INTRODUCTION

We need to consider and treat a patient as an

INDIVIDUAL
Increased

patient awareness Consumer rights Developments in various fields of dentistry and science More and more adults are seeking for orthodontic treatment Changing treatment objectives Primary motivating factor Improving dental appearance

CLASSIFICATION

This includes the interaction where in two specialties interact among themselves , such as a) PERIODONTIC ORTHODONTIC b) ENDODONTIC ORTHODONTIC c) PROSTHODONTIC ORTHODONTIC

This includes the interaction where in a group of specialties interact

PHASES OF IDT
Any type of interdisciplinary therapy(IDT) should have the following steps

PRELIMINARY THERAPY:PRELUDE TO IDT DIAGNOSTICS: PHASE I OF IDT

TREATMENT PLANNING: PHASE II OF IDT

DEFINITIVE THERAPY:PHASE III OF IDT MAINTENANCE:PHASE IV OF IDT

ORTHODONTIC PERIODONTIC INTERACTIONS

Statistically significant periodontal differences between patients with normal and malaligned teeth has been noticed indicating that irregular teeth are a predisposing factor to periodontal disease

ORTHODONTIC TREATMENT PLANNING

Adjunctive Orthodontic Treatment

Comprehensive Orthodontic Treatment

 Various studies have shown that Alveolar bone height reduced in areas of increased over jet Gingivitis is generally associated with crowding Level of bacteria is higher in areas of crowding compared with normal areas in same patient

BENEFITS OF ORTHODONTICS FOR A PERIODONTAL PATIENT

1. ALIGNING CROWDED OR MALPOSED TEETH PERMITS THE ADULT PATIENT BETTER ACCESS TO CLEAN ALL SURFACES OF THEIR TEETH ADEQUATELY.

2. TREMENDOUS ADVANTAGE FOR PATIENTS WHO ARE SUSCEPTIBLE TO PERIODONTAL BONE LOSS OR DO NOT HAVE THE DEXTERITY TO MAINTAIN ORAL HYGIENE

3. VERTICAL ORTHODONTIC TOOTH REPOSITIONING CAN IMPROVE CERTAIN TYPES OF OSSEOUS DEFECTS IN PERIODONTAL PATIENTS.

OFTEN THE TOOTH MOVEMENT ELIMINATES THE NEED FOR

RESECTIVE OSSEOUS SURGERY

4.

ORTHODONTIC TREATMENT CAN IMPROVE THE ESTHETIC

RELATIONSHIP OF THE MAXILLARY GINGIVAL MARGIN LEVELS BEFORE RESTORATIVE DENTISTRY.

5 ORTHODONTIC TREATMENT ALLOWS OPEN GINGIVAL EMBRASURES TO

BE CORRECTED TO REGAIN LOST PAPILLA. IF THESE OPEN GINGIVAL EMBRASURES ARE LOCATED IN THE MAXILLARY ANTERIOR REGION

6. ORTHODONTIC TREATMENT COULD IMPROVE ADJACENT TOOTH

POSITION BEFORE IMPLANT PLACEMENT OR TOOTH REPLACEMENT. THIS IS ESPECIALLY TRUE FOR THE PATIENT WHO HAS BEEN MISSING TEETH FOR SEVERAL YEARS AND HAS DRIFTING AND TIPPING OF THE ADJACENT DENTITION.

 Age per se is not a contraindication for orthodontic treatment , lighter forces should be used as there is an decreased cellular activity of the PDL(Reitan, Angle Orthod 1985)
Although the world wide prevalence of

gingival inflammation is high, advanced periodontal disease affects 8 % - 30% of population . (Papapanou et al, JCP 1989)

A MAGNIFICIENT ORTHODONTIC TREATMENT CAN BE DESTROYED BY POOR PERIODONTAL SUPPORT.

