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Journal of

Oral Rehabilitation

Journal of Oral Rehabilitation 2010 37; 377390

Review Article

The orthodonticperiodontic interrelationship in integrated


treatment challenges: a systematic review
N. GKANTIDIS*, P. CHRISTOU* & N. TOPOUZELIS

*Department of Orthodontics, School of Dentistry,

University of Athens, Athens and Department of Orthodontics, School of Dentistry, Aristotle University of Thessaloniki, Thessaloniki, Greece

SUMMARY Orthodontic treatment aims at providing


an acceptable functional and aesthetic occlusion
with appropriate tooth movements. These movements are strongly related to interactions of teeth
with their supportive periodontal tissues. In recent
years, because of the increased number of adult
patients seeking orthodontic treatment, orthodontists frequently face patients with periodontal problems. Aesthetic considerations, like uneven gingival
margins or functional problems resulting from
inflammatory periodontal diseases should be considered in orthodontic treatment planning. Furthermore, in cases with severe periodontitis,
orthodontics may improve the possibilities of saving
and restoring a deteriorated dentition. In modern

Introduction
The most common objectives of an orthodontic treatment are facial and dental aesthetics and the improvement in the masticatory function. There is a
continuously increasing number of adult patients who
actively seek orthodontic treatment, and it is also an
undeniable fact that the incidence of periodontal
disease increases with age. Therefore, the number of
patients with periodontal problems that attend orthodontic practices is significantly greater than in the past
(1).
The most common orthodontic problems found in a
periodontally compromised patient include proclination
of the maxillary anterior teeth, irregular interdental
spacing, rotation, overeruption, migration, loss of teeth
(Fig. 1) or traumatic occlusion. Those changes in the
dentition are a consequence of the diminished support
provided by the compromised periodontium, and they
2010 Blackwell Publishing Ltd

clinical practice, the contribution of the orthodontist, the periodontist and the general dentist is
essential for optimized treatment outcomes. The
purpose of this systematic review is to highlight the
relationship between orthodontics and periodontics
in clinical practice and to improve the level of
cooperation between dental practitioners. Potentials
and limitations that derive from the interdisciplinary
approach of complex orthodonticperiodontal clinical problems are discussed.
KEYWORDS: orthodontics, periodontics, interdisciplinary treatment, aesthetics, function, relapse
Accepted for publication 15 January 2010

can sometimes hinder periodontal treatment by reducing the conditions for good oral hygiene and impairing
function and aesthetics of the stomatognathic system
(2). Furthermore, in patients with active periodontal
disease, the presence of traumatic occlusion may inhibit
bone apposition that can occur following periodontal
treatment (3, 4).
In all the aforementioned clinical situations, orthodontic treatment may contribute significantly to the
overall rehabilitation (aesthetic and functional) of the
stomatognathic system. This is the reason that all these
periodontal conditions have to be co-evaluated by the
periodontist and the orthodontist to choose the appropriate orthodontic intervention. This may involve
adjunct tooth movement that can facilitate other dental
procedures or comprehensive orthodontic treatment to
correct a malocclusion (5). The final treatment plan
must be individualized and tailored to meet the needs,
objectives and expectations of the patient (6).
doi: 10.1111/j.1365-2842.2010.02068.x

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N . G K A N T I D I S et al.

Fig. 1. Periodontal patient presenting proclination of the maxillary anterior segment, irregular teeth spacing, rotation, overeruption, migration and loss of teeth.

The aim of the present systematic review is to


delineate the relationship between orthodontics and
periodontology and the mode that each field can
contribute to optimize treatment of combined orthodonticperiodontal clinical problems. This attempt
includes the description and analysis of (i) the effects
of orthodontic treatment on periodontal tissues, (ii)
some considerations of orthodontic treatment, (iii)
orthodontic tooth movement in compromised periodontium, (iv) periodontal treatment schedule, (v)
interdisciplinary management of aesthetic problems,
and (vi) prevention of relapse of orthodontic treatment.

