Restorative Dentistry

Adjunctive orthodontic treatment of periodontaily

involved teeth: Case reports
A-Bakr M. Rabie, MS. Cert Orth. PhD^VYti Meni: Deng. DDS. PhD PDipDS**/
Li Jian Jin. DDS. PhD, M M d S *

Elongated and spaced incisors are common in patients .suffering from severe periodontal di.wise. Intrusion and
uprighting of incisors might be the logical solution for this problem. This article describes a team appivach to
treatment planning for adult patients with .severe localized periodontitis accompanied hv marginal bone loss
and spacing and elongation of incisors. The treatment involves the combination of periodontal treatment, ortho-
dontic intrusion, and prosthetic therapy. Controlled intrusion in t\vo patients led to a decrease in the clinical
cmwn length, better access for oral hygiene procedures, better gingival form, and a more suitable distribution
of occlusatforces. (Quintessence Int 1998:27:13-19)

Key words: elongated incisors, murginal bone loss, ortliodoniii: intrusion, periodontally involved teeth.
periodotititis. spaced ineisors. team approach

O rthodontic tooth movement in periodontally

involved patients constitutes a problem distinct
from routine orthodontics.' Patients with advanced peri-
odontal disease may experience tooth migration
involving single or multiple teeth. The most common
symptoms may include tipping and extrusion of one or
several incisors and development of single or multiple
diasîemas of the anterior teeth.- Correction of these
problems demands advanced techniques and an under-
standing of the biologic situation present in those
patients.' Judicious interiiiseiplinary treaiment planning
should involve a periodontist. an orthodontist, and a
general dentist to achieve a satisfactory result. The com-
bination of periodontal treatment and orthodontic intru-
sion of elongated and migrated incisors seems to be a
necessary and benellcial pan of the total treatment plan,
provided that both the biomechanical force system and
oral hygiene are kept under control.••-"
'Assofiiilc Pr(il"cs-..'r. Dcp.irliiiL'iil nl ChiliJri;n\ IDijiiiiMrv and Orlh-
ixinmÍL-s. Faculty .il Dtnlislr>'. Univiirsily ol Hong Kon;!. Hung Kong
"-ViMiing SL-hulür, DcpíiriineTii iir Children'.s DciiUMiy ;ind
Orihiidiinlics. Faculiy iiT DL'nii^iry. Univcrsily oT Hong Koni;^
LcL-iurer. Dt-pjrliiiuni of Orlhiiilantit.s. Schim! iit" Sliimiiuilogy.
Beijing Medical LJniversiiy. Btijiny, Peoples Republic ulChinü.
'*"• Assi .Slam Prolcssiir. Dcpiinmcnl ni Periiiijonlokiçy und Public Heíillh.
Faculiy ol" Denlislry. Llmvtrsity iit Hiing Kon^, Honu Kiinj;.
Reprinl requests: Dr A. M. Ríihie. Dcparlmenl cil' Children s Denlislry
und Oriliiidonlii\s. Facully iif Denlistry. tjniversily iiT Honj; Kiin;;.
Princo Philip Dinlal Hospilill. .'4 Hospilül Road. Hung Kong. E-tiuiil:
rabie (nhkiisua.bk 11.hk
In a recent report, it was suggested that in situations
where tooth movement is indicated as an adjunct to
periodontal therapy, vigorous preparation of root sur-
laces and gingival tissues should precede placement of
the orthodontic appliance.' Deep pockets must be elimi-
nated before orthodontic treaiment is initiated, so as to
prevent apical displacement of plaque that could estab-
lish progressi\e periodontal lesions.** Results of a longi-
tudinal study of adults with reduced gingi\ al height and
a healthy periodontium showed that orthodontic treat-
ment did not result in significant further loss of attach-
ment." This finding depended on the prerequisite that
periodonial treatment was provided to arrest active dis-
ease before orthodontic treatment was begun. Further-
more, these patients received monthly reintbrccment of
plaque remoxal and also received subgingival debride-
mcnt at .1-month intervals during orthodontic treatment
to maintain healthy gingival tissues."
When periodontal treatment alone cannot correct or
control the damage produced by a pathologic occlu-
sion, then orthodontic tooth movement becomes an
important step in the overall treatment plan.'" In these
patients, orthodontic goals and mechanics must be
modified to keep orthodontic forces to an absolute
minimum.'"" This is necessary when bone has been
lost because the periodontal ligament area decreases.
and the same force against the crown produces greater
pressure in the periodontal ligament of a periodontally
compromised tooth than a normally supported one.'- '^

