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Journal of Orthodontics, Vol. 39, 2012, 303–313 CLINICAL SECTION Orthodontic treatment in the severely compromised periodontal patient Daniela Feu, Fernanda Catharino Menezes, José Augusto Mendes Miguel and Catia Cardoso Abdo Quintão Rio de Janeiro State University, Rio de Janeiro, Brazil We describe the diagnosis and treatment of a class II division 1 malocclusion complicated by severe periodontal disease, tooth loss, dentoalveolar protrusion associated with tipping and extrusion of the maxillary incisors, and a traumatic occlusion. Treatment involved the use of a modified palatal arch to intrude and retract the maxillary incisors and high-pull headgear to enhance anchorage and correct the Class II relationship. After active treatment for 19 months, a good anterior occlusion was achieved, with 17u of lingual retroclination and 3 mm of intrusion at the apex of the maxillary incisors. An acceptable occlusion and periodontal status was maintained over a retention period of 2 years. With the patient’s cooperation, a successful outcome was achieved with this approach. Key words: Adult periodontitis, Orthodontics, Anchorage Received 5 February 2012; accepted 19 May 2012 Introduction Periodontal treatment alone cannot always correct and control the damage produced by periodontal disease and a pathologic occlusion. In these cases, orthodontic tooth movement can be an important component of the overall treatment plan.1 However, orthodontic treatment can be more complicated in patients with periodontal disease and requires advanced biomechanical techniques, an understanding of the patients’ specific biological situation and an interdisciplinary treatment plan. Patients with periodontal disease often experience a number of complications, including tipping, flaring and extrusion of one or several incisors; the development of single or multiple spaces between anterior teeth2,3 and a traumatic occlusion that may contribute to destructive periodontal disease.3,4 Microbial plaque is the most important factor in the initiation, progression and recurrence of periodontal disease in a reduced periodontium.5–8 Studies have shown that orthodontic treatment is no longer contraindicated in the treatment of severe adult periodontitis.5,9 With adequate plaque control, teeth with reduced periodontal support can undergo movement without compromising their periodontal situation. In such cases, orthodontic treatment can improve the chances of saving and restoring a deteriorated dentition.1,3,5 In cases of pathological migration and extrusion, intrusive movement has been recommended to realign teeth and improve clinical crown lengths and marginal Address for correspondence: Daniela Feu, Rio de Janeiro State University, Rio de Janeiro, Brazil. Email: [email protected] # 2012 British Orthodontic Society bone levels.10 Furthermore, histological studies suggest that orthodontic intrusion may lead to the formation of new attachment.11 The use of biomechanical systems and units for improved anchorage is essential for additional control of tooth positioning, especially in the vertical dimension.10 Skeletal anchorage devices, such as orthodontic miniscrews, miniplates or even dental implants that serve as anchorage units, may be used, especially when the existing teeth are periodontally compromised.12 However, traditionally effective treatments can be considered for patients who do not accept or cannot undergo surgical or other invasive interventions. Diagnosis and aetiology A 25-year-old female of normal weight and stature presented with no relevant medical history. Temporomandibular joints were clinically normal. The roots of the teeth had a pipette shape and appeared radiographically normal. All of the fillings and root canal treatments were satisfactory, except for the root canal in the lower right first molar; a non-surgical re-treatment had been performed on this tooth during the previous month. No deleterious habits or history of mouth breathing were present. The upper left first molar had been lost to periodontal disease, and the third molars were in occlusion. Previous chronic periodontal disease had caused significant attachment loss and mobility in the upper and lower DOI 10.1179/1465312512Z.00000000042 304 Feu et al. Figure 1 Clinical Section JO December 2012 Pre-treatment periapical radiographs incisors (Figure 1 and 2). The