

obtain an esthetic final result with almost intact gingival papillae between the incisors in both the maxilla

and in

the mandible (f).

36% of these patients had one or more surfaces with or reduce, plaque accumulation and gingival inflam

bone loss

exceeding 2 mm.

mation. This implies much emphasis on oral hygiene

instruction, appliance construction, and periodical

check-ups throughout treatment (Zachrisson 1996).

Orthodontic treatment considerations

The most appropriate method for tooth movement

must be determined in each particular case. Although

The key element in the orthodontic management of minor or partial orthodontic treatment with sectional

adult

patients with periodontal disease is to eliminate,

or removable appliances may be possible in some

ORTHODONTICS AND PERIODONTICS •

749

Fig. 31-5. Radiographic and clinical occlusal appearance of the same patient as in Fig. 31-4. No noticeable progres

sion of the periodontal tissue destruction has occurred (compare a and b), and although markedly reduced the peri

odontium is healthy after the orthodontic therapy (b,c). The treatment result is maintained by means of gold-coated

lingual retainers over six maxillary and eight mandibular anterior teeth (d,e).These bonded retainers act as effec

tive orthodontic retainers as well as neat and hygienic periodontal splints.

instances, in the majority of cases a fully controlled

technique with fixed appliances in both dental arches

is preferred in order to carefully control the movement

of teeth in three planes.

The orthodontic appliance has to be properly de-

signed. It must provide stable anchorage without

causing tissue irritation, and must be esthetically ac-

ceptable. For psychologic reasons bonded ceramic

brackets are preferred in the most visible regions (Figs.

31-3 to 31-6), generally for the maxillary teeth,

whereas stainless steel or gold-coated attachments are

commonly used elsewhere in the mouth (Figs. 31-3,

31-4).

To counteract the tendency of orthodontic appli-

ances to increase the accumulation of plaque on the

teeth, attempts should be made to keep the appliances

and mechanics simple, and avoid hooks, elastomeric

rings and excess bonding resin outside the bracket

bases. The use of steel ligatures is recommended on all

brackets (Figs. 31-3, 31-4, 31-6), since elastomeric rings

have been shown to be significantly more plaque

attractive than steel ties (Forsberg et al. 1991). Bonds

are preferrable to bands (Boyd & Baumrind 1992).

Bonded molars show less plaque accumulation, gin-

givitis and loss of attachment interproximally than

banded molars during orthodontic treatment of

adults.

However, bonding is more complicated in

adult

patients than in adolescents. Many adults have

amalgam restorations and crown-and-bridge restora-

tions made of porcelain or precious metals. Thanks to

the introduction of new techniques and materials, it is

feasible to bond orthodontic brackets, buccal tubes

and

retainer wires to artificial surfaces. Clinical experience

with bonding to different artificial tooth sur

faces,

except gold, is excellent (Zachrisson 2000a,b).

Renewed oral hygiene instruction and motivation

made after the placement of the orthodontic appli-

ances. During the treatment period professional tooth

cleaning by dental hygienist or periodontist may be

performed at 3 month intervals (Boyd et al. 1989, Boyd

& Baumrind 1992), or after regular examination up-

dates at 6 and 12 month intervals, depending on the

situation. The re-examinations should include record-

ings of probing depths, mobility, bleeding on probing,

suppuration, gingival recessions, bone levels, etc. Pro-

fessional scaling may be indicated during

active intru-

sion

of elongated maxillary incisors, since orthodontic

intrusion may shift supragingival plaque to a sub-

gingival location (Ericsson et al. 1977, 1978). If efforts

at maintaining excellent-to-good oral hygiene are un-

750 • CHAPTER 31

Fig. 31-6. Adult female periodontitis patient with marked loss of the interdental papilla between the maxillary central

incisors (a,b). This gap is caused by the

fan-shaped

morphology of the central incisors, which places the inter-

proximal contact too near the incisal edge. To eliminate the unesthetic soft tissue gap, the mesial surfaces of the cen

tral

incisors were reshaped (c) to lengthen their connector area and move the contact point gingivally (d). After con

tinued

orthodontic space closure, a more esthetic final result was achieved (e,f).

ORTHODONTICS AND PERIODONTICS • 751

successful, orthodontic treatment should be termi-

nated (Machen 1990).

After appliance removal, reinstruction in oral hy-

giene measures should be given. Otherwise, sub-

sequent labial gingival recession maybe risked due to

overzealous toothbrushing, since cleaning is now eas

ier to perform.

