|Year : 2016 | Volume
| Issue : 2 | Page : 99-103
Ortho-perio integration: An orthodontic review
Luv Agarwal, Ragni Tandon, Shrish Srivastava, Ankit Gupta
Department of Orthodontics and Dentofacial Orthopedics, Saraswati Dental College and Hospital, Lucknow, Uttar Pradesh, India
|Date of Web Publication||6-Jan-2017|
23, Yog Ashram Behind Himgiri Hotel, Devpura, Haridwar, Uttarakhand
Source of Support: None, Conflict of Interest: None
A multidisciplinary approach including an orthodontist and a periodontist is done in patients with periodontal disease. Both specialists should be involved in the treatment planning of such patients, and care should be taken in evaluation of progress of the treatment undertaken. Importance of multidisciplinary approach has increased as majority of patients seeking orthodontic treatment are adults. Orthodontic patients are highly susceptible to increased accumulation of plaque which makes integration of a periodontist very essential. Careful attention needs to be given to orthodontic patients as undesirable periodontal changes are seen. The purpose of this article is to highlight the importance of both specialties and in which conditions they are used as an adjunct and the mutual benefits shared by them.
Keywords: Interrelation; multidisciplinary; orthodontics; periodontal disease
|How to cite this article:|
Agarwal L, Tandon R, Srivastava S, Gupta A. Ortho-perio integration: An orthodontic review. Indian J Multidiscip Dent 2016;6:99-103
|How to cite this URL:|
Agarwal L, Tandon R, Srivastava S, Gupta A. Ortho-perio integration: An orthodontic review. Indian J Multidiscip Dent [serial online] 2016 [cited 2019 Jul 22];6:99-103. Available from: http://www.ijmdent.com/text.asp?2016/6/2/99/197766
| Introduction|| |
A multidisciplinary approach is often required for the correction of complex dentoalveolar problems in patients and this can be better explained by ortho-perio integration. The biologic basis of orthodontic treatment is that bone remodels and tooth moves on application of prolonged pressure to the tooth. Removal of bone occurs in some areas and addition in others, in a selective manner. In essence, the tooth socket migrates and the tooth moves through the bone carrying its attachment apparatus, i.e., periodontal ligament with it. This response occurs through mediation by the periodontal ligament; therefore, orthodontic tooth movement is basically a periodontal ligament phenomenon. 
A multidisciplinary approach including an orthodontist and a periodontist is done in patients with periodontal disease. Both specialists should be involved in the treatment planning of such patients, and care should be taken in evaluation of progress of the treatment undertaken.  Since orthodontic tooth movements are strongly associated with interactions of teeth and their supporting periodontal structures, we can say every orthodontic intervention has some kind of periodontal dimension. Adult patients opting for orthodontic treatment have increased recently and also the patients with periodontal problems faced by the orthodontists. Orthodontics may be an option in case of repositioning of periodontally compromised teeth. There are osteogenic changes seen in bone during orthodontic tooth movement, and there will be alteration of bone deformities and contours. The topography of the underlying bone and other intraosseous deformities influences the prognosis of periodontal therapy and pockets elimination. 
Favorable levels of bone in periodontally susceptible patients can be achieved by orthodontic treatment. This can be done through increased plaque removal, reduction of traumatic occlusion, and enhancement of the bone formation within the intraosseous defects. ,,
| Orthodontic Treatment in Periodontally Susceptible Patient|| |
Patients who have susceptibility to periodontal disease can be subjected to orthodontic treatment under severe control. This is undertaken to prevent biofilm formation and to eliminate periodontal pockets. Furthermore, the stable periodontal status is maintained by the orthodontics. ,,,
Although there is no clear relationship between malocclusion and periodontitis or between the effects of orthodontic tooth movement and periodontal status, the literature explains clear interaction between orthodontist and periodontist. 
Notable contributions of orthodontist in the field of periodontics are as follows:
- It provides well-shaped dental arches and helps in maintaining good oral hygiene. Malocclusion as a periodontal disease accelerator is eliminated in the absence of crowding of teeth
- It orients vertical occlusal forces and makes it parallel to the long axis of the tooth. Therefore, it uniformly distributes muscle force to the dental arch
- It helps in achieving an adequate crown-root ratio in some cases by orthodontic extrusion, with no loss of surrounding bone
- It positions prosthetic pillars for the placement of fixed prostheses
- It reduces bruxism during the mechanotherapy
- It allows the use of light, precise, and continuous tooth movements.
