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10.5005/jp-journals-10021-1137
CASE REPORT
Kshitij Bansal et al
Interdisciplinary Treatment of a
Periodontally Compromised Adult
1
Kshitij Bansal, 2Surendra Lodha, 3Nidhi Bansal
ABSTRACT
This case report describes the interdisciplinary treatment of a 32-year-old female patient showing protrusive profile, a Class I canine relationship
complicated with multiple missing teeth, extruded upper left first molar, exaggerated curve of Spee, generalized bone loss and an endoperio
lesion involving lower left first premolar. After achieving a complete control of active periodontal disease, extraction of third molars, endodontic
therapy of lower left first premolar, followed by orthodontic treatment was carried out. A functional and esthetic occlusion with improved facial
profile was established at the end of treatment combined with esthetic restorations of upper anterior teeth to close the black triangles and
prosthetic replacement of missing teeth.
Chronic periodontal disease create multitude of complications which needs to be treated by a team of dental specialists and not by one
individual; in the best interest of the patients including their apprehensions, medical and oral conditions, time and cost.
Keywords: Interdisciplinary treatment, Adults, Molar and incisor intrusion, Microimplant, Endo-perio lesion, Black triangles.
How to cite this article: Bansal K, Lodha S, Bansal N. Interdisciplinary Treatment of a Periodontally Compromised Adult. J Ind Orthod Soc
2013;47(2):100-106.
INTRODUCTION
Periodontal disease is a generic term for inflammatory
diseases; triggered by bacteria; affecting the gingiva, the
supporting connective tissue and the alveolar bone; causing
the loss of connective tissue attachment and alveolar bone.
The clinical characteristics, such as increased probing depths
combined with factors, such as the age of the patient at the
onset of the disease process, the rate of progression of the
disease, psychological maladjustments and several dental
restorations; decide the treatment plan and outcome.1,2
The complications arising from periodontal breakdown,
such as pathologic migration, supraerupted teeth, spacing, loss
of interdental papillae, missing teeth often make multitasking
from dental specialties essential.
It is evident that orthodontic tooth movement can be
performed in adults with reduced but healthy periodontium
without further periodontal deterioration;2,3 provided effort
is made to eliminate or reduce, plaque accumulation and
gingival inflammation. This implies great emphasis on personal
1,3
Senior Lecturer, 2Postgraduate Student
Department of Conservative Dentistry and Endodontics, Bhojia Dental
College and Hospital, Baddi, Himachal Pradesh, India
2
Department of Orthodontics, Manipal College of Dental Sciences
Mangalore, Karnataka, India
3
Department of Orthodontics, Bhojia Dental College and Hospital, Baddi
Himachal Pradesh, India
1
Corresponding Author: Nidhi Bansal, Senior Lecturer, Department of
Orthodontics, Bhojia Dental College and Hospital, Baddi, Himachal
Pradesh, India, e-mail: [email protected]
Received on: 12/5/12
Accepted after Revision: 21/9/12
100
oral hygiene, strategic appliance construction and periodical
checkups throughout treatment.
According to Ackerman,4 adult orthodontics is concerned
with striking a balance between ‘achieving optimal proximal
and occlusal contacts of the teeth, acceptable dentofacial
esthetics, normal function and reasonable stability’ having a
realistic and not ideal treatment tactic.
CASE REPORT
A 32-year-old woman reported with a chief complaint of the
unesthetic appearance with spacing in upper front teeth. Her
medical history showed no contraindication to orthodontic
therapy. Facial photographs show protrusive lips, convex facial
profile and an unesthetic smile (Fig. 1). Dental history include
extractions of the upper right third molar, lower left first and
second molars because of dental caries.
On intraoral examination, halitosis, spontaneous bleeding
gums, gingival recession, severe loss of interdental papillae
anteriorly was seen. The maxillary left third molar 28 and lower
anterior teeth were grade 2 mobile. Maxillary anterior teeth
were grade 1 mobile. 34 was tender to percussion. A
generalized attrition was present. Dentally, she revealed 7 mm
of overjet with deep overbite of 6 mm, a deep curve of Spee
of 3 mm; 6 mm spacing in the upper dental arch, 1 mm of
crowding in the lower dental arch, a mesially tipped lower
left third molar 38, rotated left mandibular second premolar
35 and microdont 38. A Class I canine and premolar5 (Katz
modification) relationship was observed bilaterally with the
lower dental midline deviated to the right by 2 mm (Fig. 2).