Esthetic finishing of treatment results

Adults with a reduced periodontium represent differ-

ent challenges for orthodontists than adolescents.

Worn or abraded teeth, missing papillae and uneven

crown lengths are common problems, and it is there-

fore more difficult to obtain an esthetically optimal

appearance of the teeth and gingiva after bracket re-

moval.

Most incisor teeth in adults with malocclusions

have more or less worn incisal edges, which represent

an adaptation to the functional demands. When the

axial inclinations and rotations of such incisors are

corrected, there is frequently need for incisal grinding

towards a more normal contour. Such grinding can be

performed safely as long as the wear is limited, the

overbite is adequate, and the patients display enough

tooth material in conversation and on smiling. When

the abrasion is more significant, however, co-opera-

tion with a restorative dentist is generally indicated.

The presence of papillae between the maxillary

incisors is a key esthetic factor after orthodontic treat

ment. Normally, when a long-standing crowding with

incisor overlap is corrected orthodontically in adults,

it is generally not possible to have an intact papilla.

This is because the contact point becomes located too

far incisally on the triangular crowns that have not

had a normal interdental wear pattern. Similarly, in

patients with advanced periodontal disease and de-

struction of the crestal bone between the incisors, the

papillae may be absent. This produces unesthetic gaps

between the teeth after orthodontics. The best method

of correcting this problem is to recontour the mesio-

distal surfaces of the incisors during the orthodontic

finishing stage (Tuverson 1980). When the diastemata

thus created are closed, the roots of the teeth can come

closer together. The contact point is lengthened and

moved apically, and the papilla can fill out the inter-

dental space more easily (Figs. 31-4, 31-6).

In patients with high or normal smile lines, the

relationship of the gingival margins of the maxillary

anterior teeth may be another important factor in the

esthetic appearance of the crowns (Kokich 1996a,b).

When adult patients have gingival margin discrepan-

cies between adjacent teeth, the orthodontist must

determine the proper solution for the problem: ortho-

dontic movement to reposition the gingival margin

(

Fig. 31-17) or surgical correction (gingivectomy) to

increase the crown length of single or several teeth

(

Figs. 31-29, 31-30).

Retention – problems and solutions;

long-term follow-up

Due to the anatomic and biologic differences in tissue

reaction between adults and children (Melsen 1991),

adults undergoing extensive orthodontic treatment

will generally need, at least, a longer period of reten-

tion than would an adolescent patient. Also, growth

and development no longer take place and cannot aid

in changing occlusal levels or in space closure by the

eruption of posterior teeth with mesial drift. The space

reopening tendency of closed extraction sites in adults

can be mitigated by use of labially bonded retainers

(

Figs. 31-1, 31-3).

The migration of teeth associated with periodontal

tissue breakdown around the incisors in adults is

usually blamed on inflammatory swelling or the

tongue thrust. However, according to Proffit (1978),

two major primary factors are involved in the equilib-

rium which determines the final position of teeth.

These are the resting pressures of lip or cheek and

tongue, and forces produced by metabolic activity

within the periodontal membrane. With an intact pe-

riodontium, unbalanced tongue-lip forces are nor-

mally counteracted by forces from the periodontal

membrane. However, when the periodontium breaks

down, its stabilizing function no longer exists and the

incisors begin to move. A consequence of this concept

would be that persons with advanced periodontal

disease and tooth migration would need permanent

retention after the orthodontic correction. For patients

with minimum-to-moderate loss of periodontal tissue

support, more "normal" retention periods may be

sufficient.

The optimal long-term retainer for adults with re-

duced periodontium is the flexible spiral wire (FSW)

retainer bonded lingually on each tooth in a segment.

The bonded retainer in the anterior region is generally

used together with a maxillary removable plate. The

fabrication and long-term evaluation of bonded re-

tainers is described by Dahl and Zachrisson (1991).

Figs. 31-1, 31-3, and 31-5 demonstrate different de-

signs of FSW retainers in the maxilla and the mandible

in several patients. At the same time as the FSW

retainer works as a reliable, invisible orthodontic re-

tainer, it concomitantly acts as a periodontal splint,

which allows the individual teeth within the splint to

exert physiological mobility. As long as the retainer

remains intact, small spaces might open up distal to,

but not within, the retainer.