patient’s primary complaint was drifting and spacing between the maxillary incisors. Facial photographs (Figure 3) showed a straight facial profile with incompetent lips and a satisfactory mandibular chin point with a slight right deviation. Cephalometric analysis (Figure 4 and Table 1) showed that this patient had a brachyfacial skeletal pattern with a low mandibular plane angle (FMA: 18.3u; SN-GoGN: 25.8u), class II malocclusion (SNA: 85.9u, SNB: 80.5u, ANB: 5.4u, Witts: z6.0 mm) with an adequate anterior lower facial height (ALFH) (69.7 mm).13 There was a dentoalveolar class II division 1 malocclusion, 7 mm overjet, a deep bite with traumatic occlusion of the lower incisors on the palatal surface of the maxillary incisors, an accentuated curve of Spee and a posterior crossbite tendency on the left. Both maxillary and mandibular incisors were excessively flared (1-NA: 41.4u; 1-NA: 10.5 mm; 1.NB: 36.3u; 1-NB: 7.2 mm; IMPA: 107.3u). Periodontal charting demonstrated probing depths ranging from 4 to 9 mm with gingival recession on the labial and lingual surfaces of the mandibular incisors, particularly the left central incisor. There was approximately 2 mm of anterior mandibular dental crowding, and 4 mm of maxillary spacing, including a 2.9 mm diastema between the maxillary central incisors. The mandibular dental midline was displaced approximately 1.5 mm to the patient’s right (Figure 5). The maxillary central incisors were exposed on both lip closure and rest. Both mentalis and maxillary lip strain were observed (Figure 3a). Treatment objectives Treatment objectives were to: (1) acquire good plaque control and clinically healthy gingiva through periodontal treatment; (2) align and level the teeth in both arches, establishing functional occlusion and closing the maxillary anterior diastema; (3) correct the class II right molar and canine relationship; (4) normalize the overjet and overbite; and (5) improve facial aesthetics. Figure 2 Pre-treatment panoramic radiograph Figure 3 Pre-treatment facial photographs: a: Profile; b: Frontal view; c: Smiling JO December 2012 Clinical Section Table 1 Orthodontic treatment and periodontal disease Cephalometric measurements. Measurements Figure 4 Pre-treatment lateral cephalogram Treatment options The first option was orthodontic treatment in conjunction with extraction of both maxillary first premolars and the use of directional force with microimplant anchorage. Microimplant anchorage could provide absolute anchorage to achieve maximum retraction of the maxillary anterior teeth and to improve their intrusion. However, the patient declined the use of microimplants and extraction of the maxillary first premolars. It was decided to institute a treatment plan involving the use of a modified palatal arch to intrude and retract the 305 Pre-treatment Post-treatment Post-retention SNA 86.8u SNB 81.9u ANB 5.7u 1.NA 41.4u 1-NA 10.5 mm 1.NB 36.3u 1-NB 7.2 mm IMPA 107.3u Interincisal angle 93.2u FMA 18.3u SN-GoGn 25.8u PLO 21.4u ALFH (ENA-Me) 69.7 mm 87.2u 83.1u 4.1u 23.8u 6.0 mm 30.1u 5.5 mm 100.9u 119.0u 19.5u 26.7u 14.9u 70.0 mm 87.2u 83.2u 3.9u 23.5u 6.2 mm 30.0u 5.5 mm 101.2u 118.6u 19.2u 26.2u 15.2u 70.1 mm maxillary incisors. High-pull headgear was also used for anchorage and to correct the class II malocclusion. Fixed appliances were placed in a second phase of treatment. A diagnostic set-up was performed with the patient’s dental casts to assess the feasibility of this treatment plan (Figure 6). The set-up showed that an acceptable overjet and overbite could be achieved if the UR8 was extracted and if the UR6 was moved distally by 4 mm. The other first molars were maintained in the same position with no anchorage loss. The lower incisors were intruded 2.5 mm and retracted 0.5 mm. The upper incisors were intruded Figure 5 Pre-treatment intra-oral photographs: a: Frontal view; b: Right lateral view; c: Left lateral view; d: Upper occlusal view; e: Lower occlusal view 306 Feu et al. Figure 6 Clinical Section Diagnostic set–up casts: a: Frontal view; b: Right lateral view; c: Left lateral view; d: Occlusal view 2.5 mm and retracted 5.0 mm. However, this movement was achieved both with retroclination and retraction of the upper incisors, and an overjet of 2.5 mm remained. Inter-proximal reduction was needed in the six anterior maxillary (2.0 mm) and mandibular (1.8 mm) teeth. Inter-canine and inter-molar distances were unchanged