The whole periodontal apparatus involving bone, periodontal ligament, and supporting tissues remodels with orthodontic therapy.  Resorption of alveolar bone seen on the pressure side and deposition on the tension side and periodontal ligament compresses and the blood vessels squeezes out which decreases blood supply. , Hydrostatic pressure in the periodontal ligament decreases on application of excessive pressure, and if it is localized to a specific region, potential of root resorption increases.  Apart from that, periodontal tissues having different types of orthodontic tooth movement show variation in their response. 
| Prevention of Periodontal Breakdown during Orthodontic Treatment|| |
Orthodontic molar bands, brackets, and archwires compromise the self-cleaning ability of patient to maintain good oral hygiene.  These cause accumulation of microbial plaque and pathogenicity of the bacterial microbes increases.  This is often cured with professional oral prophylaxis which includes oral hygiene instructions at every visit and rubber cup prophylaxis so as to prevent plaque formation and gingival enlargement [Figure 1]. 
The efficacy of manual, electric, and ultrasonic toothbrushes in patients having fixed mechanotherapy was compared and found that the plaque scores were less on the buccal surfaces of teeth in patients using ultrasonic toothbrush. In addition, patients who used ultrasonic and electrical toothbrushes showed decrease in Streptococcus mutans count.  Studies reported that there can be an improvement in oral hygiene of orthodontic patients by the use of sanguinaria-containing toothpaste along with a sanguinaria-containing oral rinse. 
| Orthodontics as an Adjunct to Periodontal Therapy|| |
Orthodontic treatment can be used as an adjunct to periodontitis in a number of conditions for the improvement of dental health. Pathological tooth migration affects dentofacial aesthetics and is considered an important sign of periodontal disease. This occurs most commonly in the anterior dentition where stable occlusal and sagittal contact with the opposing teeth is absent.  Various orthodontic tooth movements such as intrusion, extrusion, rotation, and uprighting are needed to achieve an esthetically acceptable outcome. This helps in the control of periodontal breakdown and restoration of good oral function. 
Fixed appliance mechanotherapy is preferred in a patient who suffers from periodontal disease as suggested by Tulloch. It helps in achievement of stable anchorage by splinting of teeth. He also stresses the need to reduce the force magnitude in order to decrease the stress on periodontal ligament.  Combination approach involving orthodontic tooth intrusion and periodontal therapy improves defects in alveolar bone, gingival esthetics in patients having one- or two-wall bony defects as showed by Shoichiro in his study. These improved periodontal condition and periodontal pockets were eliminated before intrusion to prevent apical displacement of plaque. ,,
| Periodontics as an Adjunct to Orthodontic Treatment|| |
Orthodontic treatment alone cannot achieve a stable and esthetically acceptable outcome without using adjunctive periodontal procedures. For example, in orthodontics, a high labial frenum attachment causes midline diastema. Frenectomy is undertaken in such cases as the periodontal fibers prevent the approximation of the central incisors. However, periodontal procedure timing has been a debatable topic. Surgical removal of a maxillary labial frenum should be delayed until after orthodontic treatment. This is done unless the tissue prevents closure of space said by Vanarsdall [Figure 2]. 
Forced eruption of an impacted tooth either labially or palatally is also a common orthodontic treatment procedure. The expertise of a periodontist is required in cases where careful exposure of the impacted tooth is done with simultaneous preservation of keratinized tissue. This prevents loss of attachment. Placement of apically or laterally positioned pedicle graft is the preferred surgical procedure.  Orthodontists always face problems in cases of retention of achieved tooth rotation. Therefore, circumferential supracrestal fiberotomy (CSF) is done as it enhances posttreatment stability. 