Quintessence International 13
Rabie et al
Fig l a Case 1. Appearanoe of a 39-year-old Ctiinese man with
adull periodontitis after initial periodontal preparation. The incisors
are spaced and extruded, and deep overbite and overjet are
present.
The aims of the present article are to illustrate and
discuss, by meatis of case reports, the interrelationship
of orthodontics, periodontics, and prosthetic dentistry to
fulfill the needs of periodontal I y involved patients and to
highlight the benefits of the team approach.
Case report.s
Case 1
A 36-year-old Chinese man presented with the chief
complaint of drifting and spacing of the maxillary
incisors (Fig la). Clinical examination revealed incom-
petent lips. Class II malocclusion, increased overjet (9
mm), and overbite (4 mm). Periodontal charting demon-
strated that probing depths ranged from 4 to 9 mm. The
mesial aspect of the ma.\illary right premolar exhibited a
probing depth of 9 mm. Radiographie examination
revealed generahzed horizontal bone loss in both arche.s.
Treatment planning involved a team that consisted
of a periodontist, an orthodontist, and a general dentist.
Treatment plan
1. Periodontal treatment: Thorough oral hygiene in-
structions, scaling, and root planing in deep pocket
sites before orthodontic treatment
2, Periodontal maintenance: Carried out during and after
orthodontic treatment
3, Orthodontie treatment: Intrusion and letroclination of
prochned and spaced maxillary incisors and intrusion
of mandibular incisors
4. Retention: Fixed lingual retainers and regular review
of the periodontal condition
14
Fig 1b Complete-mouth radiograpfiio series before orthodontic
tfierapy, revealing horizontal bone loss around one thirt) to one
half of the roof length and vertical bohe loss ai the maxillary right
iirst premolar.
5. Restorative treatment: Prosthetic replacement of
maxillary left first molar
Periodontal treatment. This patient had been under
a periodontist's care for nearly 2 years. Intensive peri-
odontal treatment involved oral hygiene instructions,
scaling, and root planing. The maxillary left second
molar was extracted because of poor response to treat-
ment. Before the commencement of the orthodontic
treatment, plaque control was good, periodontal dis-
ease was arrested, and the gingiva was clinically
healthy. No deep pockets were identified, and only a
4-mm probing depth was measured at the maxillary
right first premolar. Radiographic examination re-
vealed generalized horizontal bone loss around one
third to one half of the root (Fig lb¡.
Periodontal maintenance. Periodontal maintenance
was carried out at regular intervals during orthodontic
treatment and home care was emphasized.
Orthodontic treatment. Treatment included a fixed
appliance with bonded brackets on the first molars and
incisors. The initial leveling wire was a 0.014-inch
stainless steel arch wire with intrusion loops mesial to
the first molars. These intrusion loops were bent in
such a way that, when the wire was not engaged in the
bracket, the anterior segment of the wire rested at the
vestibule (Fig Ic). This wire is called an intrusion
arch because, when it is engaged into the incisor
brackets, it applie,s force on the teeth in an apical
direction, thus intruding the incisors (Fig i^^ .^^^
force used in this case was light and ranged |>,.,^.|j j^j
to 15 g per t o o t h , to avoid damugjj^^ ^^^
periodontium.
Fig 1c Incisor-intrusive mechanism Initial lignt leveling wires
were 2 x 4 0.014-inch stainless steel arch wire. Simultaneous
intrusion was achieved with the mesial lirsi molar omega loop.
Fig 1e Postorttioöontic appearance. The maxillary incisors have
been intruded and retracted to contact with the mandibular
incisors. Residual spaces have been eliminated by resin compos-
ite buildup ot the lateral incisors.
Residual spaces remaining after retroclination and
i n t r u s i o n of i n c i s o r s were e l i m i n a t e d by resin
composite buildup of the maxillary lateral incisors
I Fig lel-
Releiitioii. Retention was achieved with a fixed lin-
gual splint from canine to canine. Total active treatment
time was 7 months.
Restorative treatment. The patient was referred for
prosthetic replacement of missing posterior teeth.
Results. Evaluation after the orthodontic treatment
revealed satisfactory oral hygiene except for plaque
Quintessence International
Fig Id Maxillary intrusion arch wire witn a power cnain is used to
consolidatB spaces in the incisor region.
