PERIODONTAL CONSIDERATIONS DURING ORTHODONTIC TREATMENT : PERIODONTAL CONSIDERATIONS DURING ORTHODONTIC TREATMENT www.rxdentistry.blogspot.com Slide 2: INTRODUCTION
ORTHO – PERIO INTERACTIONS
PHASES OF ORTHO-PERIO IDT
MERITS & DEMERITS
PERIODONTIUM IN RELATION TO DIFFERENT TYPES OF TOOTH MOVEMENT
COMPLICATIONS OF ADULT ORTHODONTICS
MANAGEMENT / RETENTION REGIME
SUMMARY & CONCLUSION www.rxdentistry.blogspot.com INTRODUCTION : INTRODUCTION We need to consider and treat a patient as an
Increased patient awareness
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 INDIVIDUAL www.rxdentistry.blogspot.com Slide 4: 1) INTER DISCIPLINARY
2) MULTI DISCIPLINARY
ORTHODONTICS www.rxdentistry.blogspot.com CLASSIFICATION : CLASSIFICATION INTER DISCIPLINARY ORTHODONTICS
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 www.rxdentistry.blogspot.com PHASES OF IDT : PHASES OF IDT Any type of interdisciplinary therapy(IDT) should have the following steps PRELIMINARY THERAPY:PRELUDE TO IDT TREATMENT PLANNING: PHASE II OF IDT DIAGNOSTICS: PHASE I OF IDT DEFINITIVE THERAPY:PHASE III OF IDT MAINTENANCE:PHASE IV OF IDT www.rxdentistry.blogspot.com ORTHODONTIC PERIODONTIC – INTERACTIONS : 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 www.rxdentistry.blogspot.com ORTHODONTIC TREATMENT PLANNING : ORTHODONTIC TREATMENT PLANNING www.rxdentistry.blogspot.com Slide 9: Various studies have shown that -
Alveolar bone height reduced in areas of
increased over jet
Gingivitis is generally associated with
Level of bacteria is higher in areas of
crowding compared with normal areas in
same patient www.rxdentistry.blogspot.com BENEFITS OF ORTHODONTICS FOR A PERIODONTAL PATIENT : BENEFITS OF ORTHODONTICS FOR A PERIODONTAL PATIENT www.rxdentistry.blogspot.com Slide 11: 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 www.rxdentistry.blogspot.com Slide 12: 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
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. 4. ORTHODONTIC TREATMENT CAN IMPROVE THE ESTHETIC RELATIONSHIP OF THE MAXILLARY GINGIVAL MARGIN LEVELS BEFORE RESTORATIVE DENTISTRY. www.rxdentistry.blogspot.com Slide 13: 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) www.rxdentistry.blogspot.com Slide 14: 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 www.rxdentistry.blogspot.com PERIODONTAL RISK ASSESSMENT BEFORE ORTHODONTIC TREATMENT : PERIODONTAL RISK ASSESSMENT BEFORE ORTHODONTIC TREATMENT This includes special emphasis on the following
Previous periodontal disease
Check for the following :
Bleeding on probing
Thin fragile gingiva
Pockets www.rxdentistry.blogspot.com Slide 16: Psychosocial stress
Lifestyle factors such as diet, alcohol use and especially smoking
Deficiencies in the immune
The presence of specific
bacteria Sex (disease is more common
in women than in men)
Polymorphonuclear leukocyte count www.rxdentistry.blogspot.com MICROBIOLOGY ASSOCIATED WITH ORTHODONTIC MATERIALS : MICROBIOLOGY ASSOCIATED WITH ORTHODONTIC MATERIALS Orthodontic band placement causes an overall increase in salivary bacterial counts especially lactobacillus , prevotella intermedia , porphyromonous gingivalis , bacteroids www.rxdentistry.blogspot.com EFFECTS OF ORTHODONTIC TREATMENT ON THE PERIODONTIUM : EFFECTS OF ORTHODONTIC TREATMENT ON THE PERIODONTIUM www.rxdentistry.blogspot.com PERIODONTAL TISSUE RESPONSE TO ORTHODONTIC FORCE : PERIODONTAL TISSUE RESPONSE TO ORTHODONTIC FORCE www.rxdentistry.blogspot.com EQULIBRIUM CONCEPT : 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 www.rxdentistry.blogspot.com Tooth movement and the periodontium : Tooth movement and the periodontium Cardinal Rule – Before doing any tooth movement there should be no inflammation in the periodontal attachment. www.rxdentistry.blogspot.com Periodontal response to various kinds of tooth movement in periodontally compromised patients : Periodontal response to various kinds of tooth movement in periodontally compromised patients 1. Extrusion
3. Tipping – Uncontrolled
4. Bodily movement www.rxdentistry.blogspot.com Slide 23: 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) www.rxdentistry.blogspot.com Slide 24: INTRUSION
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 www.rxdentistry.blogspot.com Slide 25: 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 www.rxdentistry.blogspot.com Slide 26: CONTROLLED TIPPING also produces high forces in the periodontal ligament as the fulcrum shifts more and more apically with increasing amounts of bone loss www.rxdentistry.blogspot.com Slide 27: 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. www.rxdentistry.blogspot.com Slide 28: 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. www.rxdentistry.blogspot.com ADULT ORTHODONTICS : ADULT ORTHODONTICS How is adult orthodontics different???
