JICDRO is a UGC approved journal (Journal no. 63927)

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Year : 2009  |  Volume : 1  |  Issue : 3  |  Page : 20-26

Treatment of malpositioned periodontally compromised teeth by an interdisciplinary approach - A case report

1 Department of Orthodontics, Dr. D. Y. Patil Dental College & Hospital, Pimpri, Pune, India
2 Department of Periodontics & Oral Implantology, Dr. D. Y. Patil Dental College & Hospital, Pimpri, Pune, India

Date of Web Publication23-Feb-2011

Correspondence Address:
Sonali Deshmukh
Department of Orthodontics, Dr. D. Y. Patil Dental College & Hospital, Pimpri, Pune
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Source of Support: None, Conflict of Interest: None

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The traditional orthodontic patient-base of adolescents has changed dramatically over the last 20 years. Adult patients now comprise a very large percentage of the orthodontic patient base. These patients bring with them unique challenges to the provision of aesthetic treatment. Gingival aesthetics, for a long time the exclusive concern of the periodontist, has now become one of the chief aesthetic challenges presented to the practicing orthodontist. This report illustrates the interdisciplinary approach in a patient requiring periodontic, orthodontic and prosthodontic treatment.

How to cite this article:
Deshmukh S, Agarkar S, Kishore A. Treatment of malpositioned periodontally compromised teeth by an interdisciplinary approach - A case report. J Int Clin Dent Res Organ 2009;1:20-6

How to cite this URL:
Deshmukh S, Agarkar S, Kishore A. Treatment of malpositioned periodontally compromised teeth by an interdisciplinary approach - A case report. J Int Clin Dent Res Organ [serial online] 2009 [cited 2022 Jan 28];1:20-6. Available from: https://www.jicdro.org/text.asp?2009/1/3/20/77011

   Introduction Top

Orthodontic treatment of adults is different than that for children and adolescents, primarily because the virtual completion of facial and dentoalveolar development eliminates the choice of treatment mechanics that depend upon growth, and secondarily because of the predilection of adults to destructive periodontal disease. Adult patients who are susceptible to periodontal disease and have experienced advanced levels of bone loss and sometimes loss of dental units may be defined as "periodontally compromised" and are the subject of this article. The reasons for considering these patients separately are that ;

  1. they are more prone to further bone loss;
  2. the reduced periodontium cannot sustain further loss without the potential loss of teeth;
  3. there is frequently an acquired malocclusion unique to this group; and
  4. the reduced periodontal support dictates altered treatment design, mechanics, and retention [1].

An expectation of a beautiful smile at the end of orthodontic treatment is a primary concern for all patients, but most are also concerned with their appearance while undergoing treatment. This is evident in the attempts by manufacturers to meet the esthetic demand of patients while undergoing orthodontic treatment, including making metal brackets smaller, developing lingual or "invisible" brackets, esthetic archwires, plastic brackets and translucent ceramic brackets [9] .

The demand for adult orthodontics is increasing. It is not unusual for orthodontic patients to have missing anterior teeth. In some patients, a hopeless anterior tooth was extracted prior to beginning orthodontic treatment. In some of these patients, orthodontic treatment alone may solve the problem. However, in others prosthetic replacement of missing teeth is the most suitable treatment. In such patients, pre-prosthetic orthodontic treatment often has to be performed to facilitate the restorative treatment by positioning the teeth for the best possible esthetic and functional results. It is important to maintain the esthetics of those individuals undergoing fixed orthodontic treatment.

This clinical report describes an interdisciplinary (periodontic, orthodontic, prosthetic) approach for the treatment of a periodontally compromised patient with anterior dental crowding and bilateral crossbite. Periodontal therapies, reinforced oral hygiene as well as orthodontic treatment achieve stable periodontal conditions and successful esthetic and functional final results.

   Case Report Top

A 24-year-old systemically healthy, nonsmoking male was referred for orthodontics consultation. Patient presented with the chief complaint of unaesthetic appearance of his dentition and malaligned lower front teeth with increased spacing since 2 to 3 years [Figure 1] a,b,c Patient's medical history was non contributory. Extra-oral examination revealed that the face was bilaterally symmetrical and did not show any signs of systemic illness [Figure 1]d Intra oral examination showed poor oral hygiene.
Figure 1:

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Patient reported with a missing maxillary right central incisor and was wearing a removable partial denture. Periodontal examination and charting were performed including assessment of probing depths (PDs), clinical attachment levels (CALs), full mouth bleeding (gingival bleeding index: GBI) and plaque scores (plaque control record: PCR). Generalized pocket depths ranging from 4 to 7 mm and gingival recession =2 mm were present for upper maxillary left incisor. The upper right lateral incisor showed pathologic anterior migration, whereas the lower anterior segment demonstrated crowding with grade II mobility.

