8522
Indian Journal of Forensic Medicine & Toxicology, October-December 2020, Vol. 14, No. 4
Ortho-Perio Continuum: An Interdisciplinary Approach
Swati Punyatoya1, Saurav Panda2, Rinkee Mohanty3, Rashmita Nayak4,
Anurag Satpathy4, Abhaya Chandra Das2, Manoj Kumar2
1
Intern, 2Reader, 3Professor & Head, 4Professor, Department of Periodontics and Oral Implantology, Institute of
Dental Sciences, Siksha O Anusandhan (Deemed to be University), Bhubaneswar-751003, Odisha, India
Abstract
Orthodontic therapy is a combination of process which is related to move the malalligned teeth by correcting
its position. There have been many dental cases where orthodontic tooth movement is assisted by periodontal
therapy and also the periodontal condition is improved by orthodontic therapy. This interdisciplinary
approach is a symbiotic relation between the two. This review highlights the various orthodontic therapies
requiring periodontal therapy for better outcome and vice-versa. Harmonious cooperation between the
periodontist and orthodontist would provide satisfactory outcome for the combined orthodontic periodontal
problems. The knowledge of this approach in the field of dentistry would help clinicians’ decide a better
outcome in patient’s favour.
Keywords: Orthodontic Therapy; Malalligned Teeth; Periodontal Therapy; Interdisciplinary Approach.
Introduction
In the different branches of dentistry, co-ordination
and co-operation among them is very important. It will
not only help to get a spectacular idea about the diagnostic
procedures but also make the treatments easier. This type
of interrelated relationship exists between Orthodontics
and Periodontics. Basically, this is a symbiosis type of
relationship where the treatment procedures of both the
branches are interrelated. There have been many dental
cases where orthodontic tooth movement is assisted by
periodontal therapy and also the periodontal condition is
improved by orthodontic therapy. Orthodontic therapy
is a combination of process which are related to move
the malalligned teeth by correcting its position. It is
shown that patients who are under orthodontic treatment
are more susceptible to develop plaque on their teeth
surfaces. It is due to several orthodontic appliances,
Corresponding Author:
Dr. Saurav Panda
Associate Professor, Department of Periodontics
and Oral Implantology, Institute of Dental Sciences,
Siksha O Anusandhan (Deemed to beUniversity),
Bhubaneswar: 751003, Odisha, India
e-mail : drsaurav87@gmail.com
brackets, wires and elements which are present on the
teeth surfaces. Because of the such elements, the oral
hygiene procedures might be more difficult. It may also
cause several compilations liketooth decalcification,
tooth discoloration, tooth devitalization, rootresorption,
gingival recession, pain, TMJ dysfunction, periodontal
problems, loss of enamel, dental caries, many types of
psychological compilations and allergic reactions also.
Out of all above complication, periodontal problems
are the most common in nature and also need proper
consideration. Despite all these, orthodontic treatment
sometimes is very helpful in increasing the periodontal
status. So,the periodontal conditions in which orthodontic
treatment is necessary should be given some special
importance at the time of interdisciplinary approach in
both the ways.
Adverse effectsof
periodontium
orthodontic
therapy
on
Orthodontic therapy may hinder the complete
procedure of oral hygiene. So, improper oral hygiene
creates feasibility of change of the subgingival plaque
to a much more aggressive periopathogenic flora. But it
can be reduced by appropriate plaque control method.
So, patients having healthy periodontium can undergo
for orthodontic treatments without infuriating the
periodontal condition.
Indian Journal of Forensic Medicine & Toxicology, October-December 2020, Vol. 14, No. 4
Orthodontic therapy produces several periodontal
complications which includes; gingivitis, periodontitis,
alveolar bone loss, gingival recession, tooth mobility,
black triangles, periodontal pocket fenestration and
dehiscence(1,2).
There are many ortho-dental cases which show the
presence of various types of bacteria in the dental plaques
of the patients who are undergoing orthodontic therapy.
Some of such bacteria are spirochetes, intermedius,
motile rods, B. forsythus T.denticola, P.nigrescens,
C.rectus and fusiform bacteria.(3) Most of the cases show
the development of gingival recession during or after
the orthodontic treatment. This type of development of
gingival recession coursesmany clinical problems. Most
of the gingival recessions which develop during the
orthodontic treatment had been shown to occur in the
upper and lower anterior teeth regions. According to a
study made by Steiner and his colleagues, the gingival
recessions occurring after the orthodontic treatment are
moretends to occur in the areas with thin underlying
bony structure and thin keratinized gingiva.(4)
Periodontal conditions which require orthodontic
treatment includes: Gummy smile, Midline diastema &
correction of black triangles,Pathological migration with
infrabony defects, Tilted molars, and Gingival margin
discrepancies etc.