Materials and methods


To find the relevant articles, the Medline and Cochrane
databases were searched from 1969 to September 1,
2009. The Medline search was based upon the following key words: orthodont* AND periodont* in all fields

(limits: Humans, English, French, Italian). A similar


search with the same keywords in all fields (limits:
Animals, English, French, Italian) was also conducted
to identify animal studies. The Cochrane Database was
searched using the following keywords: orthodontic
and periodontal.
Regarding human studies, observations based on case
reports or papers written in another language than
English, French or Italian were initially excluded.
Articles referring to patients with systemic disorders,
congenital malformations or abnormal tooth eruption
were also excluded. Irrelevant articles were excluded by
title. From the 2076 articles found in Medline, 1385 were
excluded by title as irrelevant to the study subject. From
the 25 articles found in the Cochrane Database, 21 were
also found through the Medline search and four of them
were only abstracts. The reference lists of the retrieved
articles were hand searched for relevant studies, which
may have been missed. Eligibility was determined by
reading the reports identified by this search.
In this stage, from the 412 articles selected, 324 of
them were excluded because they reported <4 patients.
Finally, 88 articles were included in the study. From
them, three were systematic reviews, nine were prospective randomised controlled studies, 16 were prospective cohort studies, 18 were prospective case
studies, six were cross-sectional studies, nine were
retrospective cohort studies, four were retrospective
case studies with re-evaluation of treatment outcome,
10 were retrospective case studies, and 13 were review
papers including a critical discussion (Table 1).

Table 1. Classification of non-experimental articles cited according to the type of publication


Type of publication
Systematic review
Prospective RCT
Prospective Cohort Study (comparative
and or controlled)
Prospective Case Study (n > 3)
Cross-sectional study
Retrospective Cohort Study (comparative)
Retrospective Case Study re-evaluation of
treatment outcome
Retrospective Case Study (n > 3)
Non-systematic review
Case report (n 3)
Clinical article
Book

Cited reference

Total

32, 33, 58
8, 9, 11, 22, 40, 42, 90, 112, 114
13, 14, 15, 16, 17, 20, 21, 23, 24, 34, 35, 36, 41, 43, 44, 89
10, 12, 18, 19, 25, 26, 28, 30, 37, 45, 51, 59, 60, 61, 68, 95, 107,
2, 101, 102, 105, 117,
29, 70, 71, 75, 81, 83, 97, 100,
27, 77, 96,

3
9
16

120
118
110
119

18
6
9
4

54, 69, 72, 73, 76, 78, 82, 99, 104, 111
4, 5, 7, 39, 64, 91, 92, 103, 106, 108, 109, 113, 116
56, 57, 65, 66, 67, 93, 94, 121
6, 79, 98, 115
1, 3, 80, 38

10
13
8
4
4

RCT, randomised controlled.


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ORTHODONTICPERIODONTIC INTERRELATIONSHIP
Table 2. Classification of animal studies cited according to
experimental subjects
Experimental
subjects

Cited reference

Rats
Dogs
Primates

46, 47
31, 48, 49, 52, 55, 63, 74, 85, 86, 87
50, 53, 62, 84, 88

Total
2
10
5

We further identified 552 animal studies. Thirty-five


of them were found relevant to the study subject.
However, 17 studies were included, related to fields
where controversial, insufficient or no clinical data
were available (Table 2). Furthermore, in such topics,
selected case reports or opinions expressed in clinical
articles and relevant books are cited (Table 1).
Conclusions drawn from animal studies and case
reports or opinions expressed in non-systematic reviews, clinical articles or books are not considered
strong evidence. However, they could provide useful
ideas and possible solutions to complicated clinical
situations. Such concepts should be subject to further
research before application in everyday clinical practice.