The occlusal examination revealed Angle Class I molar relationship bilaterally for the first molars and canines. There was presence of cross bite of right and left mandibular canines [Figure1]b, c.

Radiographic examination (OPGs & IOPAs) were done to evaluate the bony topography and quality which revealed generalized moderate vertical bone loss [Figure 3]a. The periodontal prognosis was unfavorable for upper left central and lateral incisors 21,12,22 because of the advanced bone loss in a young adult, associated with minimal plaque, vertical defects, and occlusal trauma. The periodontist recommended orthodontic treatment because the expected loss of tooth 21 would necessitate its prosthetic replacement. Correction of crossbite and elimination of the anterior crowding would allow esthetic reconstruction. Given the presented information, a diagnosis of moderate to advanced generalized chronic periodontitis with bilateral canine crossbite was made. An ortho-perio-prostho management was planned for the patient and treatment plan was formulated.

Before starting orthodontic treatment, the patient received Phase I periodontal treatment. The treatment comprised of oral hygiene instructions, supragingival and subgingival scaling and root planning under prophylactic antibiotic regimen.

It was essential to correct mandibular canine crossbite to eliminate trauma from occlusion and to aid in prosthetic replacement of upper anterior segment. Thus, orthodontic treatment was started on a nonsurgical basis using 0.018 Roth Preadjusted Edgewise Appliance with very light continuous force. The first wire used was 0.012" NiTi (Upper and lower). In order to maintain the existing gingival height and contour, it was decided to retain the 21, 12, 22 till the end of orthodontic treatment to provide incisal guidance and to guide in maintaining the pre treatment normal overjet and overbite during the course of treatment. The orthodontic therapy lasted for 10 months and it was finished with rigid wires in both the arches. The orthodontic appliance was then removed and permanent retention was given in the lower arch from 34 to 44. After removal of orthodontic appliance, splinting was done using Flexible Spiral Wire to achieve stable retention [Figure 2]c.
Figure 2:

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During the second phase of treatment, crown preparations of the upper canines was done in pre text of periodontal surgery and extraction of 21, 12, 22 was done.Upper arch impressions were made and a temporary canine to canine bridge with ovate pontic seat preparation was done thereby maintaining gingival contours and interdental papillae.

Under adequate local anaesthesia, periodontal full mouth flap surgery was done using bovine derived bone graft (Bio-oss).[Figure 2]b Patient was instructed to use 0.2% chlorhexidine mouthrinse for 1 minute twice daily and to avoid any trauma to the operated area. Prophylactic antibiotics (Amoxicillin 500 mg) and analgesics (Ibuprofen-Paracetamol) were prescribed three times daily starting from 1 hour prior to surgery up to 3 days postoperatively. Patient was given temporary ovate pontic bridge for the extracted 21,12,22.

At 4 months, nice soft tissue contours with good emergence profile were noted on removal of the temporary bridge [Figure 2]d. Final impression for bridge fabrication was made. The metal coping for a porcelain fused to metal six unit bridge with canines as abutment was then made, tried and sent for final prosthesis fabrication[Figure 2]e.The patient was scheduled for monthly follow-up visits.

3 year follow up images show nice occlusal setting with positive overjet, overbite of 2mm and Class I molar and canine relationship which was important for maintenance of periodontal health. Improved bone levels and stability of treatment outcome after extensive interdisciplinary treatment approach involved orthodontic preparation, periodontal interception and prosthetic rehabilitation. [Figure 3]
Figure 3:

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   Discussion Top

A common problem in adult patients with periodontal disease is the migration, elongation and spacing of incisors [2] . Periodontitis affected patients in younger age as shown in this case need an improvement in quality of life with esthetic and functional management.

