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Managing Treatment for the Orthodontic

Patient With Periodontal Problems
D a v i d P.. Mathews and Vincent G. Kokich

Some adult patients have mild to moderate periodontal disease before

orthodontic treatment. These patients may be at risk of developing further
periodontal breakdown during orthodontic therapy. However, careful diagno-
sis and judicious management of these potentially volatile patients can
alleviate the risk. In this article, the diagnosis and management of several
periodontal problems is discussed. The need for and timing of preorthodon-
tic periodontal surgery for these situations is elucidated. In addition, the
types of tooth movement that will ameliorate these problematic situations is
described. This information is valuable for the orthodontist who treats
patients with underlying periodontal problems. (Semin Orthod 1997;3:21-
38.) Copyright© 1997by W,B. Saunders Company

"ost orthodontic patients are children and Periodontal Examination by the

M adolescents between the ages of 8 and 16
years. Except in unusual situations, younger
patients generally have a healthy periodontium.
Although some uncooperative patients may de-
velop gingival inflammation, the majority of
children and adolescents do not experience
alveolar b o n e loss during orthodontics. Cur-
rently, orthodontists are treating m o r e adult
patients. The percentage of adults in some orth-
odontic offices is m o r e than 40%. Many of these
patients have underlying periodontal problems
that could b e c o m e worse during orthodontic
therapy. It is i m p o r t a n t for orthodontists to
identify periodontal problems before o r t h o d o n -
tic treatment, d e t e r m i n e the correct t r e a t m e n t
plan to ameliorate these problems, and se-
quence the orthodontic and periodontal therapy
correctly to enhance the patient's periodontal
health. This article describes the responsibilities
of orthodontists for diagnosing periodontal prob-
lems and discusses the interdisciplinary manage-
m e n t of several periodontal problems requiring
orthodontic intervention.
From the Department of Orthodontics, School of Dentistry,
University of Washington, Seattle, WA.
Address correspondence to Vincent G. Kokich, l)l)~S, MSI),
Department of Orthodontics, School of Dentistry, University of
Washington, Seattle, WA 98195.
Copy*Jght © 1997 by W.B. Saunder~ Company
1073-8746/97/0301-000355.00/0
Orthodontist
Because orthodontists are treating m o r e adult
patients, they must take an active role in diagnos-
ing periodontal problems before initiating orth-
odontic treatment. T h e orthodontist should in-
corporate a cursory 5 minute periodontal
examination during the initial consultation with the
patient. This is a simple screening examination. If
problems are discovered, then referral to a periodon-
fist for a more detailed diagnosis is appropriate.
T h e screening examination involves p r o b i n g key
indicator teeth, evaluating attached gingiva, and
studying a p p r o p r i a t e radiographs.
Periodontal Screening and Recording
Periodontal screening and recording (PSR) is a
rapid and effective m e t h o d to screen adult pa-
tients for periodontal diseases. 1 It smnmarizes
necessary information with m i n i m u m d o c u m e n -
tation. A special small plastic p r o b e is used to
assess each sextant. A score is given for each area
and a s u m m a r y chart will help the e x a m i n e r to
d e t e r m i n e whether further periodontal examina-
tion and treatment are necessary. PSR is easy to
carry out and understand and is a highly sensi-
tive technique for detecting deviations from
periodontal health. It can be readily incorpo-
rated into routine oral examinations without
increasing a p p o i n t m e n t time.

Seminars in Orthodontics, Vol 3, No 1 (March), 1997: pp 21-38 21

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22 Mathews and Kohich
Periodontal Probing
A n o t h e r means of detecting periodontal disease
is to use a standard periodontal probe." T h e
Michigan " O " and the Marquis p r o b e are thin,
and easy to read and record measurements.
C o m m o n areas for periodontal disease in adults
are f o u n d in the u p p e r m o l a r interproximal
regions, buccal furcations, and in the lower
canine/lateral area, especially in patients with
crowding. 3 It is i m p o r t a n t to find the d e p t h of
the interproximal osseous defect, and this can be
achieved with p r o p e r angulation of the p r o b e
(Fig 1). Radiographs can also help delineate
areas that should be evaluated with the probe.
Attached Gingiva
Areas of minimal gingiva can be easily evaluated
by one of two simple techniques. First, a periodon-
tal p r o b e can be used horizontally in the vestibule
and gently raised toward the gingiva to delineate
the mucogingivaljunction. T h e width of gingiva
can be measured with a probe. Areas with less
than 2 m m of gingiva will require further evaluation
by the periodontist. 4 A n o t h e r technique to assess
the a m o u n t of gingiva is to use light finger touch
in the vestibule a n d ruffle the mucosal tissue to
assess the mucogingival junction and a m o u n t of
gingiva. Delineation of the mucogingivaljunction
is m o r e difficult in patients with inflammation
and very thin mucosal-like tissue (Fig 2B). Pa-
tients with a very thin p e r i o d o n t i u m and promi-
n e n t roots are candidates for fllrther evaluation.
Radiographs
Most orthodontists use a p a n o r a m i c r a d i o g r a p h
which is excellent for generalized screening.
However, p a n o r a m i c radiographs are not as diag-
Figure 1. The orientation of the probe is important. The probe should be directed into the interproximal and
along the long-axis of the root to determine accurate sulcular depths (A and B).
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nostic as a vertical bitewing radiograph for the
evaluation of periodontal osseous lesions. Com-
m o n areas that are missed on the panoramic
radiograph are interproximal craters between
u p p e r molars, infrabony defects on the mesial of
the u p p e r first bicuspid, and defects around the
lower incisors. In adult patients with m o d e r a t e to
advanced periodontal disease, regular bitewings
are of minimal diagnostic value. A vertical bite-
wing is m o r e diagnostic and will show the crestal
b o n e m o r e clearly.
Parafunction
It is extremely i m p o r t a n t for the orthodontist to
identify those adult patients who may he bruxers
or clenchers. A cursory evaluation of advanced
mobility is imperative. Clenchers and bruxers
can cause extensive osseous breakdown during
orthodontic t h e r a p y ) These patients may need a
biteplate appliance (nightguard) while they are
u n d e r g o i n g active orthodontic treatment.
Preorthodontic Periodontal Therapy
Preorthodontic periodontal therapy is directed
toward the etiologic factors including plaque,
subgingival calculus, and occlusal trauma. T h e
initial phase of periodontal t r e a t m e n t involves
an individualized home-care program. Use of an
automatic t o o t h b r u s h (Oral B [Braun, Lynn-
field, MA]; Sonicare [Optiva Corp; Bellevne,
WA]; or Interplak [Bausch & Lomb, TuckeL
GA]) may be r e c o m m e n d e d for patients with
c o m p r o m i s e d home-care ability.
Root planing and subgingival d e b r i d e m e n t
are p e r f o r m e d to help diminish inflammation,
bleeding, and suppuration. This initial stage of
treatment is usually a b o u t 3 months. Occasion-
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Treatmentfor the Orthodontic-Periodontal Patient 23