Effects of orthodontic treatment on


periodontal tissues
The primary cause for the inception and progression of
gingival inflammation and periodontitis is bacterial
plaque (7). Orthodontic treatment is sometimes considered a predisposing factor for periodontal disease, as
orthodontic appliances may inhibit complete oral
hygiene procedures resulting in increased bacterial
aggregations (813). The problem is not the aggregations per se, but there is a possibility of transition of the
subgingival plaque to a more aggressive periopathogenic flora (918) that favours the conversion of
gingivitis into periodontitis. Nevertheless, if a thorough
oral hygiene regime is applied before and during
orthodontic treatment, minimal or no increase in
gingival bleeding index (1921) or plaque quantity will
be evident (19, 2123). In any case, after appliance
removal or even earlier (during treatment), there is
significant improvement on plaque index and bleeding
index values and a reduction in certain periopathogenic
bacteria (810, 12, 18, 2426).
Clinical studies have shown that with adequate
plaque control, patients with reduced but healthy
periodontium can undergo orthodontic treatment with 2010 Blackwell Publishing Ltd

out aggravating their periodontal conditions (24, 25,


2730). However, clinical and experimental studies
have shown that when inflammation is not fully
controlled orthodontic treatment may trigger inflammatory processes and accelerate the progression of
periodontal destruction leading to further loss of
attachment, even in patients with sound oral hygiene
(27, 31).
Certain studies report an increase in probing depth
measurements during orthodontic treatment (approximately 05 mm), but this is attributed to moderate
gingival hyperplasia, provided there is no loss of
attachment (8, 9, 1214, 16, 23). Some contradictory
findings regarding the effects of orthodontic appliances
on periodontal health are partially because of the
heterogeneity of the materials and differences in the
research methods employed (32). According to a recent
systematic review, there is no clinically significant
irreversible periodontal tissue destruction as a consequence of placement of orthodontic appliances (33).
Specific long-term clinical and radiographic findings
support the fact that periodontal disease develops in
regions where orthodontic bands are placed and leads
to statistically significant loss of attachment (approximately 05 mm) (34, 35). A comparative clinical trial
concluded that molars with bands present greater
gingival inflammation, plaque accumulation and loss
of attachment compared to bonded molars (34).
Mechanical irritation from the band or from remnants
of the bonding cement, along with trapped plaque
have been implicated (8). However, controversy exists
in this issue as short-term clinical studies revealed a
negative influence in subgingival ecosystem but no loss
of attachment (14, 36), while other comparative studies
concluded to no difference in microbial or clinical
periodontal parameters concerning banding compared
to bonding (13, 23). Additionally, a recent study could
not identify mature biofilm on bands obtained after the
end of orthodontic treatment (37).

Orthodontic treatment considerations


There is no contraindication for orthodontic treatment
in adults with severe periodontal condition. On the
contrary, sometimes orthodontics may be necessary to
improve the possibilities of restoring a deteriorated
dentition (30). In patients with reduced periodontium,
the periodontal ligament surface that receives forces is
diminished, and the biological and biomechanical

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conditions differ when compared to teeth with normal
periodontal support. In periodontally compromised
teeth, the centre of resistance is displaced apically
following the anatomical elements of the periodontium,
thus resulting in the expression of greater moments
during force application and an increase in the extrusion component of the applied force (38).
The use of condign biomechanical systems and units
for increased anchorage is essential for additional
control of tooth position especially in the vertical
dimension (38). Skeletal anchorage devices such as
orthodontic mini-screws, mini-plates or even dental
implants that serve as anchorage units are used especially when the present teeth are inappropriate. Additionally, mini-screws can be used for anchorage in
adjunctive orthodontic treatment when the patient
does not want full fixed appliances. The desired force is
applied directly or indirectly to the skeletal anchorage
unit, allowing better control of movements in three
dimensions with little or no loss of anchorage (39).
Alternatively, the use of occlusal forces (e.g. bite plates
or occlusal splints) may sometimes be a valuable help
for vertical control of the position of teeth, as well as for
anchorage enhancement or for dissocclusion of selected
teeth facilitating planned tooth movement.
Treatment should be performed with the simplest
possible orthodontic systems to avoid circumstances
that favour increased dental plaque accumulation,
which will happen inevitably to a certain degree in
most cases. One precaution is to avoid using wire loops
and elastomeric ligatures and remove immediately the
excess of bonding material during bracket placement.
Self-ligating brackets or wire ligatures are considered
preferable, instead of elastomeric ligatures, as the latter
favour plaque accumulation and certain periopathogens deleterious to gingival conditions (11, 40). However, a comparative clinical study on 100 subjects did
not find a significant difference concerning plaque
accumulation and periodontal parameters between
conventional brackets with elastomeric ligatures and
self-ligating brackets (41). A short-term comparative
clinical study revealed that bracket design also has a
significant impact on bacterial load and on periodontal
parameters, but this has to be further investigated with
long-term studies (42). Despite the inconclusive results
presented in the literature, bonding instead of banding
the molars appears to be a safer solution for reasons
previously stated. In patients with intact periodontium,
treatment with the Invisalign system seems to be more

