Managing Treatment for the Orthodontic Patient with Periodontal Problems David P

< < Art,, .': > > H o m e I T O C I I n d e x

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

Seminars in Orthodontics, Vol 3, No 1 (March), 1997: pp 21-38 21 << Art,, 7: >> H o m e I T O C I I n d e x 22 Mathews and Kohich

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

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). << Afil~ .~ >> H o m e I T O C I Bndex

Treatment for the Orthodontic-Periodontal Patient 2 3

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 more Preorthodontic Gingival Surgery refractory periodontal diseases. The patient is Gingiva Grafting reevaluated a few months after this initial debridement, and the tissue response is assessed. Disease Areas of minimal attached gingiva should be activity is evaluated. Usually there will be a evaluated by the periodontist betbre initiating significant decrease in bleeding, suppuration, orthodontic treatment. Teeth with less than 2 and pocket depth J; The periodontist will deter- m m of gingiva may require grafting (Fig 2). mine if the patient is stable e n o u g h periodon- However, there are some factors that need to be tally to proceed with orthodontic treatment. considered in making this decision.: The peri- Some areas in the m o u t h may require periodon- odontist can " s o u n d " these areas of thin, narrow tal surgical treatment betore the initiation of gingiva to ascertain the attachment and bone orthodontic treatment. level (Fig 2). This is p e r f o r m e d with a thin <> Home I TOC I Index

24 Mathews and Kokich

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

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

be injudicious to do p r e o r t h o d o n t i c osseous cor- the patient's access to the buccal furcation for rective surgery in lesions such as these if orth- h o m e care and i n s t r u m e n t a t i o n at the time of odontics is a part of the overall t r e a t m e n t plan. recall (Fig 4E). Class I defects are a m e n a b l e to osseous surgical c o r r e c t i o n with a g o o d prognosis. Class II Furcation Defects furcation defects can be treated with grafting Furcation defects can be classified as incipient and regenerative therapy with b a r r i e r mem- (Class I), m o d e r a t e (Class II) a n d advanced branes. Class III furcation defects are more (Class III). These lesions require special atten- difficult to treat and use of grafting and mem- tion in the 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- branes in these lesions is not as predictable. ment. Often the molars will require bands with T r e a t m e n t of Class III furcation lesions in the tubes and o t h e r a t t a c h m e n t s which will i m p e d e lower arch can range from open-flap-curettage < < 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 create a t h r o u g h a n d t h r o u g h furcation for maintain a n d can worsen d u r i n g o r t h o d o n t i c easier cleaning, to hemisection, or even extrac- therapy. These patients will n e e d to be main- tion and r e p l a c e m e n t with an implant. 19 In the tained on a 2 to 3 m o n t h recall schedule. u p p e r arch, Class II a n d III furcations can Detailed i n s t r u m e n t a t i o n of these furcations will sometimes be treated with root a m p u t a t i o n . T h e help minimize f u r t h e r p e r i o d o n t a l breakdown. most favorable root to remove is the distobuccal root of an u p p e r molar. This t r e a t m e n t has a Root Proximity good prognosis. The disadvantage of r o o t ampu- tation is that it requires e n d o d o n t i c therapy and Areas of root proximity are difficult for the full-coverage restoration. p a t i e n t to clean and restrict the hygienist d u r i n g Furcation lesions n e e d special attention be- p e r i o d o n t a l m a i n t e n a n c e , e° They are also very cause they are the most difficult lesions to difficult to p r e p a r e when i n t e r p r o x i m a l areas << Arh, 7: >> H o m e I T O C 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 be restored. Generally, anterior teeth are difficult situation to treat surgically without root easier to maintain with a root proximity because a m p u t a t i o n . Howevm, with a p p r o p r i a t e orth- of access a n d the n a r r o w e r b u c c o l i n g u a l width of o d o n t i c treatment, this situation can be cor- the alveolus. rected without p e r i o d o n t a l surgery by i n t r u d i n g Howevm; in the u p p e r m o l a r region, a r o o t the first molar, leveling the bone, and o p e n i n g proximity p r o b l e m is m o r e difficult to maintain. up the e m b r a s u r e space between the first and Access for h o m e care, and a wider b u c c o l i n g u a l second m o l a r roots. width make these areas m o r e p r o n e to osseous In a very crowded situation in the u p p e r or breakdown. Root proximity can be e x a c e r b a t e d lower a n t e r i o r region, simply unraveling the when a m o l a r supererupts. T h e distobuccal r o o t rotated teeth will improve the e m b r a s u r e form of an u p p e r first m o l a r can touch the mesiobuc- and simplify h o m e care and instrumentation. cal root of the u p p e r s e c o n d m o l a r creating a Also, if any ceramic restorations are to be placed << A~'~:{~{e >> Home I WOC l lndex