Splinting may not be needed for most teeth with

increased mobility after periodontal therapy (Ram-

fjord 1984). However, reduced mobility of teeth after

combined periodontal and orthodontic treatment by

using a bonded retainer would seem to be of consid-

erable benefit. If a bonded retainer is not used, and

instead a removable plate or spring retainer is used at

night on a long-term basis, there is a risk for ongoing

jiggling of the teeth because of the relapse tendency

during the day. Experimental studies in animals indi-

752 • CHAPTER 31

cate that jiggling forces may facilitate the progress of

attachment loss in periodontitis, or at least result in

more bone resorption. Also, more connective tissue

reattachment and bone regeneration may occur

around non-jiggled teeth. Monkey experiments have

shown that when experimental jiggling of teeth was

stopped, a significant gain of alveolar bone occurred

(

Nyman et al.

1982).

Similarly, Burgett et al.

(1992)

demonstrated that the healing following periodontal

therapy may be more advantageous in patients who

received occlusal adjustment than in non-adjusted

patients.

Long-term follow-up of patients who have received

combined periodontal and orthodontic treatment, and

have used bonded retainers for several years, demon-

strates excellent stability and apparently unchanged,

or even improved, periodontal condition (Figs.

31-7,

31-8).

It should be pointed out, however, that a bonded

maxillary retainer must be placed out of occlusion

with the mandibular incisors, because biting on a

retainer wire will lead to unacceptably high bond

failure rates (Artun & Urbye

1988).

Possibilities and limitations; legal aspects

Adult orthodontic patients with marked periodontal

destruction may represent potential problems even

when optimal treatment is provided. There are, how-

ever, no definite metric limits in terms of probing

depths or loss of attachment when orthodontic tooth

movement can no longer be performed (Diedrich

1999)

Each individual treatment plan may depend on

variety of factors and can be limited by biomechani-

cal considerations (force systems, limited anchorage),

by periodontal risk factors (tooth/alveolar bone to-

pography, sinus recesses, activity and prognosis of the

periodontitis), and by limited patient motivation and

poor oral hygiene co-operation.

Single case reports have documented successful

periodontal-orthodontic treatment with localized ju-

venile periodontitis (LJP) after conventional peri-

odontal therapy (Harpenau & Boyd

2000),

or with

continous antiseptic and short-term systemic (Folio et

al.

1985)

or local (Hoerman et al.

1985)

antibiotic ap-

plications, and microbiologic testing during the ortho-

dontic treatment period to reduce the risk of recurrent

disease. However, until more evidence is accumu-

lated, it may seem wise to avoid orthodontic treatment

in patients with particularly aggressive forms of peri-

odontal disease. Similarly, multirooted teeth with

questionable prognosis should be moved orthodonti-

cally only in exceptional situations.

"Hopeless teeth":

According to old concepts, the re-

tention of teeth diagnosed as periodontally "hope-

less"

would accelerate the destruction of the adjacent

interproximal periodontium. Such teeth were there-

fore frequently extracted in the past. However, the

theoretic rationale for such extractions would seem

unsupported, and recent follow-up studies have dem

onstrated that retained periodontally "hopeless" teeth

do not significantly affect the interproximal periodon

tium of adjacent teeth following periodontal therapy

(

Chace & Low

1993).

The clinical implication is that

these teeth can be useful for orthodontic anchorage, if

the periodontal inflammation can be controlled (Fig.

31-9).

Occasionally, the hopeless tooth may be so im

proved after orthodontic treatment that it is retained

(

Mathews & Kokich

1997).

Alternatively, a hopeless

molar may be hemisectioned after the orthodontic

treatment, and the best root may be used as a bridge

abutment (Fig.

31-10).

Most of the time, however, the

hopeless tooth will be extracted, especially if other

restorations are planned in the segment.

For improved patient care, stress reduction, and

reduction or elimination of law-suits, careful exami-

nation protocols, documentation and correspondence

techniques, and regular progress evaluations are im-

portant. The legal implications of orthodontic risk

management concepts may be that it is preferable to

terminate treatment for patients who fail to improve

oral hygiene care, despite the orthodontist's efforts. In

the long term, this will be better for both patient and

orthodontist, since termination, if properly handled,

will be more easily defended than permitting the con

dition to worsen (Machen

1990).

However, if proper

procedures are followed, termination of orthodontic

care for periodontal patients will very rarely be

needed.

