Periodontal Changes in Ortho Treatment / Orthodontic Courses by Indian Dental Academy

Periodontal changes in
orthodontic treatment
INDIAN DENTAL ACADEMY

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Introduction
The goal of orthodontic treatment is not only to improve
facial esthetics and function but also to address to the
health of supporting structures and how teeth are placed in
them. No matter how talented the orthodontist is, a
magnificent orthodontic correction can be destroyed by
failure to recognize periodontal susceptibility.

Both the short and long term successful outcomes of
orthodontic treatment are influenced by the patients
periodontal status before, during and after active orthodontic
therapy, which also includes post treatment maintenance by
the patient.
Periodontal pathogenesis is a multifactorial etiologic
process and the orthodontist must recognize the clinical
forms of inflammatory periodontal diseases.

Co-operation between different specialties in dentistry is
extremely important in establishing diagnosis as well as in
treatment planning. One such interaction exists between
orthodontics and periodontics.

The interrelationship between orthodontics and
periodontics often resembles symbiosis. In many cases,
periodontal health is improved by orthodontic tooth
movement, whereas orthodontic tooth movement is often
facilitated by periodontal therapy.
GINGIVAL AND PERIODONTAL
PROBLEMS
GINGIVITIS
Accumulation of microorganisms
around teeth can cause gingival
redness, bleeding and edema,
changes in gingival morphology,
reduced tissue adaptation to the teeth,
an increase in the flow of crevicular
fluid and other clinical signs of
inflammation. Mechanical removal of
plaque reduces gingivitis. Removal of
supragingival plaque has been shown
to have an inhibitory effect on the
formation of subgingival plaque.

Gingivitis has been classified as the
1. Initial
2. Early and
3. Established lesions.

Only the established lesion can be observed as clinical
gingivitis. The important point is that alveolar bone loss has
not yet occurred and it is hoped that the lesion can be
prevented from spreading onto the surrounding structures.
It is therefore crucial to determine the appropriate plaque
control intervals for the patient which will prevent bone
loss. Pseudo pockets or gingival overgrowth or
enlargement of the gingival margin and the papilla, whether
it is drug induced or primary plaque related, are
exacerbated by poor hygiene.

The risk factors for development of gingivitis include
uncontrolled diabetes, pregnancy, systemic illness and
poor oral hygiene. Malaligned teeth, rough edges of
fillings, unclean oral appliances can irritate the gingiva and
increase the risk of gingivitis.

Prevention
Good oral hygiene is the best prevention against gingivitis
because it removes the plaque that causes the disorder.
Special appliances and tools may include tooth picks,
tooth brushes, flossing techniques, water irrigation or other
devices.
PERIODONTITIS:
Periodontitis has been defined as an inflammatory disease of
specific bacterial origin that progresses with episodic attachment
loss of the periodontium. Adult periodontitis is the most common
form of Periodontitis. The organisms most often reported to be
associated with adult periodontitis are porphyomonas gingivalis,
prevotella intermedia and bacteroides forsythus.

Prepubertal periodontitis: It is a rare form that appears soon
after eruption of primary teeth. It can occur in either the localized
or the generalized form.
Localized or generalized juvenile Periodontitis:
It occurs in the circumpubertal period. These patients have little
plaque and calculus and they respond well to local debridement
and supplemental tetracycline therapy. Juvenile periodontitis is
characterized by a rapid loss of alveolar bone and periodontal
attachment in otherwise healthy adolescents, with onset thought
to occur after puberty. It is generally localized to the permanent
first molars and incisors, with little gingival inflammation. The
correction of malocclusion in juvenile Periodontitis patients after
periodontal therapy is a problem if increasing clinical concern,
since many teeth with severe alveolar bone loss in these patients
can now be treated successfully without extractions.
A general consensus exists that orthodontic treatment has the
potential to aggravate preexisting plaque induced periodontal
diseases and cause further loss of alveolar bone and
attachment. However, it has been demonstrated that if excellent
plaque control is achieved during orthodontic treatment,
including uprighting and intrusion procedures, then periodontally
compromised teeth can be successfully repositioned without
further loss of periodontal attachment.

The orthodontic patient may be at a greater risk of attachment
loss after teeth have become mobile because of tooth
movement.

The clinical signs of inflammation and tooth mobility must be
recognized and controlled during treatment to prevent extensive
bone loss.

Periodic monitoring of the periodontal status with
probing, microbiologic assessment with
immunologic assays, DNA probes and culturing as
well as clinical findings are useful in determining
scaling intervals, and detecting potential sites for
increased risk of attachment loss. These methods
may be used to assess the endpoint of the
effectiveness of scaling and root planing before
orthodontic treatment to ensure that no putative
pathogen exists.
Rapidly progressive periodontitis:
This occurs commonly in young adults, and the cause of
pathogenesis appears to share many of the features of
generalized juvenile periodontitis, such as rapid bone loss
and depressed neutrophil functions.

Refractory periodontitis:
This is a disease condition used to define sites present in
patients who continue to be infected with periodontal
pathogens and who have a high rate of loss of attachment
and tooth loss, despite intensive treatment to prevent bone
loss.