and the midlines were coincident. Treatment progress The patient had been under periodontal care for nearly 9 months. Intensive periodontal treatment involved oral hygiene instruction, curettage, scaling and root planing. Before the orthodontic treatment began, plaque control was good, periodontal disease was arrested and the Figure 7 JO December 2012 gingiva was clinically healthy. Probing depths were less than 4 mm, except at the mesial lingual aspect of the LR8, the distal lingual aspect of the upper first molars and the mesial-buccal aspect of the maxillary central incisors, where probing depths were 5 mm. A flap cleanout surgery to eliminate deep debris and granulation tissue was performed 10 days before the beginning of the incisor intrusion.6 The UR8 was extracted. Treatment began with the use of the high-pull headgear for at least 15 h per day. A force gauge was used monthly to check and maintain a 200-g force on each side. The modified palatal arch was placed during the same period, connecting the UR7 and UL8. This palatal arch had nickel–titanium (NiTi) pletchers linked into standard edgewise brackets bonded at the palatal surface of the Modified palatal arch: a, with; b, without the NiTipletchers linked into the brackets JO December 2012 Clinical Section Orthodontic treatment and periodontal disease 307 Figure 8 Radiographs after the first phase of treatment: a, b and c: Periapical radiographs showing the modified palatal arch; d: Panoramic radiograph showing the modified palatal arch upper maxillary incisors (Figure 7). Retraction and intrusion of these elements started with a 12-mm NiTi pletcher placed into each tooth, with the line of action of the force passing near the centre of resistance; this placement resulted in a small force of approximately 10 g per tooth. During this period, the orthodontic appliance was adjusted every 5 weeks, and the pletchers were replaced with progressively smaller ones (down to a 5-mm pletcher) to maintain the same force. A segmented 0.02260.028-inch no tip, no torque edgewise appliance was placed from the Upper Right UR 3 to 7 and Upper Left LR 3 to 8; a passive 0.01760.025-inch segmented wire was used with the high-pull headgear to complete the anchorage system. Anterior intrusion and retraction was conducted for 8 months. The inter-incisal angle decreased gradually after the first 2 months of tooth retraction. The spaces were closed while the posterior occlusal relationship was maintained (Figures 8 and 9). The palatal brackets were removed and a 0.0226 0.028-inch no tip, no torque edgewise appliance was placed in both arches. The headgear was maintained to achieve the molar class I relationship. The initial 0.012inch stainless steel wire was used in the maxillary arch. A 0.01760.025-inch beta-titanium cantilever and a 0.0196 0.025-inch passive stainless steel lower arch were used for verticalization. The mandibular incisor intrusion was Figure 9 Facial photographs after the first phase of treatment: a: Profile; b: Smiling profile; c: Frontal view; d: Smiling 308 Feu et al. Clinical Section JO December 2012 Figure 10 Post-treatment intraoral photographs: a: Frontal view; b: Right lateral view; c: Left lateral view; d: Upper occlusal view; e: Lower occlusal view obtained using tripart mechanics (‘Burstone’ intrusion mechanics). The levelling and alignment of the lower arch was continuous and began with a 0.016-inch stainless steel wire. Subsequently, larger wires were used to level the mandibular and maxillary arches, and crossbite correction was achieved using symmetric and coordinated archwires. To correct the dark spaces, stripping was performed between the six anterior maxillary (2.6 mm) and mandibular (1.8 mm) teeth in on a 0.01960.025-inch stainless steel archwire. The spaces were closed with elastic chains. The treatment was completed with ideal archwires and cuspseating elastics; additionally, a bilateral class II elastic force was applied to a hook of the maxillary archwire, mesial to the canines, from the mandibular posterior third molars to finish the occlusion. After 19 months of treatment, space consolidation and good occlusion were achieved. Root parallelism was confirmed on the panoramic radiograph, and the appliances were removed. During the treatment period, professional prophylaxis was performed at 3-month intervals. Retention was maintained with maxillary and mandibular lingual-bonded retainers