Figure2. Evaluation of amount of attached gingiva. Betbre orthodontic treatment (A) the patient had moderate
crowding. Staining of the gingiva with Schiller's solution (B) showed minimal gingiva labial to the mandibular
right central incisor. Periodontal sounding of the bone (C), showed a 5 mm depth signifying a dehiscence over
this tooth. A gingival graft was placed betbre orthodontic therapy (D), which helped to prevent gingival recession
during (E) and after orthodontic treatment (F).

ally an antibiotic is used, especially in m o r e Preorthodontic Gingival Surgery

refractory p e r i o d o n t a l diseases. T h e patient is
reevaluated a few m o n t h s after this initial debride-
m e n t , a n d the tissue response is assessed. Disease
activity is evaluated. Usually there will be a
significant decrease in bleeding, s u p p u r a t i o n ,
a n d p o c k e t d e p t h J; T h e periodontist will deter-
m i n e if the patient is stable e n o u g h p e r i o d o n -
tally to p r o c e e d with o r t h o d o n t i c treatment.
Some areas in the m o u t h may require p e r i o d o n -
tal surgical t r e a t m e n t b e t o r e the initiation o f
o r t h o d o n t i c treatment.
Gingiva Grafting
Areas o f minimal a t t a c h e d gingiva s h o u l d be
evaluated by the p e r i o d o n t i s t betbre initiating
o r t h o d o n t i c treatment. Teeth with less t h a n 2
m m o f gingiva may require grafting (Fig 2).
However, there are s o m e factors that n e e d to be
c o n s i d e r e d in m a k i n g this decision.: T h e peri-
o d o n t i s t can " s o u n d " these areas o f thin, n a r r o w
gingiva to ascertain the a t t a c h m e n t and b o n e
level (Fig 2). This is p e r f o r m e d with a thin
<<Arh, 7: >>
24 Mathews and Kokich
probe, inserted in the sulcus and gently pressed
through the attachment apparatus to the labial
crest of the bone. Teeth with underlying dehis-
cences are more p r o n e to recession and loss of
attachment.
O t h e r factors such as h o m e care, gingival
inflammation, and the direction of proposed
tooth m o v e m e n t will influence the decision to
graft in areas of minimal gingiva. During orth-
odontic treatment there is a greater likelihood of
inflammation because of compromised h o m e
care access a r o u n d orthodontic appliances. Ar-
eas of minimal gingiva that are inflamed are at
greater risk for attachment loss.
Teeth that will be proclined orthodontically
have a greater risk of recession. 8 As the tooth is
moved labially, a bony dehiscence could be
created. When areas of minimal gingiva lose
their underlying bony scaffold, there is a greater
risk of subsequent recession. 9 Also, teeth with
p r o m i n e n t roots have a higher incidence of
recession t h r o u g h mechanical and toothbrush
trauma.
All of these factors need to be considered by
the periodontist in treatment planning. The
p r u d e n t therapist will weigh the combination of
these factors to decide what is best for the pa-
tient. The benefits of grafting far outweigh the
disadvantages. Often, areas that were grafted will
have coronal "creeping attachment" of the gingi-
val margin when evaluated years later 1° (Fig 2E).
Gingival Recession and Root Coverage
Areas of recession and root exposure can be
predictably covered with various grafting tech-
niques. 11 Gingival grafting and pedicle grafting
were the traditional methods for root coverage.
At the present time the connective tissue graft
has become the treatment of choice to cover
d e n u d e d roots. 19 The connective tissue graft
gives a greater degree of root coverage, is more
esthetic, and the procedure is less traumatic than
conventional gingival grafting.
If grafting procedures are done for cosmetic
reasons, it is best to p e r f o r m them when orth-
odontic treatment has been completed. How-
ever, if the area has recession and inadequate
gingiva, then the procedure may be done before
or during orthodontic treatment (Fig 3). The
decision to p e r f o r m a root coverage procedure is
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based on esthetics, tooth sensitivity, the depth of
erosion in the root, the presence of composite
gingival restorations, and the patient's wishes
c o n c e r n i n g the esthetic outcome.
P r e o r t h o d o n t i c O s s e o u s Surgery
The extent of the osseous surgery will d e p e n d on
the type of defect, ie, crater, hemiseptal defect,
three-walled defect, a n d / o r furcation lesion. The
p r u d e n t therapist will know which defects can be
improved with orthodontic treatment and which
defects will require p r e o r t h o d o n t i c periodontal
surgical intervention.
Osseous Craters
An osseous crater is an interproximal two-wall
defect that will not improve with orthodontic
treatment. Some shallow craters (4 to 5 m m
pocket) may be maintainable nonsurgically. How-
ever, if the periodontist believes that surgical
correction is necessary, this type of osseous
lesion can easily be eliminated by reshaping the
defect and reducing the pocket depth 1~u4 (Fig
4). This in turn will enhance the ability to
maintain these interproximal areas during orth-
odontic treatment. The need for surgery is based
on the patient's response to initial treatment, the
patient's periodontal resistance, the location of
the defect and the predictability of maintaining
defects nonsurgically while the patient is wearing
orthodontic appliances.
Three-Wall Intrabony Defects
Three-wall defects are amenable to pocket reduc-
tion with regenerative periodontal therapy. 15
Bone grafts using either autogenous bone from
the surgery site, or allografts, along with the use
of resorbable or nonresorbable membranes have
been very successful in filling three-wall de-
fects) 6 Buccal and lingual flaps are reflected,
and the osseous defect is debrided (Fig 5). The
root is prepared with an appropriate material,
either citric acid, ethylene diaminetetraacetic
acid (EDTA), or tetracycline. The bone graft is
packed into the defect, the m e m b r a n e is placed
over the site, and the flaps are returned to their
original location. If a nonresorbable m e m b r a n e
is used, it must be removed in 4 to 6 weeks. After
m e m b r a n e removal, another 2 to 3 months is
necessary for further maturation of the graft. At
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Treatment Jbr the Orthodontic-Periodontal Patient 25