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after OTflmdontic ~reautlcnt~ this..will :facilitate tlie. b a n d s .:and .brackets o n file ~etl~. Izi:. a. t he .i:.estorativc.pr.occdui~es..It.:k#ill.alst)..t.,clp ..,nain- pcri.~)dontatty Iiealthy individttal, .the:positi0n > H o m e I T O C I Bndex

30 Mathews and Kokich

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

Treatment for the Orthodontic-Periodontal Patient 31

tion process. The goal of equilibration and cian should level the bone orthodontically and creative bracket placement is to provide a more equilibrate any remaining discrepancies be- favorable bony architecture as well as a more tween the marginal ridges. This method will favorable crown to root ratio. In some of these produce the best occlusal result and improve the patients, the periodontal defects that were appar- periodontal health. ent initially may not require periodontal surgery During orthodontic treatment, when teeth following orthodontic treatment. are being extruded to level hemiseptal defects, the patient should be regularly monitored by the periodontist. Initially, the hemiseptal defect will Hemiseptal Defect have a greater sulcular depth and be more In the periodontally healthy patient, orthodon- difficult for the patient to clean. As the defect is tic brackets are positioned on the posterior teeth ameliorated through tooth extrusion, interproxi- relative to the marginal ridges and cusps. How- mal cleaning becomes easier. The periodontist ever, some adult patients may have marginal should recall the patient every 2 to 3 months ridge discrepancies caused by uneven tooth erup- during the leveling process to control inflammation before orthodontic treatment. When the tion in the interproximal region. orthodontist encounters marginal ridge discrepancies, the decision as to where to place the Furcation Defects bracket or band is not determined by the anatomy of the tooth. In these situations, it is important Regenerative therapy using polytetrafluorethyl- for the orthodontist to assess bite wing or periapi- ene membranes a n d / o r bone grafting, has been cal radiographs of these teeth in order to deter- successfill in Class I and II furcations. Howevm, mine the bone level interproximally. in Class III furcations, the use of membranes has If the bone level is oriented in the same not produced consistently satisfactory results. direction as the marginal ridge discrepancy, then Therefore, another method of treatment must leveling the marginal ridges will level the bone. be used for orthodontic patients with Class III However, if the bone level is fiat between adja- furcations in the mandibular arch. cent teeth and the marginal ridges are at signifi- Ifa patient with a Class III furcation defect will cantly different levels, correction of the marginal be undergoing orthodontic treatment, a possible ridge discrepancy orthodontically will produce a method tbr treating the furcation is to eliminate hemiseptal defect in the bone. This could cause it by hemisecting the crown and root of the a periodontal pocket between the two teeth. tooth. This procedure will, however, require If the bone is fiat and a marginal ridge endodontic, periodontic, and restorative treat- discrepancy is present, the orthodontist should ment. If the patient will be undergoing orthodon- not level the marginal ridges orthodontically tic treatment, it is advisable to perform the (Fig 9). In these situations, it may be necessary to orthodontic treatment first. This is especially equilibrate the crown of the tooth. In some true if the roots of the teeth will not be separated patients, the latter may require endodontic or moved apart (Fig 1 1). In these patients, the therapy and restoration of the tooth resulting molar to be hemisected remains intact during from the amount of reduction of the length of orthodontics. This patient would require 2 to 3 the crown that is required. This approach is month recall visits with the periodontist to en- acceptable, if the treatment results in a more sure that the furcation defect does not lose bone favorable bony contour between the teeth. during orthodontic treatment. By keeping the In some patients, a discrepancy may exist tooth intact during the orthodontics, it simplifies between both the marginal ridges and the bone the finishing and tooth movement for the orth- levels between two teeth (Fig 10). These discrep- odontist. ancies may however not be of equal magnitude. After orthodontics, endodontic therapy must In these patients, orthodontic leveling of the be performed on both roots of the tooth (Fig 11). bone may still leave a discrepancy in the mar- Following this, periodontal surgery is necessary ginal ridges. In these situations, the clinician to divide the tooth. Sulcular incisions are made, must not use the crowns of the teeth as a guide a flap is elevated buccal and lingual to the molar, for completing orthodontic therapy. The clini- and a fissure bur is used to carefully divide the << Arh, 7: >> H o m e I T O C 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).