Orthodontic treatment as an adjunct to
periodontal therapy: There is a strong correlation
between the periodontal disorder and malposed teeth in
the dental arch. The correction of the malposed teeth can
eliminate any harmful occlusal interference which may
prevent plaque accumulation and provide a better oral
hygiene procedure. It may offer a great opportunity for
the development of a good periodontal health.
Generally, during orthodontic tooth movement, the
entire periodontal attachment apparatus, including the
bony structure, periodontal ligament, and soft tissue
components move along with the tooth. Brown made
a study on the influence of uprighting of molars on
the periodontium in four patients. After 7 months of
treatment, the associated pocketing at uprighted molars
had 2.5mm more pocket depth reduction than the control
tooth.(5)
A clinical study was done on orthodontically treated
patients having intact periodontium. It concluded that
extrusion of mandibular incisors resulted in displacement
of the mucogingival junction and the gingival margin
8523
by 52.5% and 80%,respectively, of the total amount of
extrusion.(6) There are some cases where movement of
attachment and margin of bone along with the tooth is
not advisable as in crown-root fractures. In such cases,
periodical circumferential supracrestalfiberotomy is
needed. It should be done at the start and every 2 weeks
during orthodontic extrusion. It has been suggested that
orthodontic tooth movement into infrabony defects can
result in healing and regeneration of the tooth attachment
apparatus.
Periodontal therapy as an adjunct to orthodontic
therapy: The aim of orthodontic treatment is to achieve
a good occlusal relation, maintain a healthy periodontal
status and to improve dental and facial aesthetics and
also function. For the success of any orthodontic
treatment, health of the periodontium is an important
factor. So good periodontal health should be maintained
not only before but also during and after the orthodontic
treatment. Appropriate orthodontic forces do not produce
any damage to the periodontium. There is different
periodontal treatment which are used as adjuncts to
orthodontic therapy.
Pre-orthodontic gingival surgery: It is seen that
insufficient width of attached gingiva prevents plaque
control and develops gingival recession. The denuded
area extending through the marginal bone is known as
‘dehiscence’ which is a risk factor for the development
of gingival recession. So, it is necessary to maintain the
adequate width of attached gingiva. An attached gingiva
with 2mm of width, is appropriate in maintaining a proper
gingival health.(7) There are different mucogingival
surgeries such as free gingival autograft, connective
tissue gingival graft, apically repositioned graft and
modified apically repositioned flap can be utilized for
augmenting the width of attached gingiva. Among these
techniques ‘Modified apically repositioned flap (MARF)
is a simple and less time-consuming procedure.
Fiberotomy: Elastic fibers,collagen fibers and
the periodontal ligament are re-organized by several
orthodontic tooth movements inorder to accommodate
the re-established tooth positions. The teeth must be
retained in the new positions to prevent orthodontic
relapse and to achieve proper rearrangement of the
supporting tissues. Supracrestal fiberotomy is usually
performed to correct the relapse of tooth rotation
corrected by orthodontic treatment. It is done before the
removal of orthodontic appliances i.e. towards the end of
the active orthodontic therapy.
8524
Indian Journal of Forensic Medicine & Toxicology, October-December 2020, Vol. 14, No. 4
Frenectomy and frenotomy: Abnormal frenum
attachment is a potent aetiological factor for the
development of midline diastema. By frenectomy
incision and relocation of frenal attachment is done.
Frenectomy is the complete excision of the frenum
along with its attachments to the underlying bone. It
can be done by either conventional scalpel technique,
electrosurgery or by using lasers.(8)
Crown lengthening: It is a surgical procedure which
is used to extend the supragingival tooth structure for
aesthetic or restorative purposes either by the method of
positioning the gingival margin apically, removing the
supportive bones or by both of these.(9) It is necessary if
there is not enough of clinical crown height. It reduces
gum tissue and shaves bone down when required.
The procedure usually performed by gingivectomy
or an apically repositioned flap in combination with
gingivectomy prior to orthodontic bonding procedures.(3)
It can be done to prevent gummy smile in which gums
are visible above the teeth while smiling.
