Interdisciplinary Approach in Periodontal

Therapy

CONTENTS

• Perio-Ortho• Perio-Prostho• Endo-Perio

Orthodontics and Periodontics

Management of periodontal conditions with

orthodontic tooth movement as an adjunct

AND

Management of periodontal problems

arising during and after orthodontic tooth

movement

Role of orthodontics – adjunct to periodontal therapy

Benefits Of Orthodontics For A Periodontal Patient

• Reducing plaque retention

– Crowded teeth– Tipped teeth– Malposed teeth– Teeth in linguoversion

• Vertical tooth positioning improves certain types of osseous defects.

• Facilitating prosthetic replacements

• Improving esthetics – allows open gingival embrasures…regain lost papilla

Implant placement

•Inflammation

+

• Orthodontic forces

+

•Occlusal trauma

=

•Rapid destruction

(Kessler 1976)

Orthodontic tooth movement in adults with periodontal tissue breakdown.

Study by Artun & Urbye (1988)

Bone level measurements on radiographs indicated that the majority of sites showed little or no additional loss of bone support.

(Nelson & Arun 1997, Ree et al 2000)

• Pretreatment evidence of periodontal tissue destruction is no contraindication for orthodontics.

• Orthodontic therapy improves the possibilities of saving and restoring a deteriorated dentition.

• The risk of recurrence of an active disease process is not increased during appliance therapy.

Orthodontic Treatment Considerations

• Eliminate/reduce Plaque accumulation Gingival inflammation

• Fixed appliances

• Design of the appliance

Need to facilitate oral hygiene

• Bonded ceramic brackets

• Appliances & mechanics simple

• Avoid hooks, elastomeric rings, excess bonding resin

• Steel ligatures preferred over elastomeric rings ( Forsberg

et al 1991)

• Bonds preferable to bands

• Periodic professional tooth cleaning at 3 months interval

Possibilities and limitations

• Each individual treatment plan may depend on a variety of

factors and can be limited by biomechanical considerations

(force systems, limited anchorage), by periodontal risk factors

(tooth/alveolar bone topography, sinus recesses, activity and

prognosis of the periodontitis), and by limited patient motivation

and poor oral hygiene co-operation.

• Single case reports have documented successful periodontal-

orthodontic treatment with ( LAP) after conventional

periodontal therapy. However, until more evidence is

accumulated, it may seem wise to avoid orthodontic treatment in

patients with particularly ( GAP) forms of periodontal disease.

Orthodontic Treatment Of Osseous Defects

Pre-Orthodontic Osseous Surgery

• Osseous Craters

• Lesion eliminated by

reshaping & PD

• Need for surgery

Initial RP

PDL resistance

Location of defect

Three-Wall Intrabony Defects

Regenerative therapy

Results stable 3-6 months

Hemiseptal defects

Tipped tooth

Supraerrupted tooth

After completion of orthodontic

tt. – stabilization for 6 months

followed by pdl reassessment.

Hemiseptal Defects

It would be injudicious to perform preorthodontic osseous corrective surgery in such lesions if orthodontics is part of the

overall treatment plan.

• In some patients, a discrepancy may exist between both the marginal ridges and the bony levels between two teeth. - discrepancies may not be of equal magnitude.

• In these patients, orthodontic leveling of the bone may still leave a discrepancy in the marginal ridges.

In these situations, the crowns of the teeth should not be used

as a guide for completing orthodontic therapy. The bone should

be leveled orthodontically and any remaining discrepancies

between the marginal ridges should be equilibrated. This

method produces the best occlusal result and improves the

periodontal health.

Outcome of orthodontic therapy

Location of bands and brackets on teeth

Health- Determined by anatomy of tooth

Advanced Horizontal Bone Loss

Bone level should act as a guide to bracket placement

Molar Uprighting

Tipped molars- a causative/aggravating factor future periodontal tissue breakdown

Indications-functionally disturbing interferences, paralleling or space problems associated with prosthetic rehabilitation, or traumatic occlusion.

It causes a shallowing-out of the angular defect, with new bone forming at the mesial alveolar crest

When there is a definite osseous defect caused by periodontitis on the mesial surface of the inclined molar, uprighting the tooth and tipping it distally will widen the osseous defect.