The maxillary left first molar, 26 was extruded 3 mm beyond
the occlusal plane. Loss of the mandibular first and second
molar resulted in mesial tipping of the lower left third molars
and overeruption of the opposing maxillary first molar.
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Interdisciplinary Treatment of a Periodontally Compromised Adult
Radiological Examination
Periapical views showed furcation involvement with reference
to 27, extensive bone resorption around 28, 34 (Figs 3A to D
to 5A to C). Evaluation of panoramic radiograph revealed
generalized moderate horizontal bone loss (Fig. 4A).
Cephalometric analysis showed normodivergent facial pattern,
proclined upper and lower incisors (Fig. 4B) (Table 1).
DIAGNOSIS
The patient presented with a Class II skeletal relationship,
bimaxillary dentoalveolar protrusion with chronic
periodontitis.
TREATMENT OBJECTIVES
The treatment objectives were to eliminate all pathosis before
contemplating orthodontic therapy; to provide acceptable
facial esthetics, a functional nontraumatic occlusion (i) to
intrude the maxillary first molar 26 and lower anteriors,
(ii) to level and align, (iii) to upright the lower left posterior
occlusion.
TREATMENT PLAN
Control of active periodontal disease was required before
orthodontic therapy could be started. Extractions of upper left
third molar 28, 48 (lower right third molar) were done. Full
mouth periodontal rehabilitation and controlling the active
disease was started. After 2 months, significant improvement
in the gum condition was seen.
However, inflammation was still persistent around the
region of 34. Endodontic therapy of 34 was done. After
3 months, resolution of inflammation with decrease in mobility
and exudation occurred. It was probably a primary periodontal
lesion involving the pulp secondarily. Henceforth, endodontic
therapy appeared to be a wise decision.
After completion of periodontal treatment, significant
reduction in probing depth, mobility, number of bleeding
Fig. 1: Pretreatment extraoral photographs
Fig. 2: Pretreatment intraoral photographs. Note the upper spacing, deep bite, loss of interdental papillae especially in the lower anteriors,
extruded upper left first molar, inflamed gingiva
The Journal of Indian Orthodontic Society, April-June 2013;47(2):100-106
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Kshitij Bansal et al
Figs 3A to D: Pretreatment periapical views: (A) 13, 12, 11, (B) 21, 22, 23, (C) 25, 26, 27, 28, (D) 31, 32, 41, 42.
Note the extensive bone loss around the teeth
Figs 4A and B: Pretreatment radiographs including the (A) panoramic film and (B) lateral cephalogram
Figs 5A to C: Progress periapical view of (A) 34 after root canal treatment
was done, (B) 34 after 3 months, (C) mini-implant placed distal to 35, 38
stabilized to mini-implant
points and exudation was seen. There was a waiting period of
6 months, after which orthodontic tooth movement was
attempted. Postorthodontic treatment, fixed lingual retention
followed by referral to the prosthodontic department for
replacement of missing lower molars.
Figs 6A to C: Intraoral progress photographs. (A) 34 was not bonded
initially. 26 being intruded, (B) after 3 months, (C) leveled occlusal planes.
Intruded 26. Thirty-eight were stabilized to mini-implant placed distal to
35. The sizes of black triangles being reduced as spaces were closed in
the upper arch. The brownish discoloration is due to chlorhexidine staining
TREATMENT PROGRESS
A full 0.022" preadjusted Roth prescription brackets were used.
Initially 34 (lower left first premolar) was not bonded to assess
its prognostic value. To ensure light and continuous forces,
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Fig. 7: Intraoral progress photographs. Lower incisors were intruded
using segmented arch
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Interdisciplinary Treatment of a Periodontally Compromised Adult
Figs 8A to D: Intraoral progress photographs. (A-C) Just before debonding. Small black triangles seen in upper anterior teeth, (D) minor
interproximal reduction was done. Further space closure was done as contact points shifted gingivally
0.016" and 0.018" round nickel-titanium wires were used. 26
was gently tied to the main continuous archwire to exert light
intrusive forces. The upper molar was progressively intruded
as archwires were sequentially changed (Fig. 6).