favourable for periodontal reasons compared to labially


or lingually fixed appliances (43, 44).

Orthodontic tooth movement in a


compromised periodontium
Movement of teeth with infrabony defects
Orthodontic movement of teeth with infrabony defects
towards the lesion can be successfully accomplished in
the absence of inflammation and adequate control of
the bacterial plaque. Although there is little evidence in
humans, a well-designed recent clinical trial on 10
subjects has shown that orthodontic tooth movement
towards the infrabony defect combined with intrusion
and surgical periodontal therapy results in significant
clinical attachment gain and in radiographic bone fill.
Appliance of orthodontic forces was almost immediate
10 days after surgical periodontal treatment (45).
Certain animal studies agree with the evidence from
humans. On rats, tooth movement into the infrabony
defect resulted in a decrease in the defect and
subsequent bone fill (46, 47). On the other hand,
studies on dogs (31, 48, 49) and other primate studies
(50) agree that in an inflammation-free environment,
there is elimination of the endosseous defect, without
attachment gain, but with a long epithelial junction. It
should be noted that in animal studies the repair of the
bony defects could be solely attributed to the metabolic
characteristics of the bone tissue of each species, which
may differ significantly from the human alveolar bone
metabolism.

Orthodontic extrusion
A recent clinical study on 10 orthodontically treated
patients with intact periodontium concluded that
extrusion of mandibular incisors resulted in displacement of the gingival margin and the mucogingival
junction by 80% and 525%, respectively, of the total
amount of extrusion (51). These observations are also
corroborated by animal studies that have shown similar
results: during extrusion, the relation between the bone
margin and the cementoenamel junction remains
unchanged (52); the free gingiva follows the tooth
90% and the attached gingiva 80% of the distance,
while the mucogingival junction remains in the same
position (53). Thus, in cases where movement of bone
margin and attachment along with the tooth is not
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ORTHODONTICPERIODONTIC INTERRELATIONSHIP
desirable (as in crown-root fractures), there is a need
for periodical circumferential supracrestal fiberotomy at
the start and every 2 weeks during orthodontic extrusion (54).
According to experimental studies and clinical reports, orthodontic extrusion of teeth with one or two
wall-infrabony defects results in a more favourable
position of the connective tissue attachment and
reduction in the defect (5557). Despite the lack of
strong evidence, these are considered important findings, as it is known that the presence of one-wall
infrabony defect is a contraindication for guided tissue
regeneration (GTR) techniques and that in wide infrabony defects the prognosis of these procedures is
poor (3).
Orthodontic extrusion of non-restorable teeth prior
to implant placement appears to be a viable alternative
for conventional bone augmentation procedures in
implant recipient sites. It is suggested to apply low
constant forces, with a rate of extrusion not >2 mm per
month and labial root torque to increase the buccolingual thickness of the alveolar ridge. The retention
period before tooth extraction should exceed 1 month.
The total treatment time is possibly shorter compared to
surgical augmentation. Further research is necessary to
clinically compare the results of this procedure with the
conventional approach to determine added benefits
(58).