Figure 3. This patient had significant recession (A). During orthodontics, the root surface was etched (B) and
connective tissue was obtained from the palate (C) and placed over the etched roots (D). The flap was replaced
(E) and the postorthodontic photograph shows complete coverage of the denuded roots (F).

this time, the sulcular depth is reevaluated and a
periapical radiograph is made to assess the
a m o u n t of bone regeneration. If the patient
remains periodontally stable over the next 3 to 6
months, the orthodontic phase of therapy can be
initiated.
Hemiseptal Defects
Hemiseptal defects are one to two wall osseous
defects. These are often f o u n d a r o u n d mesially
tipped teeth or teeth that have supererupted.
Often these defects can be eliminated with appro-
priate orthodontic treatment. In the case of the
tipped tooth, uprighting and eruption of the
tooth will level the bony defect iv,is (Fig 6). In the
case of the supererupted tooth, intrusion and
leveling of the adjacent c e m e n t o e n a m e l junc-
tions (CEJs) can help level the osseous defect.
It is imperative that periodontal inflammation
be controlled betbre orthodontic treatment. This
can usually be achieved with initial debridement
and rarely requires any preorthodontic surgery.
After the completion of orthodontic treatment,
these teeth should be stabilized for at least 6
months and reassessed periodontally. Often, the
pocket has been reduced or eliminated, and no
further periodontal treatment is needed. It would
<<Arh~ 7: >> Home TOC I Bndex

26 Mathe-a~s and Kokich

Figure 4. Before orthodontic treatment (A), this patient had a 5 mm pocket distal to the maxillary right first
molar. This defect did not improve alter preorthodontic periodontal therapy. A flap was elevated (B), revealing a
crater mesial to the maxillary right first molar. Osseous resective surgery was performed (C and D) to eliminate
the osseous defect. Surgical elimination of the crater helped to improve the patient's ability to clean
interproximally during (E), and after orthodontic treatment (F).

b e i n j u d i c i o u s to d o p r e o r t h o d o n t i c osseous cor- t h e p a t i e n t ' s access to t h e b u c c a l f u r c a t i o n for

rective s u r g e r y in lesions such as t h e s e if o r t h -
o d o n t i c s is a p a r t o f t h e overall t r e a t m e n t plan.
Furcation Defects
F u r c a t i o n defects can b e classified as i n c i p i e n t
(Class I), m o d e r a t e (Class II) a n d a d v a n c e d
(Class III). T h e s e lesions r e q u i r e special a t t e n -
tion in t h e p a t i e n t u n d e r g o i n g o r t h o d o n t i c treat-
m e n t . O f t e n t h e m o l a r s will r e q u i r e b a n d s with
t u b e s a n d o t h e r a t t a c h m e n t s w h i c h will i m p e d e
h o m e c a r e a n d i n s t r u m e n t a t i o n at t h e t i m e o f
recall (Fig 4E).
Class I defects a r e a m e n a b l e to osseous surgi-
cal c o r r e c t i o n with a g o o d p r o g n o s i s . Class II
f u r c a t i o n defects c a n b e t r e a t e d with g r a f t i n g
a n d r e g e n e r a t i v e t h e r a p y with b a r r i e r m e m -
b r a n e s . Class III f u r c a t i o n d e f e c t s a r e m o r e
difficult to t r e a t a n d use o f g r a f t i n g a n d m e m -
b r a n e s in these lesions is n o t as p r e d i c t a b l e .
T r e a t m e n t o f Class III f u r c a t i o n lesions in the
lower a r c h can r a n g e f r o m o p e n - f l a p - c u r e t t a g e
< < Ar[l~ ,2 > > Home I TOC I Bndex
Treatment Jbr the Orthodontic-Periodontal Patient 27

