Download Orthodontic treatment in the severely compromised periodontal patient

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
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Feu et al.
Figure 1
Clinical Section
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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
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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
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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
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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
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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
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Feu et al.
Clinical Section
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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
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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)
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Feu et al.
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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
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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
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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.
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