Orthodontic intrusion
In 2007, Erkan et al. (19) concluded that during
orthodontic intrusion of lower incisors in patients with
intact periodontium, the gingival margin and the
mucogingival junction moves apically 79% and 62%
of total intrusion, respectively. Regarding periodontally
affected teeth, sufficient clinical data suggest that
(a)

(b)

intrusion of teeth can considerably improve the level


of attachment when there is absolute control of
inflammation and bacterial biofilms (30, 45, 5961)
(Fig. 2a and d). These beneficial results were also found
to be considerably stable in long term (12-year followup) in periodontally compromised patients (30). In
2004, Re et al. (61) reported similar findings, as they
noted 50% reduction in recessions after intrusion of
periodontally compromised teeth, independent of the
width of gingiva. The use of light forces (515 gr per
tooth) is recommended to move teeth efficiently and
probably reduce the amount of root resorption (59).
This is of capital importance in teeth with reduced
periodontium as the specific implication results in
further loss of periodontal support and increase in
crown-root ratio.
Similar results were reported, in primates where the
gingiva followed the tooth, 60% of the total intrusion
distance, provided there was adequate control of
bacterial plaque (62). The importance of the plaque
control during intrusion was denoted in an animal
study on dogs where teeth intrusion in presence of
bacterial plaque led to the creation of infrabony defect
and loss of attachment (63).
There is no clear indication concerning the timing of
GTR in cases of teeth that require orthodontic intrusion.
Selected case reports mention that the implementation
of GTR procedures before orthodontic intrusion results
in the formation of new bone and attachment gain (64,
65). Other reports suggest that intrusion may deepen a
certain osseous defect and improve blood circulation
creating better conditions for GTR procedures (66, 67).

Molar uprighting
Orthodontic uprighting of mesially tipped molars is
accompanied by the elimination of osseous defects.
(c)

(d)

Fig. 2. Orthodontic correction of gingival margin discrepancy and formation of new interdental papilla between maxillary central
incisors. (a) Pre-treatment clinical condition, (b) orthodontic treatment in the maxillary arch, (c) correction of gingival margin discrepancy
and form of new interdental papilla between maxillary central incisors accomplished by orthodontic intrusion of the maxillary left central
incisor and approximation of the maxillary central incisors (patient refused proximal recontouring), (d) stable results 3 years after
orthodontic treatment.
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Moreover, there is improvement in pocket probing
depth and in crown-root ratio (68). However, in molars
with furcation involvement, there is an increased risk of
aggravation of the periodontal problem during the
orthodontic uprighting procedure (69). A valid alternative for a tipped mandibular molar is to split the tooth
into two roots that (one or both) can be moved
orthodontically into new positions, even though this
is considered to be a difficult procedure (70).

Movement in edentulous areas


Orthodontic movement of teeth in edentulous areas
with reduced alveolar ridge height is usually possible
with minimal loss of alveolar bone (71, 72). The
movement should be parallel and performed with low
orthodontic forces. However, even under optimal conditions, further loss of bony support can be detected
(73). In cases of reduced buccolingual width of the
alveolar ridge, tooth movement through cortical bone
may be retarded and also buccal and lingual bone
dehiscences may develop. In such cases, bone augmentation procedures to increase the alveolar bone width
have been suggested before orthodontic movement
(64).
Experimental studies on dogs confirm the beneficial
effects of the bodily movement of the tooth into the
defect. More precisely, the tooth side displaced towards
the defect (pressure side) presents an increase in the
alveolar bone height, while on the tension side the
bone level remains unaltered (74). It should be noted
that in all animal experiments the bony defects are
relatively recent with neither much loss of alveolar
bone height and buccolingual width, nor installation of
cortical bone as it frequently occurs after long term in
dental extraction sites.
Labial tooth movement proclination
These movements represent the most viable method to
resolve crowding and are frequently considered to
produce gingival recession especially in the region of
lower incisors (7577). It is stated that lingual tooth
movement results in increased labiolingual width of
labial gingiva and slight incisal migration of gingival
margin, while labial movement has the opposite
impact. The most important predisposing factor for
the development of gingival recession during or following orthodontic treatment is the reduced thickness