Periodontitis associated with systemic diseases:
Necrotizing ulcerative periodontitis
AIDS associated
Non AIDS associated
Disorders of neutrophil function
Agranulocytosis
Cyclic Neutropenia
Chediak higashi syndrome
other diseases
Hematologic diseases
Leukemia
Anemia
Histiocytosis X
Metabolic diseases
Gauchers disease
Niemann-pick disease
Connective tissue disorders
Ehler-danlos syndrome
Wegeners granulomatosis
Sarcoidosis
Bone diseases
Hypophophatasia
Pagets disease
Neoplasms
Benign tumors
Malignant tumors
Basic tooth movements and periodontal changes:
Orthodontic treatment is based on the premise that when force is
applied to a tooth it is transmitted to the adjacent investing
tissues, certain structural alterations take place within these
tissues which allow for, and contribute to tooth movement.

INTRUSION
Intrusion alters the cemento-enamel junction and angular crest
relationships, and creates only epithelial root attachment:
therefore a periodontally susceptible patient is at greater risk of
future periodontal breakdown. Tooth movement, when properly
executed, improves periodontal condition and is beneficial to
periodontal health. Orthodontic forces, when kept within biological
limits, do not induce tissue alterations leading to loss of
connective tissue attachment and periodontal pocket formation.
The gingiva moves in the same direction as that of tooth intrusion
but it moves only by about 60%. Gingival sulcus gets deepened
by about 40% of tooth intrusion.
Indications:
1.It is indicated for teeth with horizontal bone loss.
2.For increasing the clinical crown length of single teeth

Clark in AJO 1991 studied the effect of intrusion on the micro
vascular bed and fenestrae in the apical periodontal ligament of
rat molar. They found that the decrease in fenestrae numbers
per sq.micrometer of endothelium was most marked in the
venous capillaries. With intrusive loading, the small arterial
fenestrae population was unchanged.

Melsen et al in AJO 1989 found that incisor intrusion in adult
patients with marginal bone loss had a beneficial effect where
the post treatment radiographs showed positive bone
remodeling. They also reported that a new connective tissue
attachment can be formed during the intrusion of periodontally
involved teeth if gingival inflammation is eliminated and root
surfaces are adequately scaled.
Ericsson et al (journal of
periodontics 1987) have
demonstrated in experimental
animals that orthodontic intrusion
of teeth can shift supragingivally
located plaque to a subgingival
location, leading to formation of
infrabony pockets and loss of
connective tissue attachment.
These manifestations appear to be
related to the increased
accumulation of dental plaque
around orthodontic appliances and
alterations induced in the
microbiological composition of
subgingival plaque.
Zachrisson et al in measured the gingival pocket depth during
treatment and retention in orthodontic patients treated with
edgewise appliance and found that pocket depth increased
during tooth movement. They reported that the increase was
caused by edematous swelling in the gingiva and by tissue
accumulation during tooth movement, not by deepening of the
pocket. They found that gingival sulcus deepened with tooth
intrusion and the dentoperiosteal fibers and dentogingival fibers
were parted from the cementum gradually as the tooth intrusion
increased.

Melsen et al in AJO 1986 studied the tissue reaction related to
orthodontic intrusion of teeth and the influence of oral hygiene on
this reaction. They found that alveolar bone height was
maintained during intrusion. Intrusion can therefore constitute a
reliable therapeutic method in the orthodontic treatment of adult
patients with a healthy periodontal condition. Intrusion of teeth
does not result in a decrease in marginal bone level in
periodontally healthy patients provided gingival inflammation is
controlled.


Since orthodontic movement of teeth
into inflamed infrabony pockets may
create an additional periodontal
destruction, and because infrabony
pockets are frequently found at teeth
that have been tipped or elongated
as a result of periodontal disease, it
is essential that periodontal
treatment with elimination of the
plaque induced lesion be performed
before the initiation of orthodontic
treatment. Maintenance of excellent
oral hygiene during the course of
treatment is equally important.
EXTRUSION

Extrusion or eruption of a tooth or several teeth, along with
reduction of the clinical crown height is reported to reduce
infrabony defects and decrease pocket depth even causes
formation of new bone at the alveolar crest as the tooth erupts,
with no occlusal factor present.

Raymond yukna et al in AJO 1985 in animal experiments
studied the effects of extrusion of single rooted teeth with
advanced periodontal disease. Extruded teeth had shallower
pocket depths, less gingival inflammation, and no bleeding on
probing. Early in the extrusion process, the teeth appeared to be
avulsed, with more than three fourths of the root coronal to the
alveolar crest. After stabilization, approximately 2 mm of new
bone was seen coronal to the original alveolar crest, and the
periapical areas had filled in with bone. The extruded teeth had
an intact attachment apparatus.
The improved periodontal condition resulting from extrusion
may have been due to both physiologic and microbiologic
changes in the local environment. The subgingival microbial
plaque may have been converted to a supragingival plaque by
the extrusive tooth movement, thereby lessening its
pathogenicity and effect on gingival tissues. This is the reverse
finding of Ericsson et al who reported that orthodontic
treatment which involves intrusion of a tooth in a plaque
infected dentition may shift a supragingivally located plaque
into a subgingival location.