SPECIFIC FACTORS ASSOCIATED

WITH ORTHODONTIC TOOTH

MOVEMENT IN ADULTS

Tooth movement into infrabony pockets

Orthodontic forces

per se

are unlikely to convert gin-

givitis into destructive periodontitis. The plaque-in-

duced lesion in gingivitis is confined to the supra-al-

veolar connective tissue, whereas tissue reactions to

orthodontic forces occur in the connective tissue be-

tween the root and the alveolar bone. However, in-

frabony pockets, i.e. angular bony defects with in-

flamed connective tissue and epithelium apical to the

hone crest, may develop as a result of destructive

periodontitis. Infrabony pockets may also be created

by orthodontic tipping and/or intruding movements

of teeth harboring plaque (Ericsson et al.

1977).

The

effect of bodily tooth movement into infrabony defects

has been evaluated experimentally in monkeys (Poi-

son et al.

1984)

and in dogs (Wennstrom et al.

1993).

Provided elimination of the sub gingival infection was

performed before the orthodontic tooth movement

was started, no detrimental effects on the attachment

level were observed. The angular bony defect was

eliminated by the orthodontic treatment, but no coro

nal gain of attachment was found and a thin epithelial

ORTHODONTICS AND PERIODONTICS • 753

Fig. 31-7. Adult male periodontitis patient after periodontal and orthodontic therapy (a-d). The patient was treated

with generalized gingivectomies according to concepts aiming at pocket elimination. The orthodontic result is

maintained with a six-unit lingually bonded retainer (d). The bonded wire will act both as an orthodontic retainer

and

as a periodontal splint, which would appear advantageous in cases where the tissue destruction is as ad

vanced as in

this patient. (e) and (f) show the radiographic appearances 7 and 9 years, respectively, after removal of

the

orthodontic appliances. The left central incisor had so little bone support that if the bonded retainer had not

been

used, the tooth would probably had been lost over time (see also Fig. 31-8).

754 • CHAPTER 31

Fig. 31-8. Post-treatment radiographic (a) and clinical (b) appearance of the mandibular dentition in the same pa

tient as in Fig. 31-7 after periodontal and orthodontic treatment. The mandibular six-unit retainer bonded

lingual

retainer (b) concomitantly acts as a periodontal splint. Note signs of improvement of periodontal condition

7 and

years, respectively, after the orthodontic treatment (c,d), with marked crestal lamina dura contours.

lining covered the root surface corresponding to its

pretreatment position (Fig.

31-11).

It was therefore

concluded that orthodontic tooth movement into in-

frabony periodontal defects had no favorable effects on

the level of connective tissue attachment. However,

was possible to move teeth with reduced

healthy

periodontium without additional attachment loss. If,

on the other hand, the orthodontic treatment involved

movement of teeth into and through a site with in-

flammation and angular bone loss, an enhanced rate

of periodontal destruction was noted.

Conclusion

Since orthodontic movement of teeth into inflamed

infrabony pockets may create a high risk for addi-

tional periodontal destruction, and because infrabony

pockets are frequently found at teeth that have been

tipped and/or elongated as a result of periodontal

disease, it is clinically essential that periodontal treat-

ment with elimination of the plaque-induced lesion is

performed before orthodontic therapy is begun. It is

equally important that excellent oral hygiene is main-

tained throughout the course of the orthodontic treat-

ment. Following these principles, clinical and radio-

graphic observations confirm that orthodontic treat-

ment can be successfully performed in patients with

infrabony pockets resulting from periodontal disease.

Tooth movement into compromised bone

areas

Orthodontic tooth movement may sometimes be per-

formed in adults with partially edentulous dentitions

(

due to agenesis or previous extractions of teeth) and

such patients may have a more or less compromised

alveolar process. Experimental reports (Lindskog-

Stokland et al.

1993)

and clinical studies (Stepovich

1979,

Horn & Turley

1984,

Goldberg & Turley

1989,

Thilander

1996)

have shown that a reduction in verti-

cal bone height is not a contraindication for orthodon-

tic tooth movement towards, or into, the constricted

area. Mandibular second molars can be moved

mesially through remodeled edentulous first molar

areas in adults (Fig.

31-12),

with only a limited reduc-

tion in vertical bone height, averaging -1.3

mm (Horn

& Turley

1984).

Space closure is possible also in eden-

tulous maxillary first molar areas, although vertical

bone loss and some space re-opening can be a compli-

cation.