of soft tissue and bone in the region (78, 79). It is


believed that if the orthodontic movement is performed
within the genetically and or functionally predetermined bone envelope of the tooth, there is no risk of
recession (80).
In 2002, Djeu et al. (75) in a retrospective clinical trial
did not find a correlation between orthodontic labial
inclination of mandibular central incisors and age with
gingival recession. Similar results were reported in 2001
by Artun and Grobety (81), on a sample of adolescents
with pre-treatment dentoalveolar retrusion. In the
same line, Ruf et al. in 1998 (82), in 98 children and
adolescents did not find a significant correlation
between proclination of mandibular incisors caused by
Herbst appliance and gingival recession. Concerning
adults, a longitudinal study published in 1987 (83)
showed significant correlation between the incidence
and the severity of recession with excessive proclination (>10) of mandibular incisors. Three years after the
end of active treatment, the observed changes were
minimal indicating a stable condition. Melsen and
Allais in 2005 (76) concluded that the factors related
to the development or aggravation of recessions in adult
orthodontic patients are the presence of baseline recession, gingival biotype, width of keratinized gingiva and
visual gingival inflammation. Yared et al. in 2006 (77)
stated that in adults subjected to orthodontic treatment,
the factors associated to the incidence and severity of
gingival recession of mandibular central incisors are
final inclination (>95) and free gingival margin thickness (<05 mm), with thickness having greater relevance to recession than final inclination. However, a
recent longitudinal study by Ari-Demirkaya and Ilhan
in 2008 (21), in adults with mandibular prognathism
subjected to orthognathic surgery, concluded that the
decompensation process that requires excessive labial
tipping of the mandibular incisors did not have any
negative effect on periodontal structures. The abovementioned studies lend support to the bone envelope
theory.
Labial tooth movement or tooth proclination per se
does not cause gingival recession, but in specific cases
can result in thin soft tissues or bone dehiscences that
comprise low-resistance regions to inflammation or
trauma (79). This statement is corroborated by studies
on primates (84) and dogs (85, 86). Based on similar
observations, several authors suggest that the thickness
of periodontal tissues should be surgically increased
before orthodontic tooth movement when it is esti 2010 Blackwell Publishing Ltd

ORTHODONTICPERIODONTIC INTERRELATIONSHIP
mated that it will cause bone dehiscence (76, 79, 86).
On the other hand, animal studies have shown that no
such precaution is necessary for lingual movement of
labially displaced teeth with dehiscences, as it leads to
new bone formation and soft tissue thickness augmentation (87, 88). Usually, in these cases, even in the
presence of recession, the need for periodontal intervention should be evaluated after the completion of
orthodontic treatment (79). However, in 2000 Pini
Prato et al. (89, 90) compared surgically treated versus
nonsurgically treated cases with buccally erupted premolars and recommended that in buccally erupted
teeth mucogingival interceptive surgery should be
accomplished before orthodontic therapy to maintain
the width of keratinized gingiva in the long term. Given
the controversy, it seems that the issue of the optimal
timing to perform recession coverage or soft tissue
thickness augmentation in an overall treatment plan
needs further scientific support by randomised, controlled clinical studies.

Periodontal treatment schedule


When planning orthodontic treatment in adults with a
history of periodontal disease, it is suggested to allow 2
6 months from the end of periodontal therapy until
bracket placement, for periodontal tissue remodelling,
restoration of health and evaluation of patients compliance. The patient should practise sound oral hygiene
and fully understand the potential risks in case of noncompliance (91). It should be kept in mind that the
critical pocket depth for maintaining periodontal health
with ordinary oral hygiene is 56 mm (92).
Regenerative periodontal techniques (periodontal
therapy with GTR or enamel matrix derivatives) are
usually implemented before orthodontic treatment
(10 days4 months) to create favourable preorthodontic conditions in complex clinical scenarios. Case reports
and case series, implementing this approach, report
encouraging results (64, 65, 9395) (Fig. 3). Nevertheless, other reports suggest that GTR can also be
performed after orthodontic treatment when it is
estimated that the planned tooth movements will
create a better environment for the performance and
effectiveness of the technique (66, 67). The timing of
GTR remains to be clarified with adequate clinical
studies.
In case of thin periodontal tissues, the width of soft
periodontal tissues must be enhanced prior to labial
2010 Blackwell Publishing Ltd