Uprighting and leveling of maxillary and mandibular molars

Furcation Defects

Require special attention..

Bands with tubes & other attachments impede patient's access to

buccal furcation for home care & instrumentation at the time of

recall.

If a patient with a Class III furcation defect will be undergoing

orthodontic treatment, a possible method for treating the furcation

is to eliminate it by hemisecting the crown and root of the tooth.

However, this procedure requires endodontic, periodontal, and

restorative treatment.

Class III furcation

Orthodontic therapy

Eliminate it by hemisection

If roots not to be moved apart

2 to 3 months recall visits

Endodontic therapy

If roots need to be moved apart

Do hemisection pre Ortho

Place brackets on roots and coil springs to seperate

Size of eden. space and occlusion

7-8mm space may be created

• Class III furcations, tooth may have :-

Short roots

Fused roots

Advanced bone loss, thus preventing hemisection

• Extract the root and place implant

• Implant can act as anchor to facilitate prerestorative

orthodontic therapy.

• 4-6 months after placement

• If not acting as an anchor – can be placed after orthodontic

therapy

Fractured Teeth/ Forced Eruption

Root length –crown-root ratio – 1:1

Root form – broad & non tapering , root canal should not be

more than one third.

Level of fracture

Relative importance of tooth

Esthetics – high lip line

Endo-perio prognosis

Orthodontic considerations:-

Mechanics can vary from elastic traction to banding and

bracketing.

Root may be erupted – slowly or rapidly

Criteria

Orthodontic Treatment Of Gingival Discrepancies

Gingival margin discrepancies

Abrasion of incisal edges

Delayed migration of gingival margins

Can be corrected

Orthodontically Surgically

Esthetically visible

Evaluate sulcular depth

Evaluate relationship of CI to LI

Incisal abrasion – intrusion best accomplished 6 months

before appliance removal.

Open Gingival Embrasures

Tooth shape

Root angulation

Periodontal bone loss

Interproximal contact area

consists of two parts..

Evaluating the problem

Papilla

Lack of bone support due to PDL problems

Reconstruction of papilla

Tooth contact

Evaluate radiograph

Divergent roots – brackets , correct root position

Non divergent roots – triangular tooth shape

Reshape the tooth

Elimination of unesthetic soft tissue gaps

The problems that may arise during or after orthodontic therapy are

grouped as follows :-

Associated with orthodontic bands.

Associated with excessive orthodontic force.

Orthodontic relapse.

Difficulty in tooth movement.

Associated With Orthodontic Bands

Associated With Excessive Force

ORTHODONTIC RELAPSE

• When teeth are moved to a new position these fibers stretch and they remodel very slowly.

• The pull of these fibers tend to revert the teeth to their old positions.

• If the supracrestal fibers are sectioned (i.e. by circumferential supracrestal fibrotomy CSF) and allowed to heal while the teeth are held in the proper position, relapse caused by gingival elasticity is reduced.

Reorganization of collagen & elastic supracrestal gingival fibers

Reiten (1969) reported that most relapse following

orthodontic tooth movement occurred during the first five

hours after the appliance was removed hence it is advisable

to do the fiberotomy procedure few weeks before the

removal of appliance.

Several clinical and histologic investigations indicate that the

major relapse pull on a rotated tooth appears to be in the

supracrestal fibers.

Difficulties In Orthodontics Tooth Movement

• Age is not a contraindication to orthodontic treatment.

• With increasing age cellular activity decreases and the tissue

becomes richer in collagens.

• In the elderly, the tissue response to orthodontic forces

including both cell mobilization and conversion of collagen

fibers is much slower than in children and teenagers.

• In adults, hyalinized zones are formed more easily on the

pressure side of an orthodontically moved tooth and these

zones may temporarily prevent the tooth from moving in the

intended direction.

• Since the growth in adults is completed, it is not possible by

orthodontic measures to influence zone of growth and

therefore treatment in adult individuals is restricted to different

types of tooth alignment.

• It is far more difficult for an adult individual to adopt to an

orthodontic appliance than for a child.

• Phonetic adjustment to a removable appliance for instance,

generally require more time in an adult.