HENCE , EVALUATION AND MAINTENANCE OF PERIODONTAL HEALTH BEFORE , DURING AND AFTER TREATMENT IS VERY IMPORTANT

PERIODONTAL RISK ASSESSMENT BEFORE ORTHODONTIC TREATMENT

This includes special emphasis on the following HISTORY

Previous periodontal disease Drug history Systemic diseases CLINICAL EXAMINATION Check for the following : Bleeding on probing Tooth mobility Thin fragile gingiva Pockets

 Psychosocial stress
Lifestyle factors such as

Sex (disease is more

diet, alcohol use and especially smoking Deficiencies in the immune system The presence of specific bacteria

common in women than in men) Age Diabetes mellitus Osteoporosis Polymorphonuclear leukocyte count

MICROBIOLOGY ASSOCIATED WITH ORTHODONTIC MATERIALS

Orthodontic band placement causes an overall

increase in salivary bacterial counts especially

lactobacillus , prevotella intermedia , porphyromonous gingivalis , bacteroids

EFFECTS OF ORTHODONTIC TREATMENT ON THE PERIODONTIUM

TERM EFFECT Gingivitis & gingival enlargement No attachment loss Effects are reversible Root resorption ( 1.0 1.5 mm ) Attachment loss in areas of active periodontitis Effects are often irreversible

SHORT

LONG

FORCE

TISSUE RESPONSE

STRONG/ HEAVY FORCE (Forces far exceeding capillary blood pressure)

PDL on pressure side ischemia & degeneration of PDL = hyalinization = more delay in tooth movement

MODERATE FORCE (Force exceeding capillary blood

pressure) LIGHT FORCE (Force less than capillary blood pressure )

PDL strangulation resulting in delay in bone resorption

PDL ischemia with simultaneous bone resorption and formation = more continuous tooth movement

EQULIBRIUM CONCEPT
It is not only the forces of the musculature that help in maintaining tooth position. In certain areas of the dentition like the mandibular anteriors the pressure from the tongue within is more than the pressure from the extroral muscles. Here the metabolic activity of the periodontal ligament helps in maintaining tooth position

Tooth movement and the periodontium

Cardinal Rule Before doing any tooth movement there should be no inflammation in the periodontal attachment.

Periodontal response to various kinds of tooth movement in periodontally compromised patients

1. Extrusion 2. Intrusion 3. Tipping Uncontrolled - Controlled 4. Bodily movement

 EXTRUSION

Least hazardous kind of tooth movement as far as periodontium is considered. Extrusion followed by equilibration of the clinical crown has been shown to reduce infrabony defects and pockets.(Ingber JS, J Periodontol 1974)

 INTRUSION

Controversial Most authors Intrusion results in deepening of infrabony pockets, root resorption, bone defects
Birte Melsen (AJODO 1989. Vol.96) No increase in bone defects/ improvement in bony defects

 TIPPING
UNCONTROLLED TIPPING in all cases causes heavy forces at the alveolar crest resulting in severe destruction of the epithelial attachment and crestal bone loss Bone loss & Center of Resistance of a tooth

 CONTROLLED TIPPING also produces high forces in the periodontal ligament as the fulcrum shifts more and more apically with

increasing amounts of bone loss

Infact cases have been documented where a gingival lesion has been converted into a periodontal lesion by the injudicious use of tipping moments.

Mild gingival changes associated with orthodontic appliances are transitory. These cause no periodontal damage and resolve on their own.

BODILY MOVEMENT

Moving a tooth bodily into a periodontal defect has been believed to carry the bone along with the tooth resulting in improvement of the defect. However recent studies have shown that this only an illusion because it causes only an improved connective tissue attachment and infact worsens the bony defect. Hence until new evidence surfaces this is contraindicated.

ADULT ORTHODONTICS
How is adult orthodontics different???
1. Response to orthodontic force is relatively slower

2. Lack of growth Restraint

3. Motivations differ from other age groups, so do psychological reactions

4. Heightened susceptibility to periodontal disease.

5. High % of pts. Esp. Indian scenario Preexisting periodontal disease

SPECIAL CONSIDERATIONS IN ADULTS

Always defer treatment till active lesions

gingival/periodontal are arrested.

Infact applying force in the presence of inflammation

could convert a gingival lesion into a periodontal one in adults because of lesser resistance and tissue turnover.
In adults do a thorough periodontal phase involving

scaling, flaps and soft tissue grafts in cases with extremely reduced width of attached gingiva.