crown and roots of the teeth. In some situations, In some patients r e q u i r i n g h e m i s e c t i o n of a the process is m o r e difficult if the furcation is m a n d i b u l a r m o l a r with a Class III furcation, it p o s i t i o n e d toward the apices of the tooth. After may be advantageous to push the roots apart the tooth has b e e n divided, the b o n e is recon- 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 the t o u r e d a r o u n d each of the roots and the tissue is h e m i s e c t e d m o l a r will be used as an a b u t m e n t allowed to heal. If the roots are short a n d for a bridge following orthodontics, moving the tapered, the crowns that restore the two halves of roots 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 the tooth could be splinted together. If the favorable restoration and splinting across the solder j o i n t of the splinted teeth is p o s i t i o n e d adjacent e d e n t u l o u s space. toward the occlusal, the patient can clean inter- In the latter situation, h e m i s e c t i n g the tooth, proximally in the area of the previous furcation. e n d o d o n t i c therapy, and p e r i o d o n t a l surgery < < Ar[l~ .'~ > > Home I TOC I Bndex

Treatment for 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).

must be c o m p l e t e d before the start of o r t h o d o n - nal furcation p r o b l e m and allows the patient to tic t r e a t m e n t (Fig 12). After these p r o c e d u r e s clean the area with greater efficiency. have b e e n c o m p l e t e d , the o r t h o d o n t i s t may in some molars with a Class III furcation, the place bands or brackets on the root fragments tooth will have short roots, advanced b o n e loss, and use a coil spring to separate the roots. T h e fused roots, or some o t h e r p r o b l e m that prevents a m o u n t of separation is d e t e r m i n e d by the h e m i s e c t i o n and crowning of the fragments. In adjacent e d e n t u l o u s space and the occlusion in these patients, it may be m o r e advisable to ex- the o p p o s i n g arch. A b o u t 7 or 8 m m of space tract the tooth with a furcation defect and place may be created between the roots of the hemi- an osseointegrated i m p l a n t (Fig 13). if this type sected molar. This process eliminates the origi- of plan has b e e n a d o p t e d , the timing of the ex- << Arh, 7: >> H o m e I T O C 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 p l a c e m e n t of the i m p l a n t can occur may be placed after the o r t h o d o n t i c t r e a t m e n t at any time relative to the o r t h o d o n t i c treatment. has b e e n c o m p l e t e d . Considerations regarding In some situations, the i m p l a n t could be used as timing will be d e t e r m i n e d by the patient's restor- an a n c h o r to facilitate o r t h o d o n t i c treatment. ative t r e a t m e n t plan. T h e i m p l a n t must r e m a i n e m b e d d e d in the Root Proximity b o n e for 6 m o n t h s after p l a c e m e n t before it can be l o a d e d as an o r t h o d o n t i c anchor. It must be W h e n roots of posterior teeth are in close prox- p l a c e d precisely so that it will n o t only provide an imity, the ability to maintain the p e r i o d o n t a l a n c h o r for tooth m o v e m e n t , b u t may also be health a n d the accessibility for restoration of used as an eventual a b u t m e n t for a crown or these adjacent teeth may be c o m p r o m i s e d . How- bridge. If the i m p l a n t will n o t be used as an ever, if the patient is u n d e r g o i n g o r t h o d o n t i c 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 , the i m p l a n t therapy, the roots can be m o v e d a p a r t a n d b o n e << AI-tI* .c >> H o m e I T O C 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 be laid down between the adjacent roots. ets must be placed obliquely to facilitate this This will open the embrasure b e n e a t h the tooth process. To d e t e r m i n e the progress of orthodon- contact, provide additional b o n e support, a n d tic root separation, radiographs will be n e e d e d e n h a n c e the patient's access to the interproxi- to m o n i t o r the status. Generally, 2 to 3 m m of mal region. This generally improves the periodon- root separation will provide adequate b o n e tal health of this area. and embrasure space to improve periodontal If orthodontic treatment will be used to move health. During this time, the patient should be roots apart, the orthodontist must be aware of m a i n t a i n e d by their restorative dentist or peri- this plan before bracket placement. It is advanta- odontist to ensure that a favorable b o n e re- geous to place the brackets so that the ortho- sponse will occur as the roots are moved apart. In dontic m o v e m e n t to separate the roots will addition, these patients will n e e d occasional begin with the initial archwires. Therefore, brack- occlusal adjustment to r e c o n t o u r the crown 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 roots are moving apart. As this h a p p e n s , the In m o d e r a t e to advanced cases, some perio- crowns may develop an unusual occlusal contact dontal surgery will be necessary a r o u n d the with the o p p o s i n g arch. This should be equili- hopeless tooth. W h e n the flaps are reflected, b r a t e d to improve the occlusion. d e b r i d e m e n t of the roots of the hopeless tooth may be all that is necessary to control inflammation d u r i n g the o r t h o d o n t i c process. The impor- Hopeless Teeth tant factor is to maintain the health of the b o n e Patients with m o d e r a t e to advanced p e r i o d o n t a l on the adjacent teeth. Rigidly e n f o r c e d 3 m o n t h disease may have specific teeth that are d e e m e d p e r i o d o n t a l recall is imperative d u r i n g this pro- hopeless and n o r m a l l y would be extracted be- cess. fore orthodontics. However, these teeth can be Following o r t h o d o n t i c treatment, there is a useful for o r t h o d o n t i c a n c h o r a g e , if the peri- six m o n t h p e r i o d of stabilization before reevalu- odontal inflammation can be controlled (Fig 14). ating the p e r i o d o n t a l status. Occasionally, the << Artl~ .c >> H o m e I TOC I Bndex