used in combination with a removable retainer. Treatment results After 19 months of treatment, the teeth were aligned, and spacing in the upper dentition was closed. A class I relationship with proper occlusion was obtained. Adequate overjet, overbite and facial balance were also achieved (Figures 10 and 11a). Figure 11 Post-treatment facial photographs: a: Profile; b: Frontal view; c: Smiling JO December 2012 Clinical Section Orthodontic treatment and periodontal disease 309 Figure 14 Post-treatment periapical radiographs Figure 12 Post-treatment lateral cephalogram The post-treatment facial photographs show an improvement in incisor position and a well-balanced face caused by retraction of the upper lip (Figure 11). Cephalometric analysis (Figure 12 and Table 1) shows a small increase of FMA, the reduction of ANB from 5.7 to 4.1u and both intrusion and retraction of the maxillary anterior teeth (1.NA: 41.4–23.8u; 1-NA: 10.5–6 mm). The mandibular incisors were intruded and lingually inclined (1.NB: 36.3–30.1u; 1-NB: 7.2–5.5 mm; IMPA: 107.3– 100.9u). The inter-incisal angle was improved and brought into the normal range (93.2–119.0u). The cephalometric superimposition confirmed bodily retraction, retroinclination and a 3.2-mm apex intrusion of the maxillary anterior teeth. Maxillary posterior teeth were moved distally and suffered almost no extrusion through vertical control of the dentition. Thus, the lower facial height maintained an adequate proportion, and the chin presented no retrusion, resulting in a harmonious facial result (Figure 13). The treatment results were within acceptable limits, and the patient was satisfied with the final result. Periapical and panoramic radiographs (Figures 14 and 15) showed good root parallelism and no remarkable root resorption. The LR6 showed a favourable response to the non-surgical re-treatment performed before orthodontic treatment; healing of the periapical lesion was observed. Lingual bonded retainers were placed on both the mandibular anterior teeth and the maxillary anterior teeth. After 2 years of retention, adequate occlusion was maintained as well as good plaque control and clinically healthy gingiva (Figure 16a–c). A balanced facial profile with acceptable facial aesthetics was also maintained (Figures 17 and 18). During the retention period, a root canal treatment was performed in the upper lateral incisors (Figure 19). During active orthodontic treatment and retention, probing depths and bone levels in the anterior segment on radiograph were maintained at the levels achieved after periodontal treatment. Radiographic evidence also showed significant closure of the angular infrabony defect dimensions in the lower and upper molar regions and in the maxillary incisors. Figure 13 Cephalometric superimpositions: a Total superimposition; b Maxilar superimposition; c: Mandibular superimposition (best fit) 310 Feu et al. Clinical Section JO December 2012 Figure 15 Post-treatment periapical radiograph Figure 16 Intraoral photographs two years after treatment: a: Frontal view; b: Right lateral view; c: Left lateral view; d: Upper occlusal view; e: Lower occlusal view Figure 17 Facial photographs two years after treatment: a: Profile; b: Frontal view; c: Smiling JO December 2012 Clinical Section Figure 18 Lateral cephalogram two years after treatment Discussion When inflammation is not fully controlled, orthodontic treatment may trigger inflammatory processes and accelerate the progression of periodontal destruction.12,14 Orthodontic intrusion may also shift supragingival plaque to a sub-gingival location and result in the formation of infrabony pockets.8 However, if good oral hygiene is maintained, the combination of proper orthodontic intrusion and periodontal treatment can improve the periodontal condition. Nine months of intensive periodontal treatment were performed until this patient’s disease was arrested, and the gingiva became clinically healthy. A flap clean-out surgery6 was also performed 10 days before the beginning of intrusion Orthodontic treatment and periodontal disease 311 with the modified palatal arch to avoid plaque shift. Soon after this periodontal surgery, intrusion became a more reliable therapeutic treatment that led to aesthetic improvements and helped to maintain periodontally compromised teeth.6 In addition, good oral hygiene prevented further periodontal breakdown both during and after