Fig I t Compiete-mouth radiographie series atter orthodontie
therapy, demonstrating positive bone remodeling around the alve-
olar orest.
accumulation at the distogingival margin of the maxil-
lary left first molar. No probing depth was in excess of 3
mm, and no further recession was noted. The clinical
crown length decreased by 0.5 to 1.0 mm. Posttreatment
radiographie evaluation revealed positive bone remodel-
ing around the alveolar crest (Eig If).
The aims of the orthodontic treatment were achieved.
The maxillary incisors were intruded and retracted and
displayed proper overjct and acceptable o\crbitc. Exam-
ination of the patient 13 tnonlhs later revealed a stable
occlusion and acceptable functional and esthetic results.
15
Rabie et a
Fig 2a Appeataiice of a 30-year-olcl Chínese woman afler inifiai
periodontal therapy Gingival recession oí the mandibular ieft
incisors is associated with antetior crossbite, and the manûibuiar
lefl incisors are mobile.
Case 2
A 27-year-old Chitiese woman presented with mild mar-
ginal gingival inflammation, limited largely to the
mandibtilar anterior teeth. Gingival receiíKion was
observed at the lahial surfaces of the mandibular
incisors, particularly the right lateral incisor (Fig 2a).
Deep probing depths were detected on tiie maxillary
right first molar, mandibular first molars, and maxil-
lary central and lateral incisors, consi.stent with a diag-
nosis of localized juvenile pcriodontitli,. This was con-
firmed in radiographie examination where marked
bone loss was evident on anterior teeth and lirsi molars
(Fig 2b). Also, a mesioden.s was observed between ihi;
maxillary iticisors.
On clinical examinatitin, a slight anterior displace-
ment of tbe mandible was detected. The displacement
was caused by an anterior crossbite of the maxillary
left central and lateral incisors. Molars and canines
exbibited Class I relationships, and space analysis
revealed excess space in both arches.
Treatment planning involved a team tbat consisted of
a periodonti.st. an orthodontist, and a general denti.sl.
Treatment pian
1. Periodonial treatment: Oral hygiene instruction,
scaling, and 'iubgingival instrutnentation
2. Periodonml maintenance; Carried out during and
after orthodontic treatmetit
3. Orthodontic treatment: Correction of anteritjr cross-
bite, alignment of anterior teeth, and elimination of
anterior tnandibuiar displacement
4. Retention: Fixed lingual retainers and regular
review of the peritjdontal condition
16
Fig 2b CoiT.plete-tTioulh radiographie series belore orihodontic
therapy. Note the spacing of the teelh, horizontal bone loss
around one third to one half of the root length, and vertical bone
ioss at the mandibuiar incisors and first moiars.
5, Prosthetic treatment: Porceiain veneers to improve
the esthetics of the maxillary incisors
Periodontal treatment. The patient was tinder the
periodontisi's care lor 2 years for management of her
localized juvenile periodontiiis. Before the start of
ortbodontic treatment, the oral hygiene status was well
maintained and the gingival condition was registered as
sound with no bleeding on probing. Gingival recession
was evident at the mandibttlar incisors. Probing depths
measured 4 to 5 mm at the po.sterior teetb. Generalized
horizontal bone loss around one tbird to one ball' the
root lengtb was evident. Mild tootb mobility was detect-
ed at the maxillary incisor region, and severe tootb
mobility was noted at the mandibular incisor region.
Periodontal maintenance. Tbrougbout the ortbodon-
tic treatment period, ilie patient was under regular peri-
odontal care and underwent subgingival curettage wben
it was considered necessary.
Ortliodontic treatment. Treatment included the use
of fixed appliances with bonded brackets on the second
molars and ineisors. The tnitial wires were 0.014-inch
stainles.s steel arch wire, used for leveling and aligning
tbe incisors. The mandibular incisors wete retracted on
a rectangular wire with a closing loop distal to the right
lateral incisor ¡Fig 2c). The use of rectangular wire with
added lingual root torque prevented the retroclination of
the mandibular incisors during space closure. Closure ol'
the spaces in ihe mandibular anterior region resulted in
positive overjet (Fig 2c). which led to the elimination of
the traumatic occlusion.
Retention. Retention was achieved with a fixed lin-
gual splint from canine to canine. Total active fixed
appliance therapy was 12 months.
Volume 29, Number i