• A fixed appliance is usually better tolerated by adult patient.

Frenum Considerations

• Many- frenum prevents mesial migration of maxillary CI.

• Others- removal of frenum allows space to be closed

orthodontically

• Generally , removal of frenum should be delayed until after

orthodontic therapy, unless tissue becomes painful or

prevents space closure, to change irreversible hyperplastic

tissue to normal gingival form & to enhance post

treatment stability.

The Role Of Implants In Orthodontics

• Implants as a source of absolute anchorage

• Implants used for anchorage and as abutments for

restorations

• Implant site preparation improved by orthodontics

• Implants in osteogenic distraction.

Time Relationship between Orthodontic

& Periodontal Therapy

• It is generally recommended that orthodontics be preceded by PDL therapy based on the belief that orthodontics in the presence of inflammation can lead to rapid and irreversible breakdown of the periodontium (Lindhe et al. 1974).

• SRP (if necessary, by open flap debridement procedures for access) & gingival augmentation should be performed as appropriate before any tooth movement (Glickman 1964, Prichard 1965, Profflt 1993d).

• The corrective phase of periodontal therapy, i.e., osseous or pocket reduction/ elimination surgery ought to be delayed until the end of orthodontic therapy, because tooth movement may modify gingival and osseous morphology (Goldman & Cohen 1968).

Periodontal Restorative Interrelationship

• Active pdl disease …………

• Restorative dentistry performed on ….

• Implant dentistry ………….

Prep of periodontium for restorative dentistry

• Shrinkage of tissue – helps in locating ideal gingival margin …..

• Position of teeth altered in PDL disease- injurious tension &

pressure

• Impairment of functional demands

• Impressions made from inflamed gingiva – improper fit

• Mobility & pain – interferes with

masticaton & function

• Aim is not only to eliminate periodontal pockets and restore gingival

health.

• Treatment should also create the gingivomucosal environment &

osseous topography necessary for the proper function of prosthesis.

• Control of active dental disease

• Higher quality

• Pocket. – Ulceration , edema, vascularity

• Return of healthy state in 2 weeks

• Thus plaque control, calculus removal and the removal or

correction of any inadequate dental restorations in the

gingival environment should be initial procedures.

Phase I Therapy

Management of Mucogingival Problems

It often is necessary to carry out a free soft tissue autograft in the patient who has a mucogingival defect and requires a dental restoration in the immediate environment of the gingiva.

Should be carried out at least 2 months before placement of the dental restorations - allows time for mature tissue to form

Augmentation of keratinized gingiva provides stability of the free gingival margin and surrounding gingival tissues so that the dental restoration can be placed in an environment in which gingival health can be maintained.

Techniques to increase the width of attached gingiva

1.Free gingival autografts

2.Apically positioned flap

3.Free connective tissue autograft

4.Pedicle grafts:

laterally displaced

coronally displaced

Crown Lengthening Procedure

The surgical procedure to expose adequate clinical crown

to prevent the placement of the crown margin into the area

of the biologic width is termed crown-lengthening surgery.

Biological width

•Constant

•Crestal bone lost to reestablish

•Gingival inflammation

•Pocket formation

Gingivectomy

Crown lenthening procedure

• It is essential that there be at least 3 mm between the most apical extension of the restoration margin and the alveolar bone crest.

• This space allows sufficient room for the supracrestal collagen fibers that are part of the periodontal support mechanism, as well as providing a gingival crevice of 2 to 3 mm.

• If this guideline is used, the margin of the crown is finally positioned at its correct level, approximately halfway down the gingival crevice.

• Failure to allow sufficient space between the crown margin and the alveolar crest height means that the finished restoration is positioned deep in the periodontal tissues and results in increased inflammation and pocket formation.

Margins

1.Supragingival

2.Equigingival

3.Sub Gingival

• Least Impact On Periodontium• Applied In Non Esthetic Areas

Supra Gingival

Equigingival Margins

• Traditionally Not Desirable• Plaque Retentive- Greater Inflammation• Any Minor Recession-unsightly Margin Display• Advantage: Finished Easily

Subgingival Margins

• no access for finishing• violates biologicwidth when placedincorrectly.

change of microflora from health to disease

increased gingival inflammation

apical migration of junctional epithelium

bone loss

2 Different Responses

Supragingival/Subgingival Margins

• Guy.M.Newcomb (1974 )“The relationship between the location of subgingival crown margins and gingival inflammation” and concluded that the nearer a subgingival crown margin approaches the base of the gingival crevice, the more likely its that severe inflammation will occur.

