|Year : 2014 | Volume
| Issue : 2 | Page : 200-204
Orthodontic management of dentition in patients with periodontally compromised dentition
Mohinder Panwar1, B Jayan2, Vimal Arora1, Sukhdeep Singh3
1 Adjutant General's Branch, IHQ, MOD (Army), New Delhi, India
2 Department of Dentistry, AFMC, Pune, Maharashtra, India
3 Armed Forces Dental Clinic, New Delhi, India
|Date of Submission||17-Mar-2013|
|Date of Acceptance||11-Oct-2013|
|Date of Web Publication||23-Apr-2014|
Armed Force Dental Clinic, Tyagraj Marg, New Delhi - 11
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: An increasing number of adult patients are seeking orthodontic treatment to improve their dental appearance. However, special attention must be given to the periodontal status of the adults as periodontal disease and its sequel, such as pathologic migration of anterior teeth, result in esthetic and functional problems. In such adult patients, an interdisciplinary approach often offers the best option for achieving a predictable outcome to solve complex clinical problems. Materials and Methods: A prospective study was carried out on 20 adult patients [mean age = 33.3 ± 4.52 (SD), 11 females and nine males] with periodontally compromised and malaligned dentition. Loe and Silness Gingival Index (GI), Ramfjord's Periodontal Disease Index (PDI) and Dental Aesthetic Index (DAI) were recorded at the start and after completion of treatment. Results: Comparison of GI, PDI and DAI before and after completion of treatment showed statistically significant differences, indicating the relevance of combined orthodontic-periodontic treatment in periodontally compromised dentition (P < 0.01). Conclusion: The outcome of the study showed that an interdisciplinary approach is a simple solution for complex clinical problems arising as a sequel to periodontitis, such as pathological tooth migration, restoring function, esthetics and periodontal health.
Keywords: Dental esthetics, interdisciplinary dentistry, pathologic tooth migration, periodontal surgery, permanent splinting
|How to cite this article:|
Panwar M, Jayan B, Arora V, Singh S. Orthodontic management of dentition in patients with periodontally compromised dentition. J Indian Soc Periodontol 2014;18:200-4
|How to cite this URL:|
Panwar M, Jayan B, Arora V, Singh S. Orthodontic management of dentition in patients with periodontally compromised dentition. J Indian Soc Periodontol [serial online] 2014 [cited 2021 Aug 2];18:200-4. Available from: https://www.jisponline.com/text.asp?2014/18/2/200/131325
| Introduction|| |
Dentistry has undergone significant evolution in the last two decades; there is tremendous focus on cosmetics today. The relationship between a person's physical appearance and his self-esteem is well documented. , A desire to improve their dentofacial appearance has been found to be the primary motivating factor for seeking treatment in adults.  However, special attention must be given to the periodontal status of adults because they are more likely to be susceptible to or have already suffered from periodontal disease. Periodontal disease and its sequel, such as diastema or a missing tooth, often lead to functional and esthetic problems. 
The most notable clinical sign of advanced periodontitis is pathologic tooth migration, including labial flaring, irregular spacing, rotation or extrusion of anterior teeth [Figure 1]. The pathological migration of teeth is usually caused by unresolved inflammation and subsequent destruction of periodontal tissues. Anterior teeth are therefore especially prone to elongation and displacement as they are not protected by occlusal forces and have no antero-posterior contacts to inhibit tooth migration. 
To ensure a predictable outcome and avoid unwanted pitfalls, excellent co-ordination of care between disciplines of periodontics and orthodontics is crucial [Figure 2]. The aim of the study carried out was to evaluate the role of combined ortho-perio treatment in patients with periodontally compromised dentition and malaligned teeth.
| Materials and Methods|| |
This study was conducted in Army Dental Centre (R&R), New Delhi. The study protocol described herein was approved by the ethical committee of the college.
The study was carried out on 20 adult patients (mean age 33.3 ± 4.52 years; female/male ratio 11/9) with periodontally compromised and malaligned dentition.
The inclusion and exclusion criteria as well as the variables recorded were as follows:
- Adults with localized/generalized chronic periodontitis
- Pathologic migration of anterior teeth
- Periodontally compromised patients with spaced dentition in either/both arches.
- Patients suffering from systemic diseases compromising the health and integrity of the periodontium
- Patients with aggressive periodontitis
- Noncompliance to oral hygiene measures after Phase I therapy
- Patients with malalignment of teeth, but no evidence of periodontal disease.