Several reports have suggested that orthodontic force can have negative effects such as loss of attachment and further bone destruction when periodontal inflammation is present [3] . An experimental study has also shown that regeneration of the periodontal ligament does not occur in the tissue with inflammation [4] and that degenerated tissues produced on the pressure side of tooth movement are defenseless to the bacterial infection [5] . Therefore, it is essential to eliminate inflammation of periodontal tissues prior to orthodontic treatment. In this case, an intensive effort was made to recover the periodontal environment with no inflammation before the orthodontic treatment, close to its normal circumstance so that the tissue response could be the same as that in normal periodontal tissues free from infections.

In this case, correction of bilateral mandibular canine crossbite was important for removal of occlusal trauma which causes further progress of disease and hampers periodontal maintenance by the patient [1] . The planning of retention and the stability of orthodontic treatment requires greater consideration in periodontally compromised patients. Thus, permanent retention is often part of the total treatment plan for these patients [8] . In this case, we splinted the lower anteriors using Flexible spiral wire to achieve stable retention.

Special considerations must be given to force application, particularly its magnitude and duration, in a dentition that demonstrates a reduced periodontal support mechanism [6] .

In this case, ovate seat pontics were given to maintain esthetics of the patient after extraction of 21,12,22. The ovate pontic is the most esthetically appealing pontic design. Socket preservation techniques should be performed at the time of extraction to create the tissue recess from which the ovate pontic form will emerge. Meticulous attention to the contour of the pontic of the provisional restoration is essential when conditioning and shaping the residual ridge that will receive the definitive prosthesis. The ovate pontic's advantages include its pleasing appearance and its strength [7] .

Alignment of crowded or malposed teeth should be an advantage to clean up all surfaces of the teeth, which is essential care for the periodontitis [10] . Orthodontic treatment also contributes to the promotion of oral health of the patient. As a result, healthy periodontal condition was maintained.

   Conclusion Top

Adult orthodontic tooth movement can be performed on both healthy and diseased periodontia with few detrimental effects (root resorption) provided physiologic light continuous forces are used, periodontal inflammation is controlled and meticulous oral hygiene is maintained throughout active therapy. Thus, orthodontic treatment with systemic approach, is a very helpful way to prevent recurrence of periodontitis by means of not only acquiring good oral environment but also achieving functional efficiency and favorable esthetics of patient to provide better quality of life.

   References Top

1.Chester S. Handelman, DMD Orthodontic Care of the Periodontally Compromised Patient Followed Long-Term: Part - 2. World J Orthod 2001;2:127141.   Back to cited text no. 1
2.Miller BH. Orthodontics for the adult patient. I. Introduction. Br Dent J 1980;148:97100.   Back to cited text no. 2
3.Wennstrom JL, Stokland BL, Nyman S, Thilander B. Periodontal tissue response to orthodontic movement of teeth with infrabony pockets. Am J Orthod Dentofacial Orthop 1993; 103: 3139.   Back to cited text no. 3
4.Ericsson I, Thilander B, Lindhe J, Okamoto H. The effect of orthodontic tilting movements on the periodontal tissues of infected and non-infected dentitions in dogs. J Clin Periodontol 1977; 4: 27893.   Back to cited text no. 4
5.Nakamura Y, Tanaka T, Noda K, Shimpo S, Oikawa T, Hirashita A, et al. Calcification of degenerating tissues in the periodontal ligament during tooth movement. J Periodont Res 2003;38: 34350.   Back to cited text no. 5
6.Polson A, Caton J, Polson AP, Nyman S, Novak J, Reed B. Periodontal response after tooth movement into infrabony defects. J Periodontol 1984;55:197 202.   Back to cited text no. 6
7.Kulashekar N Reddy, Veena Hegde, IN Aparna, B Dhanasekar Incorporating modified ovate pontic design for anterior tooth replacement: A report of two cases.Journal of Indian Prosthodontic Society 2009,vol 9 , issue 2 page 100-104  Back to cited text no. 7
8. http://www.casesjournal.com/casesjournal/article/view/8568 Interdisciplinary approach for the treatment of periodontally compromised malpositioned anterior teeth: a case report   Back to cited text no. 8
9.Ashok Kumar Jena Orthodontic Cyber Journal: "Riding pontics";An Esthetic Aid in Orthodontics.   Back to cited text no. 9
10.Re S, Corrente G, Abundo R, Cardaropoli D. Orthodontic treatment in periodontally compromised patients: 12-year report. Int J Periodontics Restorative Dent 2000; 20:319.  Back to cited text no. 10


  [Figure 1], [Figure 2], [Figure 3]


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