• D.A.Orkin and D. Bradshaw (1987) conducted a study on the “Relationship of the positions of crown margins to gingival health” and showed that gingival tissues tend to bleed 2.42 times more frequently with subgingival margins and have 2.65 times higher chance of gingival recession

• D.A.Felton (1991) “Effects of in vivo crown margin discrepancies on the periodontal health” in his study he strongly supported the placement of supragingival margins for artificial crowns and FPD’s.

• William.G.Reeves in his review article concluded that more supragingivally a restorative margin is placed, the less chance that the margin will contribute to gingival inflammation.

Identification Of Biologic Width Adequacy

•Radiographs

•Tissue discomfort

experienced by patient

•Periodontal probe

•Sounding of bone

In 1994, Vacek et al investigated the biologic width phenomenon. Although their average width finding of 2 mm was the same as that previously presented by Gargiulo et al, they also reported a range of different, patient-specific biologic widths.

They reported biologic widths as narrow as 0.75 mm in some individuals, whereas others had biologic widths as tall as 4.3 mm.

• Dictates that specific biologic width assessment should be performed for each patient for restorations to be in harmony with their gingival tissues.

Biological Width Violations

Gingival Inflammation

Gingival Inflammation

Correction of biologic width violation

Transgingival probing/bone sounding

Measure the distance from gingival crest

to alveolar crest

if less than 3mm if more than 5mm

• ostectomy with apically gingivectomy

displaced  flap (rapid).

• orthodontic extrusion.

Tissue Retraction

In this process, the tissue must be protected from abrasion,

which will cause hemorrhage and can adversely affect the

stability of the tissue level around the tooth.

During final impression making , a clean, fluid controlled

environment is desired. Tissue management is achieved

with gingival retraction cords, using the appropriate size to

achieve the displacement required.

Thin, fragile gingival tissues and shallow sulcus - smaller

diameter cords be chosen to achieve the desired tissue

displacement.

• Journal of Prosthodontics, Vol 15, No 2 ( March-April), 2006: pp 108-112

Gingival retraction causes an acute injury that heals clinically in 2 weeks as is indicated by the GI.

It also provides the first evidence that gingival retraction results in an elevation of the proinflammatory cytokine, TNF-α, in GCF.

Marginal fit

• Marginal fit - producing an inflammatory response in the periodontium.

• It has been shown that the level of gingival inflammation can increase, corresponding with the level of marginal opening.

• Open margins are capable of harboring large numbers of bacteria and may be responsible for the inflammatory response seen.

• However, the quality of marginal finish and the margin location relative to the attachment are far more critical to the periodontium.

Crown Contour

• Restoration contour has been described as extremely important to the maintenance of periodontal health.

• Ideal contour provides access for hygiene and has the fullness to create the desired gingival form and a pleasing visual tooth contour in esthetic areas.

Emergence profile mimicking the natural tooth contour should be followed.

• Evidence - a relationship between over contouring & gingival inflammation.

• The most frequent cause of overcontoured restorations is inadequate tooth preparation by the dentist, which forces the technician to produce a bulky restoration to provide room for the restorative material.

Proper contour reduces plaque retention.

• Flat emergence profile mirrors natural tooth form and protects plaque trapping

• Over contoured restoration traps plaque• Under contoured restoration - less protection from

physical trauma

Surface finish

• The rougher the surface of the restoration, the greater the plaque accumulation and gingival inflammation.

• In clinical research, porcelain highly polished gold, and highly polished resin all show similar plaque accumulation.

• Regardless of the restorative material selected, a smooth surface is essential on all materials subgingivally.

Restorative Correction of Open Gingival Embrasures

• 2 causes of open gingival embrasures.

• Either the papilla is inadequate in height due to bone loss. OR• The interproximal contact is located too high coronally.