active orthodontic treatment. To design a modified palatal arch to intrude the maxillary incisors, special biomechanical considerations must be recognized. The design depends on the number of teeth to be moved, the availability of anchorage and the desired direction and amount of tooth movement. Maxillary incisors were retracted bodily with no use of orthodontic wires by directing the force to the centre of resistance of each tooth; this retraction was possible by planning the position of the palatal brackets and the connectors placed on the palatal arch, where the NiTi pletchers would be linked. In periodontally compromised dentitions, the loss of alveolar bone means that the centre of resistance of the involved teeth moves apically.2 This movement should be evaluated using the periapical and cephalometric radiographs to determine the correct position of the centre of resistance of each tooth. This change in the centre of resistance also makes the teeth more prone to tipping than to moving bodily when full-arch mechanics are performed in these patients.2 Intra-orally, the success of this treatment protocol depends on the control of the vertical dimension through anchorage preparation to obtain genuine incisor intrusion. Anchorage was achieved with passive segmented wires from the canines to the second molars and through high-pull headgear with slight forces due to the reasonable Figure 19 Radiographs two years after treatment: a Panoramic radiograph; b: Anterior periapical radiographs and posterior interproximal radiographs 312 Feu et al. Clinical Section periodontal condition of the upper premolars and molars. In cases with very poor periodontal conditions, these movements cannot be performed because of the lack of available anchorage units. In addition, the mechanics of this treatment means that intrusion should be performed with small forces (10 g/tooth) that can be controlled by changing the width of the NiTi pletchers. Control of the vertical dimension during treatment prevented an increase in anterior facial height and promoted an acceptable gain in the horizontal mandibular dimension in response to the class II correction. The patient also showed an increase of A-point horizontally. This may have resulted from remodelling of bone at A-point after the prolonged application of a retraction force by the palatal arch near the centre of resistance of the maxillary anterior segment. In fact, the positions of points A and B are affected by alveolar bone remodelling associated with orthodontic tooth movement of the upper and lower incisors.15 It is challenging to obtain a patient’s compliance with the need to wear headgear, especially when treating adults. Therefore, not all patients can be treated with this technique. Miniscrews are also used for orthodontic anchorage to effectively intrude periodontally compromised incisors.16 Their most significant advantage is that they do not rely on the patient’s cooperation.17 Furthermore, miniscrews have been routinely used to correct periodontal malocclusions with maxillary incisor extrusion and tipping.16 There is no significant difference between the time needed to intrude teeth through the use of miniscrews or with the modified palatal arch. Both techniques require approximately 8 months17 to complete the tooth intrusion movement; this timeline assumes reliable patient cooperation when headgear is used for anchorage. In this case, the malocclusion was corrected within a short treatment time. A balanced and harmonious face was achieved with the use of this modified palatal arch combined with a traditional treatment protocol without any unwanted invasive procedures. This shows that, with patient cooperation, a traditional non-invasive treatment protocol remains an excellent and effective option. The patient’s high satisfaction was confirmed through an oral health-related quality of life questionnaire completed before and after the treatment. Clinical results (Figure 10a–c) were superior to those obtained in the diagnostic set-up (Figure 6). The amount of intrusion and bodily movement of the upper incisors was greater than expected with the use of the modified palatal arch. Thus, the upper incisor angle and the interincisal angle became more favourable and aesthetically JO December 2012 pleasing than expected. There was a need for a greater amount of stripping between the upper incisors to accommodate this