Marc et al in J. of periodontology 2000 studied the
periodontal health of orthodontically extruded impacted teeth.
Most impacted teeth were extruded after minor periodontal
surgery. They found no difference between test and control
teeth, except gingival width, which was 1 mm larger for the
spontaneously erupted teeth. This study demonstrated that
orthodontic extrusion of impacted teeth does not jeopardize
their periodontal health
FORCED ERUPTION:
It helps to save an isolated tooth in which caries, trauma, or
iatrogenesis have destroyed the clinical crown by bringing the
fractured, diseased or prepared margins of the neck of the
tooth more coronally to reestablish biological width.
Although forced eruption is associated with an increase in the
width of attached gingiva, mucogingival junction remains
unaltered.
Fibrotomy, which is done before active eruption, is essential
for success of the procedure.
For shallowing out of isolated intraosseous defects.
Increase clinical crown length of single teeth.

Forced eruption was first introduced by Ingber in 1974 for the
treatment of one walled and two walled defects. Extrusion
results in a coronal position of the connective tissue attachment
and the bony defect are shallowed out. Because of extrusion,
the tooth is in supraocclusion and will need to be shortened.
During the elimination of an intraosseous defect by means of
extrusion, the relationship between CEJ and the crest of alveolar
bone is maintained. When the goal of treatment is to extrude the
tooth out of periodontium as required during crown fractures,
extrusion has to be combined with fibrotomy.

The supporting soft tissue structures will also follow the bone
during extrusion without fibrotomy. Kajiyama et al in AJO 1993
found that in experimental animals, the free gingiva moved
about 90% and the attached gingiva about 80% of the extruded
distance. The width of the attached gingiva and the clinical
crown length increased significantly whereas the position of the
mucogingival junction remained unaltered.
ROTATION
Relapse tendencies exist in a fairly high percentage of treated
malocclusion and it is greatest for rotation corrections. The
fibrous elements of the periodontal ligament adapt to tooth
movement in possibly 2 mechanisms:
1.Progressive osteogenic and cementogenic activity plays an
active role in the shortening of the extended fibers during tooth
movement.
2.The stretching of the wavy collagen fibers and reorientation of
their directional morphology permits a certain amount of tooth
movement.
Brauer et al found that transsecting the supracrestal fibers with
vertical incisions mesial and distal to the rotated teeth may
reduce the danger of relapse. He reported a significant reduction
in relapse after an initial retention of 4-8 weeks. Edwards et el
in AJO 1970 concluded that a simple surgical method of
severing all supracrestal fiber attachment of a rotated tooth can
significantly alleviate relapse following rotation, without apparent
damage to supporting structures of the tooth.

SPACE CLOSURE:
Wennstrom et al in AJO 1993 evaluated in animal
experiments the effect of orthodontic tooth movement
on the level of the connective tissue attachment in
sites with infrabony pockets. They found that
orthodontic movement of teeth into infrabony pockets
may be detrimental for the periodontal attachment
when realignment of teeth that have been tipped
and/or elongated as a result of periodontal disease is
considered. Hence periodontal treatment directed at
elimination of the plaque-induced lesion should
precede the initiation of orthodontic therapy and proper
oral hygiene maintained during the course of
orthodontic treatment.

Tulloch et al in AJO 1983 undertook a study to determine
the incidence and possible association of gingival
invaginations seen during space closure with gingival health
and stability of extraction-space closure. An infolding or
invagination of gingival tissue commonly forms during the
orthodontic approximation of teeth. The clinical appearance
of these invaginations ranges from a minor one-surface
crease in the attached gingiva to a deep cleft that extends
across the interdental papilla from the buccal to the lingual
alveolar surface. The precise cause of these invaginations
remains unclear.

The study revealed that
Gingival invaginations occur commonly during orthodontic
treatment that involves first premolar extraction and space
closure. Although they may decrease in size or even resolve,
many invaginations persist for years after treatment.

Invaginations are more common,
complex, severe, and persistent in the
mandibular arch than in the maxillary
arch.

Their formation is not related to the
width of the attached gingiva, canine
inclination, or overall gingival health.

Gingival invaginations do not seem to
be associated with extraction space
reopening.

The presence, severity, and
complexity of invaginations appear to
impair the patient's ability to maintain
adequate gingival health in the
extraction area.

According to Rnnerman et al AJO 1980, one cause of
relapse after orthodontic space closure has been related to the
compression of the transseptal fibers and their general
toughness and resistance. The reason for relapse may be an
increased appearance of glucoseaminoglycans in the
intercellular substance of the connective tissue. Such
substances may cause a very elastic gelatinous tissue,
facilitating relapse after the orthodontic closure of the extraction
site.

After orthodontic closure of an extraction site with a fixed
appliance, the gingival tissue as a rule becomes hyperplastic
when the space diminishes. The teeth that are moved together
thereby push the gingiva in front of them, and a fold or
invagination of epithelium and connective tissue is formed.
Edwards has recommended surgical removal of the excess
gingival tissue that appears in papillary form buccally and
lingually between the teeth that have moved together.
Traumatic occlusion and orthodontic treatment
Studies indicate that traumatic occlusion forces
1. do not produce gingival inflammation or loss of attachment in
pts with healthy periodontium
2.do not aggravate and cause spread of gingivitis
3.May aggravate an active periodontitis lesion i.e. may be a co-
destructive factor
4.May lead to less gain of attachment after periodontal treatment.