Preorthodontic osseous surgery: It is mainly
indicated for different types of defects such as; hemiseptal
defect, three-walled defect,osseous crater and furcation
involvement etc.
Missing interdental papilla are usually known as
gingival “black holes”. It may be due to a number of factors
such as over-divergence of adjacent roots and advanced
periodontal disease with loss interdental alveolar crest.
An orthodontic periodontic interdisciplinary approach is
usually advised to manage these problems.
Periodontally
accelerated
osteogenic
orthodontics: This technique was developed by Dr
Thomas Wilcko and Dr William Wilcko.(10) It is
also known as alveolar osteogenic orthodontics or
Wilkodontics. This procedure can be used as an adjunct
to conventional approaches to accelerate orthodontic
tooth movement. Basically this is a clinical procedure
that combines alveolar augmentation and selective
decortication facilitated orthodontic technique.(10)
Theoretically it is a procedure which is based on the
bone healing pattern in corticotomy regions known
as the “Regional Acceleratory Phenomenon (RAP)”.
RAP was first described by Frost in 1993.(10) Regional
acceleratory phenomenon is a localized tissue reaction to
noxious stimulus. It accelerates the healing efficiencies
of the affected tissues 2-10 times faster than normal
physiologic healing process.(11,12) This is usually seen in
osteotomy sites, fracture sites or bone grafting areas but
mainly seen in fracture sites.(13) The two main features
of RAP in bone healing which are believed to improve
orthodontic treatment are; decreased regional bone
density, accelerated bone turnover.(10) It mainly focuses
on enhancing the manner in which the periodontium
responds to applied forces and on providing for more
intact periodontium and increased alveolar volume
to support the teeth and overlying soft tissues during
retention. The procedure for the PAOO technique is
portrayed in Figure 1-6.
Advantages:
•
Increases alveolar bone width
•
Reduced treatment time to 1/3rd to 1/4th of
conventional procedure
•
Less root resorption
•
Improved periodontal support
•
Less chance of relapse
•
Alveolar grafting also benefits patients by repairing
bony dehiscence and fenestrations.
Disadvantages:
•
Not applicable to all cases
•
Costly procedure
•
Post-surgical crestal bone loss and recession may
occur
•
Sometimes there is occurrence of pain and swelling
•
Not suitable for patient who take NSAIDS o regular
basis or patient having other chronic health problems
Applications:
•
Resolve crowding
•
Accelerate
extraction
•
Facilitate slow orthodontic expansion
•
Manipulation of anchorage
•
Molar intrusion and open bite correction
canine
retraction
after
premolar
Indian Journal of Forensic Medicine & Toxicology, October-December 2020, Vol. 14, No. 4
Figure 1: Pre-operative photograph
Figure 2: Orthodontic brackets placed
Figure 3: Interdental vertical cuts given
Figure 5: Interrupted sutures placed
Different studies on orthodontic periodontal
interrelationship: Generally, the main reasons routinely
cited to justify the provision of orthodontic treatment are
important of dental and facial aesthetic and of dental
function and health. Following are some of the studies
regarding orthodontic periodontal interrelationship.
A research on correlation between periodontal
health and malocclusion was conducted by Ngom and
co-workers.(14) According to them malocclusions are the
risk factors for periodontal diseases. But in this study
the real conclusion about the cause or effect relationship
between periodontal condition and malocclusion was
not possible.
Van Gastel(15) conducted a review of literature
which showed contradictory findings on the effect
of malocclusion and orthodontic appliances on the
8525
Figure 4:Bone grafts placed
Figure 6: Palatal View
periodontal health. Dental plaque is the primary cause of
gingival inflammation and periodontitis. There are some
studies reported loss of attachment during orthodontic
therapy.
Two systemic reviews were conducted by Bollen(16)
to know whether the malocclusion and orthodontic
treatment affect the periodontal health or not. The first
one suggested that person having greater malocclusion
will have more periodontal problem. It may depend on
oral health status. The second one showed that there
is no reliable evidence on the effect of the orthodontic
treatment on the periodontal health.
A systemic literature review was conducted by Gray
and McIntyre(17) to determine the effect of Oral Health
Promotion (OHP) upon gingival health. They concluded
that an OHP for patients undergoing fixed appliances
8526
Indian Journal of Forensic Medicine & Toxicology, October-December 2020, Vol. 14, No. 4
orthodontic treatment produces a short–term reduction
(up to 5 months) in plaque and improvement in gingival
health. There are no specific oral health promotion
method that can produce a greater short-term benefit to
periodontal health during fixed orthodontic treatment.