(a)

(b)

(c)

Fig. 3. Guided tissue regeneration (GTR) procedure followed by


orthodontic treatment. (a) Pre-treatment radiographic condition.
(b) Four months after GTR procedure in the mandibular central
incisors region just before orthodontic treatment. (c) Four years
after the end of orthodontic treatment and the placement of the
retainer, sufficient bone support of the mandibular left central
incisor is maintained.

orthodontic tooth movement, when it is estimated that


otherwise the planned movement will result in the
development of bone dehiscence (76, 79, 86). However,
in cases of lingual movement of teeth with thin
periodontal tissues, there is no clear recommendation
as both the approaches (before or after orthodontic
treatment) need further investigation. The determination of the optimal timing for implementing preventive
mucogingival surgery in an overall treatment plan as
well as the optimal timing for applying orthodontic
forces (e.g. in early healing phase or 6 months after
surgery) need to be further investigated with randomised comparative clinical studies.
During orthodontic treatment, professional cleaning
and examination of periodontal tissues should be
performed routinely (91). The specific interval varies
for each patient (few weeks to 6 months), and it should
be determined considering the analysis of risk factors
for periodontal disease and the planned tooth movements. Thorough tooth cleaning and scaling is suggested at short intervals when intrusion and new
attachment is attempted (59). If the patient fails to
maintain high level of oral hygiene, orthodontic treatment should be interrupted.
Elective periodontal treatment should be implemented during the final stages of orthodontic treatment
or even later, when the final position of hard and soft
tissues can be safely determined. The decision is individualized depending on the clinical characteristics of the
case and the comprehensive treatment plan (6, 96, 97).
After the end of active orthodontic treatment and
appliance removal, the patient should receive renewed

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oral hygiene instructions for reducing the risk of
recession, because plaque removal and tooth cleaning
will be more easily performed. Also, patients should be
introduced to a programme of regular follow-up visits
to the periodontist and the orthodontist. The timing
between follow-up visits is prescribed by the team
according to the severity of the patients pre-treatment
condition and the prognosis of the post-treatment
condition.

Interdisciplinary management of aesthetic


problems
Three aesthetically unpleasant defects may need confrontation during orthodontic treatment: (i) irregularity
in vertical position of gingival margins, (ii) loss of
interdental papilla and (iii) gummy smile. These problems may require an interdisciplinary approach including periodontal surgery, enameloplasty, restorative
procedures, tooth movements and various combinations of the above or other interventions.

Uneven gingival margins


Ideally, in an aesthetic smile, the gingival margin of the
maxillary centrals should lay 1 mm below their cementoenamel junction and be at the same level as the
margins of the cuspids. Those of the lateral incisors
should be 12 mm lower than the margins of the
adjacent teeth (98).
According to Kokich (98), the proper management of
uneven gingival margins should be based on the
analysis of the following criteria. First of all, it must
be examined if the discrepancy is visible during talk or
smile. If not, any intervention is considered overtreatment. When the problem is visible and the patient
wants to restore it, the clinician must proceed with an
evaluation of probing depth of the dentogingival sulcus
of the teeth involved. If the probing depth is different, a
gingivectomy may correct the problem. If not, evaluation of clinical crown length should follow to determine whether extrusion of the tooth with the longer
clinical crown and subsequent grinding of its incisal
edge will end in the desirable result. Finally, it must be
evaluated if the gingival margin discrepancy is caused
by passive eruption of the tooth (Fig. 2a), which might
be followed by abrasion of its incisal edge. The overerupted teeth should be intruded with light orthodontic
forces (Fig. 2). Orthodontic intrusion should be accom-

plished 6 months prior appliance removal to reduce risk


of relapse (99). Possible restorative needs of the patient
must be taken into consideration.