Figure 5. This patient had a significant periodontal pocket (A) distal to the mandibular right first molar. A
periapical radiograph (B) confirmed the osseous defect. A flap was elevated (C) revealing a deep three-wall
osseous defect. Freeze-dried bone (D) was placed in the defect. Six months after the bone graft, orthodontic
treatment was initiated (E). The final periapical radiograph shows that the preorthodontic bone graft helped to
regenerate bone and elinfinate the delect distal to the molar (F).

to c r e a t e a t h r o u g h a n d t h r o u g h f u r c a t i o n f o r
easier c l e a n i n g , to h e m i s e c t i o n , o r even extrac-
tion a n d r e p l a c e m e n t with an i m p l a n t . 19 I n t h e
u p p e r arch, Class II a n d III f u r c a t i o n s c a n
s o m e t i m e s be t r e a t e d with r o o t a m p u t a t i o n . T h e
m o s t f a v o r a b l e r o o t to r e m o v e is t h e d i s t o b u c c a l
r o o t o f an u p p e r molar. This t r e a t m e n t has a
good prognosis. The disadvantage of root ampu-
t a t i o n is t h a t it r e q u i r e s e n d o d o n t i c t h e r a p y a n d
full-coverage r e s t o r a t i o n .
F u r c a t i o n lesions n e e d special a t t e n t i o n be-
cause t h e y are t h e m o s t difficult lesions to
m a i n t a i n a n d can w o r s e n d u r i n g o r t h o d o n t i c
therapy. T h e s e p a t i e n t s will n e e d to be m a i n -
t a i n e d o n a 2 to 3 m o n t h recall s c h e d u l e .
D e t a i l e d i n s t r u m e n t a t i o n o f t h e s e f u r c a t i o n s will
help minimize further periodontal breakdown.
Root Proximity
A r e a s o f r o o t p r o x i m i t y a r e difficult for t h e
p a t i e n t to c l e a n a n d restrict t h e h y g i e n i s t d u r i n g
p e r i o d o n t a l m a i n t e n a n c e , e° T h e y a r e also very
difficult to p r e p a r e w h e n i n t e r p r o x i m a l areas
<< Arh, 7: >> Home I TOC I Index

28 Malhews and Kokich

Figure 6. This patient was missing the mandibular left second premolar and the first molar had tipped mesially
(A). A pretreatment periapical radiograph (B) revealed a significant hemiseptal osseous defect on the mesial of
the molar. To eliminate the defect, the molar was erupted and the occlusal surface was equilibrated (C). The
eruption was stopped when the bone defect was leveled (D). The posttreatment intraoral photograph (E) and
periapical radiograph (F) show that the periodontal health had been improved by correcting the hemiseptal
defect orthodontically.

n e e d to b e r e s t o r e d . Generally, a n t e r i o r t e e t h a r e difficult s i t u a t i o n to t r e a t surgically w i t h o u t r o o t

e a s i e r to m a i n t a i n with a r o o t p r o x i m i t y b e c a u s e
o f access a n d t h e n a r r o w e r b u c c o l i n g u a l w i d t h o f
t h e alveolus.
H o w e v m ; in t h e u p p e r m o l a r r e g i o n , a r o o t
p r o x i m i t y p r o b l e m is m o r e difficult to m a i n t a i n .
Access for h o m e care, a n d a w i d e r b u c c o l i n g u a l
w i d t h m a k e t h e s e a r e a s m o r e p r o n e to osseous
breakdown. Root proximity can be exacerbated
when a molar supererupts. The distobuccal root
o f a n u p p e r first m o l a r c a n t o u c h t h e m e s i o b u c -
cal r o o t o f t h e u p p e r s e c o n d m o l a r c r e a t i n g a
a m p u t a t i o n . H o w e v m , with a p p r o p r i a t e orth-
o d o n t i c t r e a t m e n t , this s i t u a t i o n c a n b e cor-
r e c t e d w i t h o u t p e r i o d o n t a l s u r g e r y by i n t r u d i n g
t h e first molar, leveling t h e b o n e , a n d o p e n i n g
u p t h e e m b r a s u r e s p a c e b e t w e e n t h e first a n d
s e c o n d m o l a r roots.
I n a v e r y c r o w d e d s i t u a t i o n in t h e u p p e r o r
lower anterior region, simply unraveling the
r o t a t e d t e e t h will i m p r o v e t h e e m b r a s u r e f o r m
a n d simplify h o m e c a r e a n d i n s t r u m e n t a t i o n .
Also, if any c e r a m i c r e s t o r a t i o n s a r e to b e p l a c e d
<< A~'~:{~{e>> Home I WOC l lndex
7 ~atmen.t for.~lw. (-~tl~odor*lic4'o~iodongal.Patient 29

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c o m e ofortl~odm~ticdi.erapy,...is.:the l~ca.lic)n c~.f losS a r o d n d .ee~-laii~ ~eet.h.i..usi.ng .the .anatomy.of..
<< Arh, 7: >> Home I TOC I Bndex

30 Mathews and Kokich

the crown to determine bracket placement is
inappropriate.
In a patient with advanced horizontal bone
loss, the bone level may have receded several
millimeters from the CE]. As this occurs, the
crown to root ratio will b e c o m e less favorable. By
aligning the crowns of the teeth, the clinician
may perpetuate tooth mobility by maintaining an
unfavorable crown to root ratio. In addition, by
aligning the crowns of the teeth and disregard-
ing the bone level, there will be significant bony
discrepancies between healthy and periodontally
diseased roots. This could require periodontal
surgery to ameliorate the discrepancies.
The orthodontist can correct many of these
problems by using the bone level as a guide to
positioning the brackets on the teeth. In these
situations, the crowns of the teeth may require
considerable equilibration (Fig 8). If the tooth is
vital, the equilibration should be p e r f o r m e d
gradually to allow the pulp to form secondary
dentin to insulate the tooth during the equilibra-

