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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. JAYPEE JIOS 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):100-106 101 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, 102 Fig. 7: Intraoral progress photographs. Lower incisors were intruded using segmented arch JAYPEE JIOS 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):100-106 103 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 104 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 JAYPEE JIOS 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):100-106 105 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. REFERENCES 1. Proffit WR, Ackerman JL. Orthodontic diagnosis and treatment planning. Development of a problem list. In: Proffit WR (Ed). 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True molar intrusion attained during orthodontic treatment: A systematic review. Am J Orthod Dentofacial Orthop 2006;130:709-14. 17. Ashima V. Downs’ cephalometric analysis on Adults from India. J Indian Dent Assoc 1974;46:437-41. 18. Ashima V. Tweeds’ cephalometric analysis applied to Indian Adults. J Indian Dent Assoc 1976;215(6):481. 19. Ashima V. Steiner’s cephalometric analysis on adults from India. Kerala Dent J 1979;3:18-19. JAYPEE