• If a high contact has been diagnosed as the cause of the problem, there are two potential reasons.

• If the root angulations of the teeth diverge, the interproximal contact is moved coronally, resulting in the open embrasure.

• However if the roots are parallel, the papilla form is normal, and an open embrasure exists, then the problem is probably related to tooth shape, specifically, an excessively tapered form. Restorative

dentistry

Orthodontic therapy

Periodontral therapy

Pontic Design

A. Sanitary pontic- 3mm from underlying ridge, convex undersurface-facilitates

cleansing

B. Ridge lap pontic C. Modified ridge lap

D. Ovate pontic-ideal pontic form, flat or convex undersurface, adapts to the site.

easily maintainable

concave surfaces, difficult access for plaque control

Overhanging Restorations

• Cementation: its very important that all excess cement be

removed from the sulcus after cementation as the retained

cement particles causes gingival inflammation and plaque

accumulation.

Splinting

• Mobility of teeth - impairs patient comfort, migration of teeth, or prosthetics where multiple abutments are necessary.

• Before considering splinting, the etiology of the instability must be identified.' Excessive occlusal forces from parafunction or deflective tooth contacts …..

• Whenever the occlusion is the cause, occlusal therapy is always performed first.

• The mobility is then evaluated over time to determine whether it resolves before splinting is considered.

• In addition, any inflammation of the periodontal supporting apparatus must be controlled before making a decision on splinting because inflammation can produce mobility in the presence of normal occlusal forces and normal periodontal support.

• The rigidity of the splint and the number of teeth used determines how the forces are distributed.

• It is critical that adequate crown length on the teeth is being splinted Also, adequate space is needed between the connector and the papilla for access with - interproximal brush ..

Periodontics and Endodontics

Interrelationship

Potential Routes

Dentinal tubules

• Communication pathway

• Exposure …..

• Developmental defects of cementum Enamel do not meet,

Palatogingival & apical grooves

• Disease

• Periodontal procedures

Lateral and accessory canals

• Maybe present anywhere along the root

• The prevalence of accessory canals may

vary from 23% to 76%.

• DeDeus found that 17% of teeth had

lateral canals in the apical third of the

root, 9% in the middle third, and < 2% in

the coronal third.

• C.T, vessels , that connect the

circulatory system of the pulp with that

of the periodontium.

Apical foramen

• Most direct route of communication between the pulp and periodontium.

• Bacterial and inflammatory by products may exit…. periapical pathosis.

• Portal of entry …… from deep periodontal pockets.

Communication Through Apex Or Lateral Canal May Cause Furcation

Involvement

Pathways Of Endodontic Periodontic Disease

• Physiological – Developmental

• Non – Physiological

Pathologic Iatrogenic

•Empty spaces on root•Root fractures•Idiopathic•Loss of cementum

•Exposed dentinal tubules following SRP•Accidental root perforations

• CLASSIFICATION OF CLASSIFICATION OF ENDODONTIC PERIODONTIC ENDODONTIC PERIODONTIC

LESIONSLESIONS

• Based on etiology - by Simon, (1972)

• Type1 - Primary endodontic lesions• Type2 - Primary endodontic lesions with secondary

periodontal • involvement• Type 3 - Primary periodontal lesions• Type 4 - Primary periodontal lesions with secondary

endodontic • involvement• Type 5 - True combined lesions

Effect Of Pulpal Disease On Periodontium

• As long as the pulp maintains vital ….. unlikely

• Impact of pulpal necrosis – result in bone

resorption ….

Pdl fistulation

Extraosseous fistulation

Effect Of Periodontal Disease On Pulp

• A clear cut relationship …..less evident.

• Bacterial & inflammatory products….via accessory canals, apical foramina or dentinal tubules.

• Retrograde pulpitis

• Inflammatory changes are noted adjacent to accessory canals exposed by ….periodontitis rarely produces significant changes in the dental pulp.

• Intact layer of cementum• Intact blood supply via apical

foramina.• Retrograde periodontitis…rare

Influence Of PeriodontalTreatment Measures On The Pulp

• SRP …Cementum & dentin may also be removed …

• Microbial colonization of the exposed root dentin may result in bacterial invasion of the dentinal tubules.