Conclusion
Healthy periodontium is required for all types of
dental treatment, mostly for orthodontic treatment.
Orthodontic therapy has both beneficial and harmful
effects on periodontium. For adult patients, combined
orthodontic and periodontal treatment is required,who
are seeking orthodontic treatment for aesthetic
correction. Orthodontic treatment cannot be performed
on periodontally compromised conditions. In such
conditions regular follow up is required to check the
periodontal status. Harmonious cooperation between
the periodontist and orthodontist provides a satisfactory
outcome for the combined orthodontic periodontal
problems.
Conflict of Interests: None
Erkan M, Pikdoken L, Usumez S. Gingival
response to mandibular incisor intrusion. Am J
Orthod Dentofacial Orthop. 2007 Aug 1;132(2):
143.e9-143.e13.
7.
Lang NP, Löe H. The relationship between the
width of keratinized gingiva and gingival health. J
Periodontol. 1972 Oct;43(10):623–7.
8.
Devishree, Gujjari SK, Shubhashini PV.
Frenectomy: A Review with the Reports of
Surgical Techniques. J Clin Diagn Res JCDR. 2012
Nov;6(9):1587–92.
9.
Glossary of Periodontal Terms 2001 Edition.
pdf [Internet]. [cited 2020 Feb 9]. Available
from:
https://www.perio.org/sites/default/
files/files/PDFs/Clinical%20Resources/
GlossaryOfPeriodontalTerms2001Edition.pdf
10. Amit G, JPS K, Pankaj B, Suchinder S, Parul B.
Periodontally accelerated osteogenic orthodontics
(PAOO) - a review. J Clin Exp Dent. 2012 Dec
1;4(5): e292–6.
11. Verna C. Regional Acceleratory Phenomenon.
Front Oral Biol. 2016; 18:28–35.
Funding: Nil
12. Shenava S, Nayak USK, Bhaskar V, Nayak A.
Accelerated Orthodontics – A Review. 2014;1(5):5.
Alfuriji S, Alhazmi N, Alhamlan N, Al-Ehaideb
A, Alruwaithi M, Alkatheeri N, et al. The Effect
of Orthodontic Therapy on Periodontal Health:
A Review of the Literature [Internet]. Vol. 2014,
International Journal of Dentistry. Hindawi;
2014 [cited 2020 Apr 6]. p. e585048. Available
from:
https://www.hindawi.com/journals/
ijd/2014/585048/
2.
Turki
MA
Alsubaie
AA.
Ortho-perio
interrelationship. INDO Am J Pharm Sci. 2018 Dec
18;05(12):16359–64.
3.
Ahad M, Shafi M, Bhat MYS, Lanker F. Perioortho interrelationship: A Review. Sch J Appl Med
Sci. 2016 Jun;4(6):2238–43.
4.
Steiner GG, Pearson JK, Ainamo J. Changes of
the marginal periodontium as a result of labial
tooth movement in monkeys. J Periodontol. 1981
Jun;52(6):314–20.
5.
6.
Ethical Permission: Approved
References
1.
findings. J Periodontol. 1973 Dec;44(12):742–56.
Brown IS. The effect of orthodontic therapy on
certain types of periodontal defects. I. Clinical
13. Harshita N, Kamath DG, Kadakampally D. PerioOrtho Interactions-A Review. J Pharm Sci. 2018;
10:4.
14. Ngom PI, Diagne F, Benoist HM, Thiam F. Intraarch
and Interarch Relationships of the Anterior Teeth
and Periodontal Conditions. Angle Orthod. 2006
Mar 1;76(2):236–42.
15. van Gastel J, Quirynen M, Teughels W, Carels
C. The relationships between malocclusion, fixed
orthodontic appliances and periodontal disease.
A review of the literature. Aust Orthod J. 2007
Nov;23(2):121–9.
16. Bollen A-M. Effects of malocclusions and
orthodontics on periodontal health: evidence
from a systematic review. J Dent Educ. 2008
Aug;72(8):912–8.
17. Gray D, McIntyre G. Does oral health promotion
influence the oral hygiene and gingival health of
patients undergoing fixed appliance orthodontic
treatment? A systematic literature review. J Orthod.
2008 Dec;35(4):262–9.