Figure 8. Before orthodontic treatment, this patient had a significant Class III malocclusion (A). The maxillary
central incisors had overerupted (B) relative to the occlusal plane. A pretreatment periapical radiograph (C)
showed that significant horizontal bone loss had occurred. To avoid creating a vertical periodontal defect by
intruding the central incisors, the brackets were placed to maintain the bone height (D). The incisal edges of the
centrals were equilibrated (E) and the orthodontic treatment was completed without intruding the incisors (F).
< < Ar[l~ .': > >
Treatmentfor the Orthodontic-Periodontal Patient
tion process. The goal of equilibration and
creative bracket p l a c e m e n t is to provide a m o r e
favorable b o n y architecture as well as a m o r e
favorable crown to root ratio. In some of these
patients, the periodontal defects that were appar-
ent initially may not require periodontal surgery
following orthodontic treatment.
Hemiseptal Defect
In the periodontally healthy patient, o r t h o d o n -
tic brackets are positioned on the posterior teeth
relative to the marginal ridges and cusps. How-
ever, some adult patients may have marginal
ridge discrepancies caused by uneven tooth erup-
tion before orthodontic treatment. When the
orthodontist encounters marginal ridge discrep-
ancies, the decision as to where to place the
bracket or band is not d e t e r m i n e d by the anatomy
of the tooth. In these situations, it is i m p o r t a n t
for the orthodontist to assess bite wing or periapi-
cal radiographs of these teeth in order to deter-
mine the b o n e level interproximally.
If the b o n e level is oriented in the same
direction as the marginal ridge discrepancy, then
leveling the marginal ridges will level the bone.
However, if the b o n e level is fiat between adja-
cent teeth and the marginal ridges are at signifi-
cantly different levels, correction of the marginal
ridge discrepancy orthodontically will p r o d u c e a
hemiseptal defect in the bone. This could cause
a periodontal pocket between the two teeth.
If the b o n e is fiat and a marginal ridge
discrepancy is present, the orthodontist should
not level the marginal ridges orthodontically
(Fig 9). In these situations, it may be necessary to
equilibrate the crown of the tooth. In some
patients, the latter may require e n d o d o n t i c
therapy and restoration of the tooth resulting
f r o m the a m o u n t of reduction of the length of
the crown that is required. This a p p r o a c h is
acceptable, if the treatment results in a m o r e
favorable bony c o n t o u r between the teeth.
In some patients, a discrepancy may exist
between both the marginal ridges and the b o n e
levels between two teeth (Fig 10). These discrep-
ancies may however not be of equal magnitude.
In these patients, orthodontic leveling of the
b o n e may still leave a discrepancy in the mar-
ginal ridges. In these situations, the clinician
must not use the crowns of the teeth as a guide
for completing orthodontic therapy. The clini-
Home I TOC I Index
31
cian should level the b o n e orthodontically and
equilibrate any r e m a i n i n g discrepancies be-
tween the marginal ridges. This m e t h o d will
p r o d u c e the best occlusal result and improve the
periodontal health.
During orthodontic treatment, when teeth
are being e x t r u d e d to level hemiseptal defects,
the patient should be regularly m o n i t o r e d by the
periodontist. Initially, the hemiseptal defect will
have a greater sulcular d e p t h and be m o r e
difficult for the patient to clean. As the defect is
ameliorated through tooth extrusion, interproxi-
mal cleaning becomes easier. T h e periodontist
should recall the patient every 2 to 3 months
during the leveling process to control inflamma-
tion in the interproximal region.
Furcation Defects
Regenerative therapy using polytetrafluorethyl-
ene m e m b r a n e s a n d / o r b o n e grafting, has been
successfill in Class I and II furcations. Howevm,
in Class III furcations, the use of m e m b r a n e s has
not p r o d u c e d consistently satisfactory results.
Therefore, a n o t h e r m e t h o d of t r e a t m e n t must
be used for orthodontic patients with Class III
furcations in the m a n d i b u l a r arch.
I f a patient with a Class III furcation defect will
be u n d e r g o i n g orthodontic treatment, a possible
m e t h o d tbr treating the furcation is to eliminate
it by hemisecting the crown and root of the
tooth. This p r o c e d u r e will, however, require
endodontic, periodontic, and restorative treat-
ment. If the patient will be u n d e r g o i n g orthodon-
tic treatment, it is advisable to p e r f o r m the
orthodontic t r e a t m e n t first. This is especially
true if the roots of the teeth will not be separated
or m o v e d apart (Fig 1 1). In these patients, the
m o l a r to be hemisected remains intact during
orthodontics. This patient would require 2 to 3
m o n t h recall visits with the periodontist to en-
sure that the furcation defect does not lose b o n e
during orthodontic treatment. By keeping the
tooth intact during the orthodontics, it simplifies
the finishing and tooth m o v e m e n t for the orth-
odontist.
After orthodontics, endodontic therapy must
be p e r f o r m e d on both roots of the tooth (Fig 11).
Following this, periodontal surgery is necessary
to divide the tooth. Sulcular incisions are made,
a flap is elevated buccal and lingual to the molar,
and a fissure b u r is used to carefully divide the
<< Arh, 7: >> Home I TOC I Bndex