Fig 2c Brackets bonded on the second molars and inciso's.
Initial lighi leveling wnes were 2 x 4 0 014-inch stainless sleel arch
wire to derotate the maxillary lelt central incisor, redistribute space
lor orown buildup, and correct the anterior crossbite In Ihe linal
leveling stage, in the mandible, the first molars were bonded and
2 x 6 0.016 X 0022-inch TMA rectangular arch wire with closing
loop, step ups/step downs, and lingual root torque was used to
close spaoe and upright and intrude the inoisors.
Fig 2d Appearance alter orlhodontic treatment Note the esthet-
ic appearance ol the porcelain veneers lor the maxillary inoiscrs
Restorative treatment. Porcelaiti veneers were used
to build up ihe size of the maxillary lulerui iticisors and
improve the esthetics ot the central inci,sor,s (Fig 2d).
Results. Evulttatioti after urlhodontic treatment
revealed tio increase in probing depth and no increase in
gingival recession. The hone remained at pretreatment
levels (Fig 2e). The orthodotitif goals and objectives
were achieved, beeause the crossbite was eliminated
and the overjet and overbite were corrected. Porcelain
veneers on the tnaxillary ineisors improved esthetics
and triLisked the residual spaces produced as a result ol
small maxillary lateral incisors.
Discussion
This paper describes a team approach toward treatment
planning tor adult patients with severe localized peri-
odontitis accompanied by marginal bone loss and spac-
ing and elongation ol" the incisors. The relationship
Ouintessenoe International
Rabie et al
Fig 2e Cornpiete-mouin raüioyraphic series aitei orifiooontic
therapy The bone remained at pretieatment levels.
between periodontal disease and maioeelusion has been
a controversial subject. Tooth ma!po,sitioning has been
recognized as both an etiologic factor contributing to
periodontal destruction as well as a result of chronic
destructive periodontal disease.'•* Malposed or rotated
teeth may be predisposed to more rapid breakdown of
tbe periodontium when the roots are too close to one
another, resulting in a thin interproximal septum.^
Klassman and Zaeher" reported that correction of the.se
malposed teeth may be therapeutic and/or prophylactic.
At the present titne. there ha\e been no significant
studies tbat confirm a definite relationsbip between mal-
occlusion and periodontal disease,'"'' On the contrary.
the consensus of the majority of studies i,s that tbere is
no relation between various types of malocclusion and
periodontal diseases.'-"''" In a study of IÍÍ8 persons with
periodontal di.sease, no relationship was found between
periodontal di.sease and Angle's classification, overbile.
overjet. open bite, rotation, or inclination of the man-
Rabie et al
dibniar incisors. Grewe and associates'" reported thai
plaque retention based on oral hygiene habits may be
the major lactcn- in periodontal disease, while irregular-
ities of tooth position may play another minor compli-
cating role.
The only exceptions to this appear to be extremely
severe overbite, in which there is direct impingement ol
the teeth on the soft tissues, and localized crossbite with
traumatic oeclusion.'" The patient in case 2 exhibited the
destructive effects of traumatic occlusion, caused by
localized crossbite, on ihe periodonial supporting struc-
ture (see Figs 2a and 2b). Gingival recession and mobili-
ty affecting isolated mandibular incisors are not uncom-
mon in association with lingually positioned incisors.-"
In such cases, the risk of accelerated loss of attachment
appears likely.-" Beeause traumatic occlusion may have