movement. The overjet and overbite were also more harmonious than expected in the diagnostic set-up due to the more favourable incisor angulation. Two years after treatment, the same residual probing depth with negative bleeding on probing for each site and an enhanced bone level in the anterior segment on radiograph were maintained. Radiographic evidence of significant closure of the angular infrabony defect dimensions was also shown in the lower and upper molar regions and in the maxillary incisors, leading to a new periodontal architecture. This case supports the argument that orthodontic treatment may be used to achieve more favourable bone levels and contours around periodontally involved teeth.11 In addition, tooth realignment corrected the traumatic occlusion that could contribute to destructive periodontal disease and also facilitated oral hygiene, thus improving the patient’s chances of maintaining the reduced but otherwise healthy periodontium.3,4 Conclusions This case shows that a treatment protocol with a modified palatal arch and traditional orthodontics is a viable option in adults with severe periodontitis. If a patient requests less invasive treatment or wants to avoid surgical interventions and is willing to comply with treatment requirements, this protocol can be used to correct maxillary protrusion and achieve a balanced occlusion and a harmonious profile. Proper periodontal treatment and good oral hygiene are essential to achieve success in any treatment protocol in a patient with periodontitis. References 1. Thilander B. The role of the orthodontist in the multidisciplinary approach to periodontal therapy. Int Dem J 1986; 36: 12–17. 2. Williams S, Melsen B, Agerbaek N, Asboe V. The orthodontic treatment of malocclusion in patients with previous periodontal disease. Br J Orthod 1982; 9: 178–84. 3. Wagenberg BD, Eskow RN. Langer B. Orthodontic procedures that improve the periodontal prognosis. J Am Dent Assoc 1980; 100: 370–73. 4. Zachrisson BU. Clinical implications of recent orthodonticperiodontic research findings. Semin Orthod 1996; 2: 4–12. 5. Re S, Corrente G, Abundo R, Cardaropoli D. Orthodontic treatment in periodontally compromised patients: 12-year report. Int J Periodont Res Dent 2000; 20: 31–38. JO December 2012 Clinical Section 6. Cardaropoli D, Re S, Corrente G, Abundo R. Intrusion of migrated incisors with infrabony defects in adult periodontal patients. Am J Orthod Dentofacial Orthop 2001; 120: 671–75. 7. van Gastel J, Quirynen M, Teughels W, Carels C. The relationships between malocclusion, fixed orthodontic appliance and periodontal disease. A review of the literature. Aust Orthod 2007; 23: 121–29. 8. Ericsson I, Thilander B. Orthodontic forces and recurrence of periodontal disease. Am J Orthod 1978; 74: 41–50. 9. Boyd RL, Leggott PJ, Quinn RS, Eakle WS, Chambers DW. Periodontal implications of orthodontic treatment in adults with reduced or normal periodontal tissues versus those of adolescents. Am J Orthod Dentofacial Orthop 1989; 96: 191–98. 10. Melsen B, Agerbaek N, Markenstm G. Intrusion of incisors in adult patients with marginal bone loss. Am J Orthod Dentofacial Orthop 1989; 96: 232–41. 11. Melsen B, Agerbaek N, Eriksen J, Terp S. New attachment through periodontal treatment and orthodontic intrusion. Am J Orthod Dentofacial Orthop 1988; 94: 1104–16. Orthodontic treatment and periodontal disease 313 12. Gkantidis N, Christou P, Topouzelis N. The orthodonticperiodontic interrelationship in integrated treatment challenges: a systematic review. J Oral Rehabil 2010; 37: 377– 90. 13. Varlik SK, Demirbaş E, Orhan M. Influence of lower facial height changes on frontal facial attractiveness and perception of treatment need by lay people. Angle Orthod 2010; 80: 1159–64. 14. Bondemark I. Interdental bone changes after orthodontic treatment: a 5-year longitudinal study. Am J Orthod Dentofacial Orthop 1998; 114: 25–31. 15. Nanda R. Biomechanics and Esthetic Strategies in Clinical Orthodontics. Oxford: Elsevier, 2004, 38–73. 16. Fukunaga T, Kuroda S, Kurosaka H, Takano-Yamamoto T. Skeletal anchorage for orthodontic correction of maxillary protrusion with adult periodontitis. Angle Orthod 2005; 76: 148–55. 17. Deguchi T, Murakami T, Kuroda S, Yabuuchi T, Kamioka H, Yamamoto T. Comparison of the intrusion effects on the maxillary incisors between implant anchorage and J-hook headgear. Am J Orthod Dentofacial Orthop 2008; 133: 654– 60.