32 Mathews and Kokich

Figure 9. This patient showed overeruption of the maxillary right first molar and a marginal ridge defect
between the second premolar and first molar (A). A pretreatment periapical radiograph (B) showed that the
interproximal bone was fiat. To avoid creating a hemiseptal defect, the occlusal surface of the first molar was
equilibrated (C and D) and the malocclusion was corrected orthodontically (E and F).

c r o w n a n d r o o t s o f t h e teeth. I n s o m e situations, In some patients requiring hemisection of a

t h e p r o c e s s is m o r e difficult if t h e f u r c a t i o n is
positioned toward the apices of the tooth. After
t h e t o o t h has b e e n d i v i d e d , t h e b o n e is r e c o n -
t o u r e d a r o u n d e a c h o f t h e r o o t s a n d t h e tissue is
a l l o w e d to heal. If t h e r o o t s a r e s h o r t a n d
t a p e r e d , t h e c r o w n s t h a t r e s t o r e t h e two halves o f
t h e t o o t h c o u l d b e s p l i n t e d t o g e t h e r . If t h e
s o l d e r j o i n t o f t h e s p l i n t e d t e e t h is p o s i t i o n e d
t o w a r d t h e occlusal, t h e p a t i e n t can c l e a n inter-
p r o x i m a l l y in t h e a r e a o f t h e p r e v i o u s f u r c a t i o n .
m a n d i b u l a r m o l a r with a Class III f u r c a t i o n , it
m a y b e a d v a n t a g e o u s to p u s h t h e r o o t s a p a r t
d u r i n g o r t h o d o n t i c t r e a t m e n t (Fig 12). If t h e
h e m i s e c t e d m o l a r will b e u s e d as a n a b u t m e n t
for a bridge following orthodontics, moving the
r o o t s a p a r t o r t h o d o n t i c a l l y will p e r m i t m o r e
f a v o r a b l e r e s t o r a t i o n a n d s p l i n t i n g across t h e
a d j a c e n t e d e n t u l o u s space.
I n t h e l a t t e r situation, h e m i s e c t i n g t h e tooth,
e n d o d o n t i c therapy, a n d p e r i o d o n t a l s u r g e r y
< < Ar[l~ .'~ > > Home I TOC I Bndex
Treatmentfor the Orthodontic-Periodontal Patient 33

Figure 10. Before orthodontic treatment, this patient had significant mesial tipping of the maxillary right first
and second molars causing marginal ridge discrepancies (A). The tipping produced root proximity between the
molars (B). To eliminate the root proximity, the brackets were placed perpendicular to the long axis of the teeth
(C). This method of bracket placement fhcilitated root alignment and elimination of the root proximity, as well as
leveling of the marginal ridge discrepancies (D, E and F).

m u s t b e c o m p l e t e d b e f o r e t h e start o f o r t h o d o n -
tic t r e a t m e n t (Fig 12). A f t e r t h e s e p r o c e d u r e s
have b e e n c o m p l e t e d , t h e o r t h o d o n t i s t m a y
p l a c e b a n d s o r b r a c k e t s o n the r o o t f r a g m e n t s
a n d use a coil s p r i n g to s e p a r a t e t h e roots. T h e
a m o u n t o f s e p a r a t i o n is d e t e r m i n e d by t h e
a d j a c e n t e d e n t u l o u s s p a c e a n d t h e o c c l u s i o n in
the o p p o s i n g arch. A b o u t 7 o r 8 m m o f s p a c e
may be created between the roots of the hemi-
s e c t e d molar. This p r o c e s s e l i m i n a t e s t h e origi-
n a l f u r c a t i o n p r o b l e m a n d allows t h e p a t i e n t to
c l e a n t h e a r e a with g r e a t e r efficiency.
in s o m e m o l a r s with a Class III f u r c a t i o n , t h e
t o o t h will have s h o r t roots, a d v a n c e d b o n e loss,
f u s e d roots, o r s o m e o t h e r p r o b l e m that p r e v e n t s
h e m i s e c t i o n a n d c r o w n i n g o f the f r a g m e n t s . In
t h e s e p a t i e n t s , it m a y b e m o r e advisable to ex-
t r a c t t h e t o o t h with a f u r c a t i o n d e f e c t a n d p l a c e
a n o s s e o i n t e g r a t e d i m p l a n t (Fig 13). i f this type
o f p l a n has b e e n a d o p t e d , t h e t i m i n g o f t h e ex-
<< Arh, 7: >> Home I TOC I Bndex

34 Mathews and Kokich

Figure 11. This patient had a Class III furcation defect before orthodontic treatment (A and B). Orthodontic
treatment was performed and the filrcation defect was maintained by the periodontist on 2 month recalls until
after orthodontic treatment (C). After appliance removal, the tooth was hemisected (D) and the roots were
restored, and splinted together (E). The final periapical radiograph (F) shows that the fiarcation defect has been
eliminated by hemisecting and restoring the two root fiagments.