been a predisposing factor for the gingival recessiím and
mobility of the mandibular incisors of the patient in case
2, elimination of the anicrior crossbite became a major
objective of the treatment planning.
This type of orthodontic ireatment is considered
adjunctive orthodontic treatment.' By definition, it is
tooth movement carried out to facilitate other dental pro-
cedures necessary to control disease and restore func-
tion.' During the treatment planning for this adjunctive
orthodontic treatment, special biomechanical considera-
tions were emphasized. The design of the appliance used
depended on ihe number of teeth to be moved, the avail-
ability of anchorage, and the desired direction and
amount of crown or tooth movement.' Thus in case 2.
fixed appliances were used only on the maxillary and
mandibular incisors and second molars. Second molars
were used as anchorage units instead of first molars
because of the poor periodontal condition of the latter.
Mandibular incisors were retracted bodily on rectangular
wires to prevent lingual tipping of the crowns while ihe
roots were being moved lingually.
It has been proposed that orthodontic treatmeni may
be used to attain more favorable bone levels and con-
tours around periodontally involved teeth.^'•' Kessler'-'
propased that changes in osseous topography could be
accomplished by moving teeth into an area of the arch
that has a greater volume of bone and by repositioning
periodontally involved anterior teeth.
On the one hand, traumatic occlusion may con-
tribute to destructive periodontal disease, but. on ihe
other hand, advanced periodontal disease with the los.s
of periodontal supporting structure can cause migra-
tion, extrusion, flaring, and loss of teeth,'-' This is
because a secondary occiusal trauma may further com-
plicate an already difficult problem. This pattern of
occlusion was manifested by the patienl in case I. The
patient presented with the chief complaint of migration
18
of his teeih with resultani spaces. The same biome-
chanical considerations discussed earlier were imple-
mented for this patient. Fixed appliance therapy was
limited to tbe incisors and tbe first molars. Buccal seg-
ments were not involved in the fixed appliance therapy
because of their poor periodontal condition.
Orthodontic treatment resulted in successful intrusioti
and space closure. Meisen et aP*' concluded that intru-
sion of incisors in adult patients with marginal bone
ioss offers a beneficial effect on the periodonta! condi-
tion at the clinical and radiographie levels. Sueh a
result was seen in Case I, where Fig I f demonstrates
positive bone remodeling when compared to pretreat-
ment radiographs IKig lb).
Summary
The efficacy of intrusion and uprighting of pathologi-
cally migrated anterior teeth with deep overbite and an
anterior crossbite has been discussed. Intrusion is a
reliable therapeutic meihod for orthodontic treatment
of periodontally involved palients. A multidisciplinary
approach can better serve the needs of periodontally
involved patients with malposed teeth.
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Con ten fï I Acute Inflammatory Process

Vascular Response to Injury
Chemical Mediators of the Vascular
Response
The Blood Leukocytes
Systemic Manifestations of Intlamrnation
II Immunity
The Immune System
Hypersensitivity Reactions
Chronic Intlammatory Processes
III Repair of Host Tissues
Healing
IV Application of Basic Principles
Clinical Connections

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