Response to orthodontic force is relatively slower
Lack of growth – Restraint
Motivations differ from other age groups, so do psychological reactions
Heightened susceptibility to periodontal disease.
High % of pts. Esp. Indian scenario – Preexisting periodontal disease www.rxdentistry.blogspot.com SPECIAL CONSIDERATIONS IN ADULTS : 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. www.rxdentistry.blogspot.com SPECIAL CONSIDERATIONS IN ADULTS : 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 www.rxdentistry.blogspot.com Slide 32: www.rxdentistry.blogspot.com Slide 33: www.rxdentistry.blogspot.com CLASSIFICATION BASED ON THE DEGREE OF INVOVEMENT : CLASSIFICATION BASED ON THE DEGREE OF INVOVEMENT Minimal periodontal involvement
Moderate periodontal involvement
Severe periodontal involvement www.rxdentistry.blogspot.com CLASSIFICATION BASED ON THE DEGREE OF INVOVEMENT : CLASSIFICATION BASED ON THE DEGREE OF INVOVEMENT MINIMAL PERIODONTAL INVOLVEMENT
Hygiene status – Cannot let appliance induced gingivitis go untreated in an adult because it could very well result in periodontal involvement however good their initial status is.
Advise fastidious oral hygiene, mechanical and chemical www.rxdentistry.blogspot.com CLASSIFICATION BASED ON THE DEGREE OF INVOVEMENT : CLASSIFICATION BASED ON THE DEGREE OF INVOVEMENT MODERATE PERIODONATL INVOLVEMENT
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 www.rxdentistry.blogspot.com CLASSIFICATION BASED ON THE DEGREE OF INVOVEMENT : CLASSIFICATION BASED ON THE DEGREE OF INVOVEMENT SEVERE PERIODONTAL INVOLVEMENT
All other measures additional do the following
Periodontal maintenance scheduling as frequent as orthodontic appointments.
Treatment goals & mechanics modified to keep force levels to a minimum & lessen the span of tooth movement. www.rxdentistry.blogspot.com Slide 38: 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 www.rxdentistry.blogspot.com Periodontal compromised case : Periodontal compromised case www.rxdentistry.blogspot.com Slide 40: OPG reveals generalized bone resorption
with increased severity in anterior segment www.rxdentistry.blogspot.com Slide 41: www.rxdentistry.blogspot.com Slide 42: www.rxdentistry.blogspot.com Slide 43: PRE & POST TREATMENT COMPARISON www.rxdentistry.blogspot.com Slide 44: 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 www.rxdentistry.blogspot.com RETENTION & STABILTY : 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 www.rxdentistry.blogspot.com Circumferential Supracrestal Fibrotomy : 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 www.rxdentistry.blogspot.com Slide 47: 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. www.rxdentistry.blogspot.com Adult orthodontics with orthognathic surgery : Adult orthodontics with orthognathic surgery Minimal amount of tooth movement
was carried out since bone was not very conducive , hence surgery was opted www.rxdentistry.blogspot.com Adult orthodontics with orthognathic surgery : Adult orthodontics with orthognathic surgery Intraoral photographs with severe overjet and periodontally compromised
Status www.rxdentistry.blogspot.com Slide 50: Adult orthodontics with orthognathic surgery www.rxdentistry.blogspot.com Slide 51: Adult orthodontics with orthognathic surgery www.rxdentistry.blogspot.com Slide 52: Permanent retention is mandatory for adult patients Adult orthodontics with orthognathic surgery www.rxdentistry.blogspot.com Molar protraction : Molar protraction Note the amount of bone formation www.rxdentistry.blogspot.com Slide 54: NOTE- THE AMOUNT
OF BONE FORMATION
MESIAL TO II MOLAR
MANAGEMENT www.rxdentistry.blogspot.com SUMMARY : SUMMARY www.rxdentistry.blogspot.com ORTHO - PERIO IDT PHASES : ORTHO - PERIO IDT PHASES PRELIMINARY THERAPY:
Control of active pd disease –Main objective
All except definite osseous surgery & repositioned flaps TREATMENT PLANNING :
Decide on types of tooth movement, force levels DIAGNOSTICS:
Evaluate the degree of compromise,
Identify sites of active periodontal destruction 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 www.rxdentistry.blogspot.com Slide 57: www.rxdentistry.blogspot.com Slide 58: Thank you www.rxdentistry.blogspot.com Slide 59: www.rxdentistry.blogspot.com