After 3 months, modest signs of intrusion were seen; a
separator was placed between the left upper first and second
molars, to prevent door-wedge effect.6 Once the upper occlusal
plane was leveled, 26 was included in the continuous archwire.
An orthodontic miniscrew (SK Surgicals, Pune; 1.4 mm
in diameter and 8 mm in length), inserted distally to 35
buccally, at the level of the mucogingival junction (Figs 5A to
C and 6A to C). The angle of insertion was right angles to the
ridge. Postinsertion instructions were given and the miniimplant was loaded after a waiting period of 7 days. Thirtyeight was stabilized to miniscrew using a thick ligature wire.
The lower incisors were intruded using 0.017 × 0.025" ß
TMA intrusion arch delivering a force of 40 gm7,8 (Fig. 7). A
tight cinch-back bend distal to the molar tube was placed, to
prevent incisor flaring during intrusion and to minimize
Fig. 9: Post-treatment extraoral photographs
tipback.9 38 being stabilized to the miniscrew could withstand
the undesirable moments created during incisor intrusion. It
took 4 months for lower intrusion.
After 6 months of start of orthodontic treatment, the lower
left first premolar was bonded and was brought into alignment.
The NiTi coil was compressed between 38 and 35 to close the
space distal to 34. NiTi coil allowed for the delivery of a more
Fig. 10: Post-treatment intraoral photographs
The Journal of Indian Orthodontic Society, April-June 2013;47(2):100-106
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Kshitij Bansal et al
Table 1: Cephalometric parameters and comparison of pre- and post-treatment
Down’s analysis
Indian norms17
Facial angle
Angle of convexity
AB-NPog
Y axis
Mand plane angle
Cant occlusal plane
Interincisal angle
Lower incisor—MP
Lower incisor—occlusal plane
Upper incisor—APog
Pretreatment
Post-treatment
76.5-91.0°
0-17°
–5 to –11°
56-69.5°
13.5-33°
–2 to 14°
91-144°
88-129.5°
14-44°
2.5-12 mm
93°
19°
–13°
57°
28°
8°
117°
9°
32°
14 mm
93°
19°
–14°
57°
28°
10°
130°
7°
30°
9 mm
Tweed’s analysis
Indian norms18
Pretreatment
Post-treatment
FMA
IMPA
FMIA
13.5-33°
88-129.5°
62.5-66.5°
28°
109°
43°
28°
107°
45°
Steiner’ s analysis
Indian norms19
Pretreatment
Post-treatment
SNA
SNB
ANB
Upper incisor—NA
Lower incisor—NB
NB-Pog
Interincisal angle
Go-Gn-SN
OP-SN
Wits appraisal
H angle
72-90.5°
73.5-84.5°
2-8°
5-12 mm, 71-80°
4-14 mm
2.25 mm
85°
79°
6°
12 mm, 40°
8 mm, 33°
–2 mm
117°
31°
10°
4.5 mm
24°
84°
80°
4°
7 mm, 28°
7 mm, 31°
0 mm
130°
31°
12°
2 mm
19°
20-40°
4.5-22°
0.83 mm
7-15°
Figs 11A and B: Post-treatment radiographs including the lateral
cephalometric and panoramic films
constant force, preventing the need for subsequent reactivation.
Rectangular archwires with closing loops were used in upper
arch for space closure. The case was finished with 0.019" ×
0.025" rectangular stainless steel archwires.
To close upper black triangles esthetic composite
restoration were done just before debonding thus maintaining
the golden proportions (Figs 8A to D). Orthodontic treatment
was retained using bonded lingual retainers for both the upper
and lower dentition. The upper left buccal segment was
stabilized using fixed buccal retainer. An interim partial lower
acrylic denture was given till implants are placed.
RESULTS
After 15 months of active orthodontic treatment, a functional
occlusion was established in the right posterior dentition by
intruding the upper first molar and uprighting the lower third
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Fig. 12: Post-treatment periapical radiographs
molar, creating adequate space for an endosseous implant and
crown. The facial profile and the smile esthetics were improved
(Fig. 9). The arches were leveled; the spaces closed; axial
inclinations and midlines were corrected. A Class I canine
relationship and normal overjet and overbite were obtained
(Figs 10 and 11A and B). Periapical radiographs (Fig. 12)
showed intact lamina dura around the first molar within the sinus
floor, with no radiographically observable root resorption.