• (Adriaens et al 1988)

• Vitality of the pulp is not normally put at risk ( Bergenholtz , lindhe 1978)

• Rare occasions, deep scaling……………expose lateral canals…symptoms of pulpitis.

Impact Of Endodontic Treatment Measures On The Periodontium

• a) Root filled teeth of poor quality:• Unfilled spaces in root canal

Spread of infectious products into the periodontium

Contribute to increased probing depth. Retarded or impaired periodontal tissue healing subsequent to periodontal therapyJansson, Ehnevid, Lindskog & Blomlof (1993)

Localized Edema

Increased Intrapulpal Pressure

Inflammatory Exudate

Collapse Of Venous Part Of Local Microvasculature

Cell Death

Hypoxia

Anoxia

Necrosis

Pathogenesis – Endodontic Lesion

Pathogenesis :Pulpo-periodontal Disease

Plaque-calculus

Destruction Of Connective Tissue,pdl,alveolar Bone

Altered Root Surface

Shallow Resorptive Lesions Of Cementum

Soft Tissue Irritation

If Cementum Not Intact

Retrograde Pulpitis

•History •Clinical examination– Intra oral visual – Swelling

•Probing•Mobility•Tests•Percussion & palpation•Cold test•Electric pulp test•Radiographs

DiagnosisDiagnosis

LDF

PO

MRI

Test Test performedperformed

PulpalPulpal PeriapicalPeriapical PeriodontalPeriodontal

Percussion Normal Sensitive Usually normal

Periodontal probing

No defects Single defect, may

be in unusual site

Numerous defects

throughout mouth,

subgingival calculus

Response to ice

Lingering response or reduces pain

No response Normal

Electric pulp test

Low, normal, or high

response

No response Normal

Radiographic findings

Shallow caries, recent filings,

occlusal & physical trauma

Deep caries or filling, pulp cap

Alveolar bone loss, calculus

CLINICALCLINICAL PULPALPULPAL PERIODONTALPERIODONTAL

Etiology Pulp infection Periodontal

infection

Pulp test Non - vital Vital

Restorative Deep/extensive Not related

Plaque/Calculus Not related Primary cause

Inflammation Acute Chronic

Pocket Single/ Narrow Multiple/ wide

Differential diagnosis

Treatment decision-making

• The main factors to consider are:– Pulp vitality and – Type and extent of the periodontal defect.

• Primary endodontic lesions should only be treated by endodontic therapy and has a good prognosis.

• Primary periodontic lesions should only be treated by periodontal therapy. Prognosis depends on severity of the periodontal disease and patient response.

• Primary endodontic disease with secondary periodontal involvement should first be treated with endodontic therapy.

• Treatment results should be evaluated in 2 to 3 months and

only then should periodontal treatment be considered.

• Prognosis depends primarily on the severity of periodontal

involvement, periodontal treatment and patient response.

• Primary periodontal disease with secondary endodontic

involvement and true combined endodontic periodontal

diseases require both endodontic and periodontal therapies.

Coming together is the beginning

Keeping together is progress

But working together is success.”

THANK YOU

References

Clinical Periodontology – Carranza – 9th edition

Clinical Periodontology and Implant Dentistry – 4th edition - Jan Lindhe

Interrelationships between Periodontics and adult OrthodonticsJ Clin

Periodontol 1998; 25: 271-277

The role of implants in orthodontics – Net ref

The endo-perio lesion: a critical appraisal of the disease condition. Endodontic

Topics 2006, 13, 34–56

Tylman’s “Theory and practice of fixed prosthodontics” 8th edition.

Paul A. Fugazzotto “ Preparation of the periodontium for the restorative

dentistry”1st edition.

Thomas G. Wilson “Fundamentals of periodontics”

M.Martignoni “Precision fixed prosthodontics:Clinical and

labobatory aspects.

Rosenstiel “Contemporary fixed prosthodontics” 3rd edition

Shillingberg H.T – Fundamentals of FPD 3rd edition

Reconstruction of the maxillary midline papilla following a

combined orthodontic–periodontic treatment in adult

periodontal patients. J Clin Periodontol 2004; 31: 79–84.

References