Treatment for 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).

hopeless tooth may be so i m p r o v e d after orth- 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 odontic t r e a t m e n t that it is retained. Howevei, least 6 m o n t h s after b a n d removal for a d e q u a t e most of the time, it will require extraction (Fig bone r e m o d e l i n g , cessation of mobilities, and 14), especially if o t h e r restorations are p l a n n e d narrowing of the p e r i o d o n t a l ligaments. It is in the segment. Again, these decisions n e e d to be advisable at this p o i n t to take a new set of negotiated between the specialists, restorative periapical radiographs. A r e e x a m i n a t i o n is sched- dentist and the patient. uled with the 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 reassessment of the patient 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 needs. Borderline Postorthodontic Periodontal Treatment p o c k e t d e p t h areas that may have b e e n main- After 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 com- tained 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 poten- pleted, the patient should r e m a i n on a 3 m o n t h tial candidates for osseous correction at this << AI-[I~ .': >> Home I TOC I Index

38 Mathews and Kokich

time. Also, t h e r e m a y be areas o f b o r d e r l i n e keratinized gingiva and gingival health..] Periodontol a t t a c h e d gingiva that can b e c o m e n a r r o w e r dur- 1972;43:623. 5. Lindhe J, Svanberg G. Influence of trauma fi'om occlu- 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 s e areas m a y sion on progression of experimental periodontitis in the r e q u i r e tissue grafting. beagle dog. J Clin Periodontol 1974; 1:3. 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 the 6. Lindhe J, Nyman S. I~ong-term maintenance of patients o c c l u s i o n a n d d i m i n i s h any f r e m i t u s f r o m lateral treated for advanced periodontal disease..] Clin Periodon- i n t e r f e r e n c e s . This will f u r t h e r aid in h e a l i n g o f to11984;11:504-514. any 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. Occa- 7. Gartrell JG, Mathews DE Gingival recession: The condi- tion, process, and treatment. Dental Clin North Am 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 1976;1:199-213. 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 an excel- 8. Steiner GG, Pearson JK, Ainamo J. Changes of the l e n t a p p l i a n c e for this p u r p o s e , a n d can also b e marginal periodontium as a result of labial tooth move- u s e d as a p o s t o r t h o d o n t i c retainer. It m a y take ment in monkeys.J Periodonto11981;52:314. u p to a year after o r t h o d o n t i c t r e a t m e n t to 9. Dorfman HS. Mucogingival changes resuhing from man- c o m p l e t e the final p h a s e o f p e r i o d o n t a l therapy. dibular incisor tooth movement. Am J Orthod 1978;74: 286. W h e n the p a t i e n t is p e r i o d o n t a l l y stable, the 10. Dorfmann H, Kennedy J, Bird W. Longitudinal evalua- restorative d e n t i s t can p r o c e e d with any restor- tion of free autogenous gingival grafts: A fore-year ative t r e a t m e n t . report.J Periodontol 1982;53:349-352. 