SPECIAL CONSIDERATIONS IN ADULTS

After preorthodontic treatment there should be a phase of maintenance allowing the tissues to recover as well as evaluate patient co-operation.
These cases require routine scaling and other hygeine aids like electric toothbrushes, interdental brushes, water piks , chemical aids like chlorhexidine etc depending on the degree of periodontal ligament

MANAGEMENT OF GINGIVITIS IN AN ORTHODONTIC OFFICE

Brushing with proper oral hygiene Oral prophylaxis Powered tooth brushes Mouth rinses

Disclosing solutions

MANAGEMENT OF PERIODONTALLY COMPROMISED PATIENTS IN AN ORTHODONTIC OFFICE

CLASSIFICATION BASED ON THE DEGREE OF INVOVEMENT

1. Minimal periodontal involvement

2. Moderate periodontal involvement 3. Severe periodontal involvement

CLASSIFICATION BASED ON THE DEGREE OF INVOVEMENT

CLASSIFICATION BASED ON THE DEGREE OF INVOVEMENT

MODERATE PERIODONATL INVOLVEMENT Disease control Preliminary periodontal therapy here includes all but

osseous surgeries Important to remove all irritants, flap surgeries are especially recommended for complete calculus removal. Use bonding, self ligating brackets, steel ligatures Routine scaling at 2-4month interval. Mechanical and chemical adjuvants for oral hygeine

CLASSIFICATION BASED ON THE DEGREE OF INVOVEMENT

SEVERE PERIODONTAL INVOLVEMENT All other measures additional do the following 1. Periodontal maintenance scheduling as frequent

as orthodontic appointments.
2. Treatment goals & mechanics modified to keep

force levels to a minimum & lessen the span of tooth movement.

MANAGEMENT OF PERIODONTALLY COMPROMISED PATIENTS IN AN ORTHODONTIC OFFICE - GIST

Disease control, hygiene maintenance

Use bonded rather than banded attachments Use self ligating brackets/steel ligatures.

Schedule periodontal maintenance visits in addition to orthodontic visits.

Advise mechanical aids such as powered

toothbrushes, interdental brushes etc. Advise chemical aids such as chlorhexidine

Periodontal compromised case

OPG reveals generalized bone resorption with increased severity in anterior segment

PRE & POST TREATMENT COMPARISON

Comparison of pre and post treatment OPG note the amount of bone is maintained if not reduced and significant amount of bone formation in upper anterior segment due to tooth Moving closer to each other

RETENTION & STABILTY

MILD & MODERATE COMPROMISE

1. Stability of the achieved results is usually fair. 2. However other than the mild cases most of them require permanent retention in the form of removable wrap around retainers. 3.Fixed retention in terms of bonded retainers is usually not recommended because of the difficulty in maintaining adequate hygiene

Circumferential Supracrestal Fibrotomy

The retention period should continue part time for at least 12 months to allow time for remodelling
CSF reduces the mean relapse by 30

%(Edwards AJO 1970) Should be performed towards the end of finishing phase

 SEVERELY COMPROMISED CASES

1.These require immediate splinting after debonding. 2.Splinting is provided by vaccum formed retainers to be worn for a period of 4-6 weeks. 3.Following this permanent retention using removable retainers is mandatory. 4.Routine followup visits at regular intervals for periodontal maintainence/evaluation of patient hygeine measures are recommended.

Adult orthodontics with orthognathic surgery

Minimal amount of tooth movement was carried out since bone was not very conducive , hence surgery was opted

Adult orthodontics with orthognathic surgery

Intraoral photographs with severe overjet and periodontally compromised Status

Adult orthodontics with orthognathic surgery

Adult orthodontics with orthognathic surgery

Adult orthodontics with orthognathic surgery

Permanent retention is mandatory for adult patients

Molar protraction

Note the amount of bone formation

NOTE- THE AMOUNT OF BONE FORMATION MESIAL TO II MOLAR KNOWN AS ORTHODONTIC SITE MANAGEMENT

ORTHO - PERIO IDT PHASES

PRELIMINARY THERAPY:
Control of active pd disease Main objective All except definite osseous surgery & repositioned flaps

DIAGNOSTICS:
Evaluate the degree of compromise, Identify sites of active periodontal destruction

TREATMENT PLANNING :
Decide on types of tooth movement, force levels

DEFINITVE THERAPY:
Use bonded appliances whenever possible, Self ligating brackets, avoid O-rings, Plan periodontal maintenance schedules.

MAINTAINENCE:
Use of vacuum formed retainer immediately after debonding. Concept of permanent retention

Although comprehensive orthodontic treatment cannot preclude the possibility of periodontal disease developing later, it can be useful part of the overall treatment plan for a patient who already has periodontal involvement.