Some studies conclude that occlusal adjustments should be
carried out in the evidence of trauma after the control of
inflammation
Burgett et al in J. of periodontology have demonstrated
that there is a significant gain in attachment in patients who
received occlusal adjustment as part of treatment plan.

1.The importance of reducing jiggling of teeth after orthodontic
treatment of patients with moderate or advanced
periodontitis may be significant
2.Studies demonstrate that bone dehiscences caused by
jiggling forces will regenerate after elimination of trauma.
3.Occlusal adjustments may be a factor in the healing of
periodontal defects, especially bone defects.

PERIODONTAL CONSIDERATIONS
IN SURGICAL EXPOSURE:
It is often seen that teeth have a delayed eruption and at times
do not erupt at all. In such conditions, management of the
periodontal tissues is very much vital. According to the current
concepts, electro surgery or lasers should be avoided for such
cases, but their use could be restricted towards removing the
overlying tissue.

Prato et al in J. of periodontology 2000 compared the width
of keratinized gingiva after orthodontic therapy for buccally
erupting premolars that had been pretreated by extraction of
deciduous teeth alone versus interceptive mucogingival
surgery. It was noted that there was no significant difference in
the mean width of keratinized tissue at the start of treatment.
By the end of treatment, mean width at the site where
mucogingival surgery was performed was found to be significantly
higher (2.3 mm) than the site where extraction alone was
performed (1.3 mm). This proved conclusively that mucogingival
surgery was an effective technique to maintain keratinized tissue
in correspondence with buccally erupted teeth. Mucogingival
interceptive therapy in patients with buccally erupting teeth is
performed to prevent the ectopic permanent tooth from
developing periodontal lesions.

Christina Hansson et al in angle 1998 reviewed the periodontal
status of patients who had unilateral palatal impacted canines
and their adjacent incisors 1-18 years post treatment. The results
showed greater mesial probing depth of the canines on the
treated side, on the adjacent lateral incisors distolingually, and on
the first premolars mesiolingually. In general, the results showed
a good gingival and periodontal status with slight differences
between treated and untreated sides.
Kohavi et al in AJO 1984 found that the extent of surgical
exposure and the degree of orthodontic force had a definite impact
in the loss of bone support of teeth. He studied the consequences
of surgical exposure for the purpose of effecting orthodontic
treatment. Patients who had been treated orthodontically for
unilateral impaction of maxillary canine were studied. No significant
difference was found in light and heavy exposure group as far as
plaque index, gingival index and pocket depth was concerned.
Bone loss was found to be greater for heavy exposure group. The
most serious damage in the treatment of a palatally impacted tooth
is the result of surgical intervention that exposes the buried tooth to
beyond CEJ and will express itself in the form of loss of bone
support.
MUCOGINGIVAL PROBLEMS

Mucogingival deformities in children and adults
have been described as recession, gingival clefts
and localized pathologic recession. Inadequate
keratinized gingiva, minimal attached gingiva,
coronally attached frenal and muscle attachments,
abnormal tooth position, fenestrations or bony
dehiscence in the alveolus and other factors have
been predisposing and etiologically related
pathosis.

Etiologic factors for recession

Factors that may be etiologic or predisposing to mucogingival
problems of the mandibular incisors may be developmental or
acquired. ( Geiger AJO 1980)

Developmental
1.ectopic tooth bud development and eruption
2.inadequate arch length with crowding and rotation
3.excessive labial inclination
4.fenestration of labial alveolar bone
5.coronally positioned frenal and muscle attachments

Acquired
1.plaque and salivary accretions
2.chronic inflammatory gingivitis
3.magnitude and direction of orthodontic forces
4.functional malocclusion

When a mandibular incisor is lingually displaced, the alveolar
bone housing is extremely thin on the lingual aspect and quite
thick on the labial aspect. In such cases, excessive labial tipping
may result in further lingual movement of root apex, which may
fenestrate the lingual plate. The ability to torque such teeth is
limited. The direction of tooth movement should be away from the
thin attachment apparatus. When such movement is possible, an
increase in attached gingiva may occur.

Mandibular incisors that have a marked labial inclination may also
have a thin alveolar bone. The anterior thrust of class II elastics
might cause breakdown of the fragile gingival attachment. In
some cases, teeth which initially exhibited some localized
pathologic recession may show no loss of attachment despite the
prolonged use of class II elastics. This suggests that destruction
may not be predictable despite the application of some degree of
labial force and that only the prevention of gingival inflammation
may be critical.
Abnormal frenal and muscle attachments
Abnormal frenum and muscle pull has been considered
detrimental to periodontal health by pulling away the gingival
margin from the tooth contributing to accumulation of plaque and
calculus, and leading to inflammation and pocket formation.
Adequate depth of the vestibule has been similarly held
significant. Several surgical procedures to deepen the vestibule
as well as to reduce the height of frenal attachments have been
developed as preventive therapeutic measures.