Cephalometric superimpositions (Figs 13 and 14A and B)
revealed significant retraction of upper incisors, correcting
the steep occlusal planes. Table 1 compares the cephalometric
parameters pre- and post-treatment.17-19
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Interdisciplinary Treatment of a Periodontally Compromised Adult
Fig. 13: Superimpositions using Ricketts five-point analysis
Figs 14A and B: Profile tracings (A) pretreatment, (B) post-treatment
DISCUSSION
Rendering a comprehensive treatment involving interdisciplinary approach while treating especially the adults shall
yield successful results. During comprehensive orthodontics,
a patient with moderate periodontal problems must be on a
maintenance schedule, with the frequency of cleaning and
scaling depending on the severity of the periodontal disease.
Periodontal maintenance therapy at 2- to 4-month intervals is
the usual plan.2,10 The periodontal status was maintained by
regular control and by the meticulous hygiene maintained by
the patient, thus providing satisfactory results.
Anchorage was critical in third quadrant as first, second
molars were missing. 38 was microdont and 34, 35 were
periodontally compromised. To provide adequate resistance
to various orthodontic tooth movements, a 1.5 mm in diameter
× 8 mm long mini-implant was placed in the edentulous ridge
distal to 35. Edgewise appliance, twin brackets of 0.022" slot
dimension was used as rectangular slot controls buccolingual
axial inclination and win bracket prevents undesirable rotations
and tipping.1
In this case, the lower extraction space was not closed
orthodontically as the periodontium was already compromised. In adults, closing an old extraction site with bone defects
is challenging and time consuming. After several years
following extraction, the remodeling of the bone produces a
buccolingually narrowed alveolar process, and closure of the
extraction spaces requires reshaping of the cortical bone.1,11
As proper root position allows for better periodontal health
in adults,12 the uprighting of the lower left third molar was
selected as the appropriate treatment strategy.
Implant-supported prosthetic rehabilitation was planned
for the restoration of the extraction site. However, the
placement of implants was deferred as a healing radiolucency
was present in relation to lower left premolars raising stability
issues for the implants, although patient was asymptomatic.
The case shall be re-examined after a year to decide whether
to place implants or not. Meanwhile, an interim partial lower
acrylic denture was given.
In this case, light forces with long activation intervals
favored easy maxillary molar intrusion without any undesirable
rotations seen. The left lower premolar and molar occlusion
prevented upper premolar and molar extrusion. Professional
scaling may be particularly indicated during active intrusion
of elongated incisors, and when new attachment attempts are
made because orthodontic intrusion may shift supragingival
plaque to a subgingival location.12,13 Melson et al13 reported
that in addition to frequently controlling soft tissue
inflammation, it is necessary to prevent excessive jiggling and
tooth mobility during treatment. Increasing tooth mobility
superimposed on reduced but healthy periodontal tissues
produces no effect on the level of connective tissue
attachment.
True incisor intrusion is achievable in both arches. The
utility arch and the base arch seemed to result in both the
largest intrusion and the largest gain in bony support.14 In
adults, mandibular incisor intrusion is readily achieved
compared with maxillary incisor intrusion.15,16
There was extensive loss of interdental papillae in upper
anteriors. The size of black triangles was considerably reduced
as upper spacing closed and slight interproximal enamel was
removed to create adequate crown morphology.1,10 This moves
the contact points more gingivally, minimizing the open space
between the teeth. The upper anterior teeth were restored with
composites.1
CONCLUSION
Interdisciplinary approach combining periodontics, oral
surgery, orthodontics, endodontic, esthetic, prosthodontic
treatments helped to achieve good esthetic and functional
results in this case with multiple dental problems complicated
by periodontal breakdown. There is a defined beneficial effect
on the periodontal condition of the patient when judged at the
The Journal of Indian Orthodontic Society, April-June 2013;47(2):100-106
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Kshitij Bansal et al
clinical and radiographic levels. Adult age is no contraindication for orthodontic treatment. Orthodontics can
contribute toward optimal oral health, eliminate occlusal
trauma and prevent adverse periodontal conditions from
developing and improve the psychological well being of the
patient at any age.
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