CSF is essentially performed in maxillary arch as it prevents relapse in a more successful manner as concluded by Edwards from his long-term studies. It does not affect the periodontal tissues negatively.  Additional surgeries may be done during orthodontic treatment such as mucogingival surgery. This maintains sufficient width of attached gingiva. Crown lengthening is also undertaken in patients with short clinical crowns which cause easy placement of orthodontic attachments on teeth. Such technique is also used for procedures such as smile designing. 
| Orthodontic Treatment Considerations|| |
The elimination and reduction of plaque accumulation and gingivitis with removal of pockets are the key elements in the orthodontic management of adult patients with periodontitis. Extra emphasis should be laid on oral hygiene instructions which need to be given on each visit, appliance fabrication, and periodical evaluations throughout the treatment.  The appliance has to be properly designed for each particular case. To counteract the effects on the teeth, actions should be made to keep the orthodontic appliance and mechanics simple and avoid tendency of orthodontic appliances to increase the plaque formation by skipping use of hooks, elastomeric ligatures, and excess bonding resin outside the bracket bases. Since elastomeric rings attract more plaque than steel ligatures, steel ties should be used. 
Bondable tubes are preferred instead of bands during orthodontic treatment of adults as it expresses less plaque accumulation, gingivitis, and interproximal attachment loss as compared to banded molars. Professional tooth prophylaxis can be performed on 3 months intervals by dental hygienist or periodontist, depending on the case.  Probing depth recording, mobility, bleeding on probing, gingival recessions, bone levels, etc., should be reexamined. Orthodontic intrusion causes a shift from supragingival plaque to a subgingival plaque; therefore, professional scaling may be substituted during active intrusion of elongated maxillary incisors. ,,,
| Esthetic Finishing of Treatment Results|| |
Orthodontists experience different challenges in treating adults with a reduced periodontal support as compared to adolescents. Worn out tooth, abrasion, eroded teeth, missing papillae, and unequal crown lengths are common problems, and an esthetic appearance of the teeth and gingiva after bracket removal is difficult to obtain. Many incisors in adults with malocclusions have more or less worn incisal edges. This represents an adaptation to the functional demands such as mastication, swallowing, and respiration. Need for incisal grinding arises to correct rotations and axial inclination of incisors; however, association with a therapeutic dentist is necessary. The papillae may be absent in patients with advanced periodontitis and also in cases of loss of the crestal bone between the incisors, hence producing unaesthetic gaps between the teeth after orthodontic tooth movement. Recontouring of the mesiodistal surfaces of the incisors during the orthodontic finishing stage is the best method for correction of this problem. 
| Retention Problems and Solutions|| |
Adults and children show different tissue reactions with adult being need a longer duration of retention than an adolescent as adults undergo extensive fixed appliance therapy.  According to Proffit, resting pressures of lip, cheek, tongue, and forces produced by metabolic activity within the PDL are major factors that decide the final teeth positioning.  In an intact periodontium, forces from periodontal membrane counteract unbalanced tongue-lip forces. Its stabilizing function fails when the periodontium breaks down and the incisors movement begins. Hence, permanent retention after the orthodontic correction is essential in persons with advanced periodontal disease.
"Normal" retention may be sufficient for patients with minimum-to-moderate loss of periodontal tissue support. Flexible spiral wire (FSW) retainer bonded lingually on each tooth is a treatment of retention in adults with reduced periodontium. FSW retainer not only works as orthodontic retainer but also simultaneously acts as a periodontal splint. This allows the individual teeth within the splint to exert physiological mobility. Excellent stability is demonstrated in long-term follow-up of patients who received combined periodontal and orthodontic treatment. It should be noted that since biting on a retainer wire can cause a high bond failure rates, bonded maxillary retainer must be seated out of occlusion with the mandibular incisors. 
| Conclusion|| |
Clinically, the orthodontic intervention can be initiated in periodontally compromised patients with crowding only when there is control of periodontal inflammation and when stable periodontal conditions are achieved after significant reduction of periodontal pockets. Orthodontic treatment maintains periodontal homeostasis after the periodontal treatment has been performed. Patient's education and motivation as complemented by interdisciplinary approach transform the patient's unattractive dentition (due to migrated teeth secondary to periodontal breakdown and inflamed periodontium) into an attractive dentition with a radiant smile. Since orthodontic therapy and periodontal health shares a close relation, an understanding of the ortho-perio relationship helps in executing the best possible outcomes in needy patients.
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Conflicts of interest
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[Figure 1], [Figure 2]