Occasionally in the developing dentition, abnormal frenal or
muscle attachments may extend onto the crest of the alveolar
ridge. The erupting tooth may pass through the alveolar gingiva
and be deficient in keratinized tissue. Surgical recession will
ensure normal eruption of the tooth with adequate attached
gingiva.
Fan shaped frenal attachment
Orthodontic force and labial recession:
Teeth having adequate attached gingiva occasionally develop
localized recession during treatment. It has generally been
assumed that such destruction has been associated with
excessive force that has not permitted repair and remodeling of
alveolar bone. It is more likely that the direction and extent of
tooth movement have forced the tooth through the cortical plate.

This concept is supported in cases of severe gingival recession
consequent to tooth movement, in which remaining gingival
attachment appears relatively free of inflammation. Such
sequelae may be readily explained if the direction of tooth
movement has been towards areas of attachment deficiency.

When adverse forces and local factors do not exist, however, the
prior presence of an unseen dehiscence should be suspected.
Chronic marginal gingivitis may rapidly destroy the marginal
alveolar bone and gingival attachment during the application of
modest forces normally well tolerated by the periodontium.
Mandibular incisors with minimal attached gingiva may be
particularly susceptible to the adverse effect of a cross bite or an
edge to edge occlusion. If the resulting occlusal forces are in the
direction of the inadequate gingival attachment, they may
accentuate the destructive capacity of the inflammatory process
and crestal alveolar bone may be lost.

If the destruction of the gingival attachment has resulted in deep
gingival cleft with denudation of half the length of the root, tooth
movement may at best prevent further destruction. If a gingival
graft becomes necessary, the new environment provided by
tooth alignment will enhance the surgical repair. Areas of
minimal attached gingiva with good alignment may only require
frequent maintenance visits.
Sabine Ruf et al in AJO 1998 studied the effect of
orthodontic proclination of lower incisors in children and
adolescents on the possible development on gingival
recession. Either no recession developed or preexisting
recession remained unchanged during herbst therapy. No
interrelationship was found between the amount of incisor
proclination and recession.

Artun and Kronstad in AJO 1987 found that gingival
recession in adults developed mostly during the active phase
of orthodontics and the first 3 years after appliance removal.
Later only negligible recession took place.

Melsen et al in EJO 2003 studied the influence of labial
movement of lower incisors on the gingival margin. They
found that controlled proclination under maintenance of good
oral hygiene can be carried out in periodontally healthy
patients without any risk to the periodontium. New recessions
and dehiscences developed in 10% of the sample patients.
Vardimon et al in J. of periodontics 2001 found that
orthodontic tooth movement is a stimulating factor of bone
apposition. Conversion in repair pattern was seen which
supported the link between tooth movement and enhanced
bone deposition. Clinical implication suggests incorporation of
orthodontic tooth movement in regenerative therapy.

Handelmann et al in Angle 2000 in a review of non surgical
RPE cases have shown that buccal attachment loss was not
statistically significant for males when the adult expansion
group was compared to the adult control group. The average
increase in crown length was 0.5 mm. They suggested that
patients who demonstrated the largest increase in gingival
recession following RME would be the oldest, those who had
the greatest maxillary transarch deficiency, those with the
greatest amount of transarch expansion, and those who
initially had the longest crown heights.
Interdental recession:
Causes of open gingival
embrasures
Severely malaligned maxillary
incisors
Dimensional changes in the
interdental papilla
Location and size of
interproximal contact.
divergent root angulation
Triangular shaped crowns.
Interdental recessions manifest
as dark triangles between teeth.
Main indication of correction of
interdental recession is esthetics.
Options available for treatment of interdental
recessions are
mucogingival surgeries with coronally positioned grafts and
GTR
provision of gingival prosthesis
orthodontic paralleling of the roots of neighboring teeth
mesiodistal enamel reduction

The principle involved in stripping is to recontour the teeth which
have an abnormal shape. By this procedure, a good occlusion with
optimal tooth contact point relationships and normal interdental
gingival papillary contours will be achieved. When crowding is
unraveled in orthodontic patients, the contact points are located in
the incisal thirds. The amount of tooth material to be removed by
enamel reduction will be around 0.5-0.75 mm. After diastema is
created, the space is closed orthodontically. As this takes place,
roots of neighboring teeth come closer and the contact point is
lengthened and the reduce papilla can fill the embrasure.

Kokich et al AJO 2001 determined the prevalence of
posttreatment open gingival embrasures in adult orthodontic
patients. A posttreatment alveolar bone interproximal contact
distance greater than 5.5 mm was associated with open
gingival embrasures. Short and more incisally positioned
posttreatment interproximal contacts were associated with
open gingival embrasures. An increase in Interproximal
contactincisal edge distance by 1-mm increased the chances
of an open gingival embrasure by 78% to 97%.
PERIODONTAL SURGICAL PROCEDURES:
GINGIVAL CURETTAGE:
Curettage means scraping of the gingival wall of a
periodontal pocket to remove infected and necrotic tooth
substance. It removes the inflamed soft tissue lateral to the
pocket wall. The aim of curettage is to reduce pocket depth by
enhancing gingival shrinkage and new connective tissue
attachment.
It can be performed as part of new attachment attempts in
moderately deep infrabony pockets located in accessible areas
where a type of closed surgery is deemed advisable.
It can be done as a non definitive procedure to reduce
inflammation prior to pocket elimination using other methods or
in patients in whom more aggressive techniques are
contraindicated.
It is also performed on recall visits as a method of maintenance
treatment for areas of recurrent inflammation and pocket
deepening.