11. Miller PD. Root coverage using a free soft tissue autograft following citric acid application. Part I. IntJ Periodont Summary Rest Dent 1982;2:65-70. 12. Langer B, Langer L. Subepithelial connective tissue graft This article has discussed a n d illustrated t h e technique fur root coverage. J Periodontol 1985;56:715- b e n e f i t s o f i n t e g r a t i n g o r t h o d o n t i c s a n d peri- 720. o d o n t i c s in the m a n a g e m e n t o f a d u l t patients 13. Schluger S. Osseous resection--a basic principle in with u n d e r l y i n g p e r i o d o n t a l defects. T h e key to periodontal surgery. Oral Surg 1949;2:316. t r e a t i n g these types o f patients is c o m m u n i c a t i o n 14. Ochsenbein C, Ross S. A re-evaluation of osseous surgery. a n d p r o p e r diagnosis b e f o r e o r t h o d o n t i c t h e r a p y Dent Clin North Am 1969; 13:87. as well 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 - 15. Becket W, Becket BE. Treatment of mandibular 3-wall intrabony defects by flap debridement and expanded 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 are polytetrafluoroethylene barrier membranes. Long-term t r e a t e d in the s a m e way. Hopefully, this discus- evaluation of 32 treated patients..l Periodontol 1993;64: sion o f gingival recession, h o r i z o n t a l b o n e loss, 1138-1144. i n t r a b o n y defects, h e m i s e p t a l defects, f u r c a t i o n 16. Shallhorn R, McClain P. Combined osseous composite p r o b l e m s , r o o t proximity, a n d p e r i o d o n t a l l y grafting, root conditioning and guided tissue regeneration. IntJ Periodont Rest Dent 1988;8:9-31. h o p e l e s s t e e t h p r o v i d e s the clinician with a 17. IngberJ. Forced eruption: Part I. A method of treating f r a m e w o r k that will b e h e l p f u l in t r e a t i n g t h e s e isolated one and two wall infrabony osseous defects - situations. rationale and case report.J Periodontol 1974;45:199-206. 18. Brown IS. The eitect of orthodontic therapy on certain lypes of periodontal defects. I. Clinical findings. J Peri- References odontol 1973;44:742-756. 1. gamcht A, Zohn H, Deasy, M, et al. Screening for 19. Iga-amerGM. Surgical ahernatives in regenerative therapy periodontal disease: Radiographs versus PSR..] Am Dent of the periodontium. IntJ Periodont Rest Dent 1992;12: Assoc 1996;127:749-756. 11-31. 2. Van der Velden U. Probing force and the relationship of 20. Gould MSE, Picton DCA. The relation between irregnlari- the probe tip to the periodontal tissues. J Clin Periodon- ties of the teeth and periodontal disease. Br Dent J tol 1979;6:106-114. 1966;121:21. 3. Ramfjord SE Indices for prevalence and incidence of 21. Axelsson P, Lindhe J. The significance of maintenance periodontal disease. J Periodonto11959;30:51-59. care in the treatment of periodontal disease..] Clin 4. Iang NP, L6e H. The relationship between the width of Periodonto11981;8:281.