traction and placement of the implant can occur m a y b e p l a c e d after t h e o r t h o d o n t i c t r e a t m e n t

at a n y t i m e relative to t h e o r t h o d o n t i c t r e a t m e n t .
I n s o m e situations, t h e i m p l a n t c o u l d b e u s e d as
an a n c h o r to facilitate o r t h o d o n t i c t r e a t m e n t .
T h e i m p l a n t m u s t r e m a i n e m b e d d e d in t h e
b o n e for 6 m o n t h s after p l a c e m e n t b e f o r e it c a n
b e l o a d e d as a n o r t h o d o n t i c a n c h o r . It m u s t b e
p l a c e d p r e c i s e l y so t h a t it will n o t o n l y p r o v i d e a n
a n c h o r for t o o t h m o v e m e n t , b u t m a y also be
u s e d as an e v e n t u a l a b u t m e n t for a c r o w n o r
b r i d g e . If t h e i m p l a n t will n o t b e u s e d as a n
a n c h o r for o r t h o d o n t i c m o v e m e n t , t h e i m p l a n t
has b e e n c o m p l e t e d . C o n s i d e r a t i o n s r e g a r d i n g
t i m i n g will b e d e t e r m i n e d by t h e p a t i e n t ' s restor-
ative t r e a t m e n t plan.
Root Proximity
W h e n r o o t s o f p o s t e r i o r t e e t h a r e in close p r o x -
imity, t h e ability to m a i n t a i n t h e p e r i o d o n t a l
h e a l t h a n d t h e accessibility for r e s t o r a t i o n o f
t h e s e a d j a c e n t t e e t h m a y b e c o m p r o m i s e d . How-
ever, if t h e p a t i e n t is u n d e r g o i n g o r t h o d o n t i c
therapy, t h e r o o t s c a n b e m o v e d a p a r t a n d b o n e
<< AI-tI* .c >> Home I TOC I Bndex

Treatment,[or the Orthodontic-Periodontal Patient ::}5

Figure 12. Before orthodontic treatment, this patient had a Class Ill thrcation defect in the mandibular left
second molar (A and B). Because the patient had an edentulous space mesial to the molar, the tooth was
hemisected (C) and the root fragments were separated orthodontically (D). After orthodontic treatment, the root
fragments were used as abutments to stabilize a nmlti-unit posterior bridge (E and F).

will b e laid d o w n b e t w e e n the a d j a c e n t roots. ets m u s t be p l a c e d o b l i q u e l y to facilitate this

This will o p e n the e m b r a s u r e b e n e a t h the t o o t h
contact, provide a d d i t i o n a l b o n e s u p p o r t , a n d
e n h a n c e the p a t i e n t ' s access to the i n t e r p r o x i -
mal region. This generally improves the p e r i o d o n -
tal h e a l t h o f this area.
If o r t h o d o n t i c t r e a t m e n t will be u s e d to move
roots apart, the o r t h o d o n t i s t m u s t be aware of
this p l a n b e f o r e b r a c k e t p l a c e m e n t . It is advanta-
geous to place the brackets so that the ortho-
d o n t i c m o v e m e n t to separate the roots will
b e g i n with the initial archwires. T h e r e f o r e , brack-
process. To d e t e r m i n e the progress of o r t h o d o n -
tic r o o t s e p a r a t i o n , r a d i o g r a p h s will be n e e d e d
to m o n i t o r the status. Generally, 2 to 3 m m of
r o o t s e p a r a t i o n will p r o v i d e a d e q u a t e b o n e
a n d e m b r a s u r e space to i m p r o v e p e r i o d o n t a l
health. D u r i n g this time, the p a t i e n t s h o u l d be
m a i n t a i n e d by t h e i r restorative d e n t i s t or peri-
o d o n t i s t to e n s u r e that a favorable b o n e re-
s p o n s e will o c c u r as the roots are m o v e d apart. I n
a d d i t i o n , these p a t i e n t s will n e e d occasional
occlusal a d j u s t m e n t to r e c o n t o u r the c r o w n as
< < Artl~ .'~ > > Home TOC I Bndex

36 Mathews and Kokich

Figure 13. This patient was missing several teeth in the mandibular left posterior quadrant (A). The mandibular
left third molar had a Class III furcation defect and short roots (B). The third molar was extracted and two
implants were placed in the mandibular left posterior quadrant (C). The implants were used as anchors to
facilitate orthodontic treatment (D) and to help reestablish the left posterior occlusion (E and F).

tile r o o t s a r e m o v i n g a p a r t . As this h a p p e n s , t h e I n m o d e r a t e to a d v a n c e d cases, s o m e p e r i o -

crowns m a y d e v e l o p a n u n u s u a l occlusal c o n t a c t
with t h e o p p o s i n g arch. This s h o u l d b e equili-
b r a t e d to i m p r o v e t h e o c c l u s i o n .
Hopeless Teeth
P a t i e n t s with m o d e r a t e to a d v a n c e d p e r i o d o n t a l
disease m a y have specific t e e t h t h a t a r e d e e m e d
h o p e l e s s a n d n o r m a l l y w o u l d b e e x t r a c t e d be-
f o r e o r t h o d o n t i c s . However, t h e s e t e e t h c a n b e
useful f o r o r t h o d o n t i c a n c h o r a g e , if t h e peri-
o d o n t a l inflammation can be controlled (Fig 14).
d o n t a l s u r g e r y will b e n e c e s s a r y a r o u n d t h e
h o p e l e s s t o o t h . W h e n t h e flaps a r e r e f l e c t e d ,
debridement of the roots of the hopeless tooth
m a y b e all t h a t is n e c e s s a r y to c o n t r o l i n f l a m m a -
tion d u r i n g t h e o r t h o d o n t i c process. T h e i m p o r -
t a n t f a c t o r is to m a i n t a i n t h e h e a l t h o f t h e b o n e
o n t h e a d j a c e n t teeth. Rigidly e n f o r c e d 3 m o n t h
p e r i o d o n t a l recall is i m p e r a t i v e d u r i n g this p r o -
cess.
F o l l o w i n g o r t h o d o n t i c t r e a t m e n t , t h e r e is a
six m o n t h p e r i o d o f s t a b i l i z a t i o n b e f o r e reevalu-
a t i n g t h e p e r i o d o n t a l status. Occasionally, t h e
<< Artl~ .c >> Home I TOC I Bndex
Treatmentfor the Orthodontic-Poiodontal Patient 37