GINGIVECTOMY:

Gingivectomy means excision of gingiva. By removing
diseased tissue and local irritants, it creates a favorable
environment for gingival healing and the restoration of a
physiological gingival contour.

Indications:
Elimination of suprabony pockets, if the pocket wall is firm and
fibrous.
Elimination of gingival enlargements.

Contraindications:
When osseous surgery is needed.
Bottom of pocket located apical to the mucogingival location.
Esthetic considerations, particularly in the anterior maxilla.

According to Kokich et al in Sem. Orthod 1996, the
relationship of the gingival margin of the six maxillary
anterior teeth plays an important role in esthetic appearance
of teeth. In some instances, it may be necessary to increase
the clinical crown length of one or several teeth during or
after orthodontic treatment. If a gingival margin discrepancy
exists and the patients lip does not move to expose the
discrepancy, then no treatment is required. If the
discrepancy is apparent, one of the four possible treatment
modalities may be undertaken:
Gingivectomy
Intrusion and incisal restoration
Extrusion with fibrotomy and porcelain crown.
Surgical crown lengthening

The Gingivectomy technique is useful in improving orthodontic
results, especially in cases with missing maxillary central or
lateral incisors, after premolar auto transplantation or in
gummy smiles. It is possible to permanently increase the
clinical crown length after orthodontic treatment by labial
gingivectomy technique.

In adult patients with vertical maxillary excess, orthognathic
surgery is necessary to correct a gummy smile. In patients
with delayed apical migration of gingival margins, usually
seen between 12 and 15 years of age, the timing of gingival
surgery (before or after orthodontic appliances are removed)
depends on the wear at the incisal edges of the central and
lateral teeth.

GINGIVOPLASTY:

Gingivoplasty is the reshaping
of gingiva to create physiologic
gingival contours, for the sole
purpose of recontouring the
gingiva in the absence of
pockets. Gingival and
periodontal diseases often
produce deformities in the
gingiva that interferes with
normal food excursion, collect
plaque and food debris and
aggravate the disease
process.
Crown lengthening
A simple localized gingivectomy to the bottom of the clinical
gingival sulcus will increase the crown length. As shown in a
human experimental model, nearly 50% of the excised tissue
will regenerate and become clinically and histologically
indistinguishable from normal gingiva. This means, that if a
labial probing pocket depth of 4mm is recorded on the cuspid,
a gain of 2mm in crown length can be anticipated. Even if the
excision is extended into the alveolar mucosa, the coronal
part of the regenerated gingiva will still become keratinized.
Careful oral hygiene procedures, using single-tufted brushes,
are required for two months after the gingivectomy so that the
regenerated gingiva will appear entirely normal.
Gingival extension procedures
This consists of surgical deepening of the mucogingival line. To
prevent the mucogingival line from creeping back coronally, a
free mucosal or a gingival autograft obtained from the palate is
placed.
Free gingival autografts:
They are used to create a widened zone of attached gingiva.
The donor sites may be attached gingiva, masticatory mucosa,
edentulous areas and hard palate. They are also used for the
coverage of nonpathologic dehiscences and fenestrations.
FIBROTOMY:

Methods to reduce of relapse of orthodontically treated
teeth, especially rotated teeth include
1.Complete correction or over correction of rotated teeth.
2.Stable long term retention with bonded lingual retainers.
3.Use of fibrotomy

Periodontal fiber bundles that influence stability are the
principal fibers of PDL and the supra alveolar fibers.

Fibers of PDL remodel completely only after 2-3 months.
The supra alveolar fibers are stable and have a slower
turnover.
The supra crestal gingival tissues contribute to rotational
relapse and hence the technique of Circumferential
Supracrestal Fibrotomy. The transseptal fibers are cut
interdentally by entering the PDL space. Clinical healing
occurs in 7-10 days

The fibrotomy procedure is not indicated during active tooth
movement or in the presence of gingival inflammation. When
performed in healthy tissues after orthodontics, there is
minimal attachment loss.

Edwards in AJO 1988 studied the long term effect of
fibrotomy. It was found that CSF was more effective in the
maxillary anterior than the mandibular arch. It was more
effective in alleviating rotational than labiolingual relapse.
There was no clinically significant increase in sulcus depth nor
any gingival recession that was observed.
FRENOTOMY:

Hyperplastic types of frenum with fan shaped attachment may
obstruct diastema closure and hence surgical intervention is
desirable. In the past frenectomy was undertaken. The
complication with frenectomy is that the complete removal of
the frenum may result in gingival recession between the
central incisors. Hence frenotomy with only partial removal of
the frenum with the purpose of relocating the attachment in a
more apical direction is currently undertaken. Tissue healing
is uneventful although some scarring may occur.
REMOVAL OF GINGIVAL CLEFTS:
Incomplete adaptation of supporting tissues during
space closure may result in invaginations or
infolding or clefts in the gingiva. A simple removal
of only the excess gingiva in the buccal and lingual
areas would be sufficient to alleviate the tendency
of teeth to separate after space closure.
DISTRACTION OSTEOGENESIS OF THE
PERODONTAL LIGAMENT
DO is the process of growing new bone by mechanical
stretching of pre existing bone tissue. A new concept of
distracting the PDL is proposed to elicit canine retraction in 3
weeks. This is called dental distraction. The PDL acts as a
suture between the bone and the tooth.