The following parameters were recorded at baseline and after completion of combined ortho-perio treatment:
Gingival Index (GI; Loe and Silness)
The GI  was scored on a numerical scale of score 0 for normal gingiva to score 3 corresponding to severe inflammation, marked redness and edema, ulceration; tendency to spontaneous bleeding. The rating of the GI was recorded from excellent as score 0 to poor, where scores ranged from 2.1 to 3.
Each tooth was scored in four areas: Distofacial, midfacial, mesiofacial and lingual surfaces. The GI score for a tooth was obtained by adding four values per tooth and dividing by four. Scores of each tooth are added and then divided by the number of teeth examined to give GI scores for the individual.
Ramfjord's Periodontal Disease Index
The Periodontal Disease Index (PDI)  comprises of three components, namely, Plaque component, Calculus component and Gingival and Periodontal component. The gingival and periodontal components are scored separately using six Ramfjord selected teeth. The criteria ranged from 0 to 6, correlating to normal gingivitis to severe periodontitis. The PDI score can be calculated for an individual and a group. For an individual, it is the total of individual tooth scores/number of teeth examined.
Dental Aesthetic Index
The Dental Aesthetic Index (DAI)  links clinical and esthetic components mathematically to produce a single score, which reflects the malocclusion severity. The index can be used to determine the need for orthodontic treatment. The DAI is based on a social acceptability scale of occlusal conditions. 
The DAI scores correspond to the malocclusion severity and help to place patients in various treatment needs categories. The total score equal to or less than 25 requires no treatment and scores equal to or more than 36 correspond to mandatory orthodontic treatment. 
The GI, PDI and DAI were recorded at baseline before the start of treatment and after completion of the combined ortho-perio treatment to assess the change in periodontal health and esthetics.
The collected data were subjected to statistical analysis (paired t-test) using the SPSS software. The level of significance was set at 0.05 (P < 0.05).
| Results|| |
The severity and quantity of gingival inflammation was assessed by GI. The mean of the pretreatment GI was 2.8 ± 0.50 (SD) and that of the posttreatment GI was 1.2 ± 0.43 (SD), showing a statistically significant difference of 1.6 ± 0.31 (SD) (P < 0.05).
The extent of periodontal disease in the study carried out was assessed by PDI. The mean of the PDI pretreatment was 4.0 ± 0.42 (SD) and that posttreatment was 1.4 ± 0.55 (SD), showing a statistically significant difference of 2.6 ± 0.45 (SD) (P < 0.05).
The comparison of pre- and posttreatment DAI showed a pretreatment mean of 38 ± 4.16 (SD) and a posttreatment mean of 25 ± 2.71 (SD), showing a statistically significant difference of 13 ± 3.12 (SD) (P < 0.05).
| Discussion|| |
There is an ever-increasing concern for dentofacial esthetics in the adult population; hence, in contemporary dental care, an increasing number of adult patients are seeking orthodontic treatment. In this group of patients, the primary motivating factor is a desire to improve their dental appearance.  Majority of the adult orthodontic patients manifest with a co-existing periodontal pathology, resulting in pathologic migration, spacing, flared incisors and trauma from occlusion [Figure 3]. Periodontal pathology usually results in severe bone loss [Figure 4]. The management of such cases requires interdisciplinary treatment planning by the periodontist and the orthodontist.
|Figure 4: Intra Oral Periapical Radiograph showing severe bone loss in the upper lateral incisor|
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Adjunctive orthodontic management of pathologic tooth migration has unique effects in subjects with moderate to advanced periodontitis. A predictable treatment outcome needs co-ordination of care between two disciplines along with appropriate risk assessment. These interactions are mutually beneficial, allowing the diseased periodontium to be significantly improved and permitting tooth movement. Combined periodontic and orthodontic treatment can greatly enhance periodontal health and dentofacial esthetics [Figure 5] and [Figure 6]. Orthodontic treatment is no longer a contraindication in the therapy of severe adult periodontal disease or in the maintenance of a healthy periodontium after orthodontic treatment. 