Figure 14. This patient had an impacted mandibular right second molar (A). The mandibular right first molar
was periodontally hopeless because of an advanced Class III filrcation defect. The impacted second molar was
extracted, but the first molar was maintained as an anchor to help upright the third molar orthodontically (B, C
and D). After orthodontic uprighting of the third molar, the first molar was extracted and a bridge was placed to
restore the edentulous space (E and F).

h o p e l e s s t o o t h m a y be so i m p r o v e d a f t e r o r t h -
o d o n t i c t r e a t m e n t t h a t it is r e t a i n e d . Howevei,
m o s t o f t h e time, it will r e q u i r e e x t r a c t i o n (Fig
14), especially if o t h e r r e s t o r a t i o n s a r e p l a n n e d
in t h e s e g m e n t . Again, t h e s e d e c i s i o n s n e e d to b e
n e g o t i a t e d b e t w e e n t h e specialists, r e s t o r a t i v e
d e n t i s t a n d the p a t i e n t .
Postorthodontic Periodontal Treatment
A f t e r o r t h o d o n t i c t r e a t m e n t has b e e n c o m -
p l e t e d , t h e p a t i e n t s h o u l d r e m a i n on a 3 m o n t h
p e r i o d o n t a l m a i n t e n a n c e p r o g r a m . 91 It takes at
least 6 m o n t h s after b a n d r e m o v a l for a d e q u a t e
bone remodeling, cessation of mobilities, and
n a r r o w i n g o f t h e p e r i o d o n t a l l i g a m e n t s . It is
advisable at this p o i n t to take a new set o f
p e r i a p i c a l r a d i o g r a p h s . A r e e x a m i n a t i o n is sched-
u l e d with t h e p e r i o d o n t i s t a n d a total p e r i o d o n -
tal r e a s s e s s m e n t o f t h e p a t i e n t is p e r f o r m e d to
evaluate f u r t h e r p e r i o d o n t a l n e e d s . B o r d e r l i n e
p o c k e t d e p t h a r e a s t h a t m a y have b e e n main-
t a i n e d d u r i n g o r t h o d o n t i c t r e a t m e n t are p o t e n -
tial c a n d i d a t e s for osseous c o r r e c t i o n at this
<< AI-[I~.': >>
38 Mathews and Kokich
t i m e . Also, t h e r e m a y b e a r e a s o f b o r d e r l i n e
attached gingiva that can become narrower dur-
ing orthodontic treatment. These areas may
r e q u i r e tissue g r a f t i n g .
O c c l u s a l a d j u s n n e n t is h e l p f u l to f i n e - t u n e t h e
occlusion and diminish any fremitus from lateral
i n t e r f e r e n c e s . T h i s will f u r t h e r a i d in h e a l i n g o f
a n y w i d e n e d p e r i o d o n t a l l i g a m e n t spaces. O c c a -
sionally, a n i g h t g u a r d is i n d i c a t e d to c o n t r o l
p a r a f u n c t i o n . A m a x i l l a r y n i g h t g u a r d is a n e x c e l -
l e n t a p p l i a n c e f o r this p u r p o s e , a n d c a n also b e
u s e d as a p o s t o r t h o d o n t i c r e t a i n e r . It m a y t a k e
u p to a y e a r a f t e r o r t h o d o n t i c t r e a t m e n t to
complete the final phase of periodontal therapy.
W h e n t h e p a t i e n t is p e r i o d o n t a l l y stable, t h e
restorative dentist can proceed with any restor-
ative t r e a t m e n t .
Summary
T h i s a r t i c l e has d i s c u s s e d a n d i l l u s t r a t e d t h e
benefits of integrating orthodontics and peri-
o d o n t i c s in t h e m a n a g e m e n t o f a d u l t p a t i e n t s
w i t h u n d e r l y i n g p e r i o d o n t a l d e f e c t s . T h e key to
t r e a t i n g t h e s e types o f p a t i e n t s is c o m m u n i c a t i o n
and proper diagnosis before orthodontic therapy
as w e l l as c o n t i n u e d d i a l o g u e d u r i n g o r t h o d o n -
tic t r e a t m e n t . N o t all p e r i o d o n t a l p r o b l e m s a r e
t r e a t e d in t h e s a m e way. H o p e f u l l y , this discus-
s i o n o f g i n g i v a l r e c e s s i o n , h o r i z o n t a l b o n e loss,
intrabony defects, hemiseptal defects, furcation
problems, root proximity, and periodontally
hopeless teeth provides the clinician with a
f r a m e w o r k t h a t will b e h e l p f u l in t r e a t i n g t h e s e
situations.
References
1. gamcht A, Zohn H, Deasy, M, et al. Screening for
periodontal disease: Radiographs versus PSR..] Am Dent
Assoc 1996;127:749-756.
2. Van der Velden U. Probing force and the relationship of
the probe tip to the periodontal tissues. J Clin Periodon-
tol 1979;6:106-114.
3. Ramfjord SE Indices for prevalence and incidence of
periodontal disease. J Periodonto11959;30:51-59.
4. I a n g NP, L6e H. The relationship between the width of
Home I TOC I Index
keratinized gingiva and gingival health..] Periodontol
1972;43:623.
5. Lindhe J, Svanberg G. Influence of trauma fi'om occlu-
sion on progression of experimental periodontitis in the
beagle dog. J Clin Periodontol 1974; 1:3.
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