Liou and Huang in AJO 1998 studied patients who needed
canine retraction and first premolar extractions in the maxilla
and mandible. At the time of first premolar extraction, the
interseptal bone distal to canine is undermined grooving
vertically inside the extraction socket both buccally and lingually.
Activation of 0.5 1 mm/day can be carried out immediately
after extraction.

It was observed from this study
that the periodontal ligament
can be rapidly distracted
without complications.

Changes in the periodontal
ligament on the mesial side of
the canine can be classified into

1. stretching and widening of the PDL
2. active growth of new bone spicules in the distracted PDL
during the second week
3. Recovery of the distracted PDL during the fourth week.
4. remodeling of striated bone from the fourth week to the third
month after distraction
5. maturation of the striated bone
ADULT ORTHODONTICS:

The changes that are seen in the PDL as a result of ageing
are

IN GINGIVA
Diminished keratinisation
Reduced stippling
Increased width of attached gingiva
Decreased connective tissue cellularity
Increased intercellular substance
Reduced oxygen consumption
Thinning of oral epithelium
Atrophy of connective tissue with loss of elasticity
IN PERIODONTAL LIGAMENT
Increased elastic fibers
Decreased vascularity
Decreased mitotic activity
An increase in the width of the ligament

IN ALVEOLAR BONE AND CEMENTUM
Osteoporosis
Decreased vascularity
Decrease in healing capacity
Continuous increase in the amount of cementum
Adult patients present a challenge to orthodontists because they
have high esthetic demands and they often have dental
conditions that may complicate treatment, such as tooth wear,
poorly contoured restorations and periodontal diseases.
Advanced periodontal disease may cause pathologic tooth
migration involving a single tooth or a group of teeth. The
sequelae may be tipping and extrusion of one or several incisors,
and development of a single diastema or multiple spacing of the
front teeth. In such cases orthodontic treatment may be required
for cosmetic reasons to attain an aligned front tooth segment.

Artun and Nelson on AJO 1997 found a close relation
between age and cumulative loss of attachment. Adult
orthodontic patients are more likely to present with periodontal
pockets than adolescents. It is thought that age is a predisposing
factor for bone loss during orthodontic treatment. Resistance to
periodontal breakdown is reduced with age.
adults may be at a higher risk than adolescents for periodontal
breakdown during appliance therapy. Mean bone loss in adults
not undergoing orthodontic therapy was found to be 0.07-0.11
mm. Bone loss for the average orthodontic patient was found to
be 0.31 mm suggesting that adults have an increase rate of
periodontal breakdown.

Boyd et al in AJO 1989 monitored the periodontal status of 20
adults and 20 adolescents undergoing fixed orthodontic
treatment. They found that during the course of fixed orthodontic
treatment,

1. Tooth movement in patients with a reduced but a healthy
periodontium does not result in significant loss of attachment
2. Tooth loss for periodontal reasons may occur in adults with
severely periodontally compromised teeth that have pocket
depths greater that 6 mm or advanced furcation involvement.

3. Adolescents are likely to show significantly more plaque
accumulation and gingival inflammation during treatment
than adults.

Kurashima et al in AJO 1963 reported that the periodontal
ligament fibers in an adult are more organized and the
normal fibroblast turnover is substantially reduced resulting
in alteration of overall elastic properties. It was found that a
lower force is desirable for orthodontic tooth movement in
adults particularly during the initial application of the load.

In periodontally compromised dentitions, the loss of alveolar
bone results in the center of resistance of the involved teeth
moving apically, and the net effect is that teeth are more
prone to tipping than to moving bodily.
CHANGES IN PDL DURING ORTHODONTIC
TREATMENT:
Yoshiki Nakamura in AJO 1996 studied the degenerating
tissue changes in the PDL during tooth movement. There were
two types of degenerating tissues found in the compressed
periodontal ligaments:

1. type A tissue stained differently from collagen and the other
2. type B tissue showed the same color as collagen. The
electron micrograph showed deposition of fibrin in type A
tissue. No collagen fibers with typical bandings were seen in
either tissue. The results indicated that collagen degradation,
fibrin deposition, and calcification occurred in the degenerating
tissues, especially in type A tissue during the experimental
tooth movement.
Tanaka described histologically and immunohistochemically the
degenerating tissues in the periodontal ligament during the tooth
movement. That study showed two types of degenerating
tissues in the compressed periodontal ligament; a collagenous
type and another that was noncollagenous.

Reitan in 1957 noted the degenerating tissues in the
periodontal ligament on the pressure side during the tooth
movement and termed these areas hyalinized tissues because
the degenerating tissues usually stained eosinophilically with
glass-like structures, with hematoxylin-eosin (H-E) stain.
Occasional periodontal complications may arise during adult
orthodontic therapy although they may also be seen in the
adolescent patients. Adult patients with pre existing periodontal
disease are considered to be at considerable risk during
orthodontic treatment. Prior to orthodontic treatment, it is
mandatory that periodontal disease be properly controlled with
debridement and reinforcement of oral hygiene. Periodontal
problems are generally minimal and in frequent in adolescents.