|Figure 5: Posttreatment alignment of teeth with healthy periodontium and periodontal splint|
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|Figure 6: Intra Oral Periapical Radiograph showing improved alveolar bone levels post perio– ortho treatment|
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It is apparent that the crucial factor in the orthodontic treatment of patients with periodontal disease is the appropriate control of existing inflammation prior to commencing of the orthodontic treatment and subsequent regular periodontal supportive care during orthodontic treatment. Therefore, orthodontic treatment for realignment of migrated periodontally involved teeth is initiated only after the control of inflammation has been achieved. If the patient is reasonably motivated and responds well to the initial periodontal therapy, adult orthodontic treatment has a role in providing complete rehabilitation in terms of both function and appearance, with a satisfactory long-term prognosis. Dental health education, enhanced oral hygiene instructions and regular periodontal care are essential during orthodontic treatment.  When considering the best time to begin orthodontic treatment in patients with moderate to advanced periodontitis, multiple factors should be considered.  These include the patient's compliance, motivation, plaque control levels, an effective periodontal treatment response, periodontal stability and establishment of a relatively stable occlusion.  The patient should be followed for a period of about 3-6 months after active periodontal treatment for observation of resolution of inflammation and healing prior to commencing of orthodontic tooth movement. 
A comprehensive clinical management protocol before, during and after orthodontic treatment is key for the long-term success of orthodontic treatment in patients with periodontally compromised dentition.  Orthodontic treatment in periodontal patients with reduced periodontium differs considerably from that performed in subjects with healthy periodontium. One should be aware of the biomechanics involved and the treatment sequence to be followed.  In the study carried out, comprehensive orthodontics was initiated with preadjusted edgewise appliances using very light forces, which resulted in optimal biological response. During active orthodontic treatment, due attention was paid to the optimal force magnitudes. Dental clinicians must take into consideration potential periodontal problems before, during and after orthodontic treatment. There is no universal treatment protocol that is applicable to all patients with periodontally compromised dentition undergoing combined ortho-perio treatment. However, in the present study, Phase I therapy and nondefinitive open flap curettage was carried out in all the cases to eliminate gross inflammation and enhance attachment level. Definitive periodontal surgeries and regenerative procedures should follow orthodontic treatment. In patients with advanced periodontitis, the crucial issue is often to what extent the osseous topography can be favorably influenced by orthodontic tooth movement. , Clinical studies have shown that a reduction in vertical bone height is not a contraindication for orthodontic tooth movement and that alveolar bone is recreated ahead of moving the tooth as movement is performed with lighter forces. 
In adults bone remodeling is slower and hence longer retention periods are required. In cases with significant loss of periodontium prior to orthodontic treatment, permanent splinting is always a preferred option. In the study carried out, fixed bonded retainers were provided to all the patients after completion of treatment, which not only acted as a periodontal splint but also prevented relapse [Figure 4]. The planning of retention and stability after orthodontic treatment requires greater consideration in periodontally compromised patients. Thus, permanent retention is often part of the treatment plan. 
In adults with pathologic migration of anterior teeth, esthetics is a primary motivating factor for seeking orthodontic treatment. Pre- and posttreatment esthetics in the present study was evaluated with DAI. The reliability and validity of DAI is well documented and it has been accepted by the World Health Organization as a cross-cultural index. , In the study that was carried out, the difference in pre- and posttreatment DAI was statistically significant, which signifies the role of combined ortho-perio treatment in enhancing dentofacial esthetics.
The DAI is a valid and reliable index, and its advantage is the use of threshold scores (i.e. 31 or higher) to equate with the needs for orthodontic services.  Different cut-off points for the DAI have been proposed to prioritize orthodontic care needs.  However, there are possible limitations when using DAI for epidemiological or association studies. The lack of assessment of occlusal anomalies such as buccal crossbite, impacted teeth, center-line discrepancy and deep overbite weaken the index. These limitations should be considered when using the DAI for epidemiological studies or for studies assessing the relationship between malocclusion and other variables. , Another limitation of the present study was the lack of a control group, which can be addressed in future studies.
Esthetics has become a respectable concept in dentistry. This trend toward a heightened awareness of esthetics has challenged dentistry to look at dental esthetics in a more organized and systematic manner so that the health of the patients and their dentition is the most important underlying objective.  The results of the present study carried out suggest that in periodontally compromised adult cases, a close interdisciplinary approach is critical for successful outcome without compromising structural, functional and biological aspects. Interdisciplinary dentistry complimented by patient education and continued good care of oral hygiene will transform patients with unattractive smile due to pathologic migration of anterior teeth into individuals with attractive dentition and radiant smiles.
| Conclusion|| |
This study showed that orthodontic treatment can positively affect the periodontal health and prevent progression of periodontal disease. Future studies with a control group can further investigate the effect of orthodontic treatment in patients with periodontal problems.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]