Potential benefits of orthodontic treatment:
Improved width of attached gingiva especially when moving a
labially positioned tooth lingually.
Induction of bone formation

Can re-establish biologic width in teeth with subgingival
restoration margins by forced eruption.
Closure of spaces of extracted teeth may help prevent
periodontal disease complications

Harmful effects:
Gingival and periodontal changes related to orthodontic
treatment are, in general, transient with no permanent damage.
However, lengthy orthodontic treatment, accompanied with
sustained poor oral hygiene leads to gingival and periodontal
damage. The deleterious effects include gingivitis, gingival
hyperplasia, marginal periodontitis, gingival recession at
extraction sites, loss of attachment, interdental clefts,
especially at vestibular aspects of extracted mandibular
premolars, reduced width of keratinized gingiva, marginal bone
loss and apical root resorption.
CHANGES IN PDL FOLLOWING ORTHODONTICS:
Periodontal tissues adapt to teeth that are moved orthodontically
along the dental arch. Furthermore, experimental studies have
shown that orthodontic tooth movements along the arch will not
result in loss of periodontal support provided the gingival tissue is
kept free of inflammation
If the alveolar bone becomes thinned out during orthodontic
intervention due to expansion, the gingival tissue may be more
susceptible to long-term recession.

rtun and Krogstad in AJO 1987 studied on the periodontal
status of mandibular incisors following excessive proclination.
They found that development of bone dehiscence and some
gingival retraction during excessive proclination of mandibular
incisors seem to be inevitable, especially in patients with thin
alveolar housing.
Retention of teeth with reduced periodontal
support
Dentitions with reduced periodontal support show a marked
tendency to return to their pretreatment position following
active appliance therapy. Thus, semi-permanent or
permanent retention may be required. Thin, flexible spiral wire
bonded to the lingual surface of each tooth in a segment may
represent a simple and effective way of retaining realigned
front teeth
Vascular changes in the PDL following force
application:
Murrel and Yen in AJO sep 1996 studied on the vascular changes
in the periodontal ligament after removal of orthodontic forces. The
pattern of blood vessel distribution in the periodontal ligament was
likely affected by changes in the direction of tooth movement
produced by the application and removal of the orthodontic force.
Changes in blood vessel number and density were associated with
the direction of tooth movement. The periodontal vascular
distribution and density was summarized as follows:

1. increased after application of orthodontic force,
2. transient decrease subsequent to removal of force,
3. transient increase during reactivated distal drift, and
4. normalization. Normalization was achieved during an interval
equivalent to the duration of orthodontic force, suggesting that the
vasculature could be a factor in production of tissue forces resulting
in relapse of relocated teeth.
Long-term effects of orthodontic treatment
on periodontal health:
Sadowsky and BeGole in AJO 1981 evaluated the
periodontal health of a large group of patients who had received
comprehensive orthodontic treatment during adolescence at
least 12 years previously and compared the periodontal health
of this group with that of a group of similar adults who had
malocclusions that had not been orthodontically treated. The
findings were:

While no differences were observed in the prevalence of
moderate to severe periodontal disease, the orthodontic group
manifested a greater prevalence of mild to moderate periodontal
disease than the control group in the maxillary posterior and
mandibular anterior regions of the mouth.
2. A greater prevalence of mild to moderate periodontal disease
was found in the posterior regions of the mouth in those
orthodontic patients whose treatment included extractions
than in those treated without extractions.

Polson in AJO 1988 evaluated the clinical periodontal status
of persons who had completed orthodontic therapy at least 10
years previously and compared the findings to those of adults
with untreated malocclusions. The comparisons showed no
significant differences between the groups for any of the
periodontal variables. It was concluded that orthodontic
treatment during adolescence had no discernible effect upon
later periodontal health.

Zachrisson suggested that a relationship may exist between
orthodontic therapy and conversion of gingivitis into
periodontitis for example, orthodontic bands may increase
subgingival plaque retention. Furthermore, orthodontic
movement resulting in tooth intrusion may shift supragingival
plaque into a subgingival location and predispose toward
destructive periodontitis.

Long-term effect of root proximity on periodontal health after
orthodontic treatment were studied by rtun and Kokich in
AJO 1987. No statistically significant differences in
inflammation, level of attachment, and bone level were observed
between root proximity sites and control sites. The results
indicate that anterior teeth are not predisposed to more rapid
periodontal breakdown when roots are in close proximity.
Preventive program for orthodontic patients
Before orthodontic treatment:
control active periodontal disease and caries
Risks of treatment have to be explained to the patient.
Awareness of the existing problem and the possible
complications that may arise during treatment must be explained.

During orthodontic treatment:
Emphasis on oral hygiene.
brushing instructions.
check plaque removal effectiveness
periodic periodontal evaluation and check up

After orthodontic treatment
Patient must be motivated to maintain good oral hygiene.
Maintenance of routine dental check ups.


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