Missing interdental papilla


Another aesthetic problem that may require an interdisciplinary approach is the missing interdental papilla.
In an average adult orthodontic population of 337
subjects, the prevalence of post-treatment open gingival
embrasures in the maxillary incisors region was 38%.
The same study, in a subsample of 119 patients, found
that increased distance from the alveolar bone to the
interproximal contact, shorter and more incisally positioned interproximal contacts, increased embrasure
area and divergent or triangular-shaped crown forms
are parameters associated with open gingival embrasures after orthodontic therapy, while post-treatment
maxillary central incisor root angulation is slightly
convergent in normal gingival embrasures (100). Also,
according to a recent cross-sectional study, in randomly
selected periodontal patients, the interradicular distance between adjacent teeth and the distance from the
base of the contact area to the bone crest affect the form
and the shape of the interdental papilla (101).
Usually, when the papilla is lost as a result of
advanced periodontal disease which involves loss of
interdental alveolar crest, the aesthetic improvement in
the situation requires a combination of enameloplasty
(interproximal reduction), tooth movement and selective addition of composite resin (98). After proximal
recontouring and orthodontic teeth approximation, the
interdental soft tissues are compressed and form a new
papilla (Fig. 2). If this is not enough for the remodelled
tissue to cover the area of the papilla, direct-bonding
resin can be added to lower the contact point and create
the illusion of a healthier papilla.
Loss of interdental papilla may also result from
diverging roots of adjacent teeth (100). In this case,
the inclination of the roots must be evaluated through a
periapical radiograph, followed by proper alignment of
teeth. If the aesthetic appearance is not fully restored,
the option of enameloplasty can be adopted (98).
Some patients have wide, triangular or bell-shaped
teeth. Thus, the contact point lies at the incisal edge of
the tooth resulting in the development of black triangles (100). Interproximal enamel reduction along with
closure of the resultant diastema is sufficient in most
cases to restore the missing papilla (98).
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ORTHODONTICPERIODONTIC INTERRELATIONSHIP

Gummy smile
In conformity to the present aesthetic standards, maxillary gingival display in an attractive adult smile will
range between 1 and 2 mm. The specific parameter is
increased in children and is reduced progressively
with ageing (102). Clinicians should always consider
patients age in diagnosis and treatment planning of
gummy smile (103). Increased gingival exposure may
be attributed to different causes, which designate the
appropriate management: vertical growth of the maxilla, retardation of the physiological apical migration of
gingival margins, extrusion of maxillary anterior teeth
and anatomical considerations.
Patients with excessive vertical growth of the maxilla
usually present clinical crowns with normal dimensions
and healthy gingiva. In growing patients, growth
modification should be considered to inhibit vertical
growth with orthopaedic forces, while management of
this condition in adults possibly demands orthognathic
surgery including Le Fort I osteotomy and maxillary
impaction (104).
Certain patients present significant retardation of the
physiological apical migration of gingival margins,
which occurs during childhood and adolescence until
the margins occupy their adult position (97, 98). These
patients usually present thick gingival biotype or fibroid
gingival tissues and probing depth of gingival sulcus of
approximately 34 mm, sometimes even without clinical signs of inflammation. Main clinical features of this
type of gummy smile are the short clinical crowns and
the apparently increased labiolingual thickness of gingival tissues. This condition is most of the times evident
in patients who are 1215 years of age and is an
indication for mucogingival aesthetic surgery, as normal gingival margin migration may require several
years to be completed (98). However, when the
aesthetic problem is not severe enough, aesthetic
interventions to reshape or reposition gingival margins
should be postponed and re-evaluated in early adulthood, because in adolescence significant alterations of
the shape and the position of gingival level are likely to
occur (96, 97).
Sometimes a gummy smile may be attributed to
extrusion of maxillary anterior teeth. It frequently
happens in Angle class II, division 2 malocclusions. The
indicated treatment usually includes orthodontic intrusion of maxillary incisors, which is expected to eliminate the gummy smile (105).
2010 Blackwell Publishing Ltd

In 2003, Sarver and Ackerman (106) stated that


gummy smile caused by decreased philthrum height of
the upper lip may be effectively corrected by V-Y
cheiloplasty, practically covering the gummy smile with
the upper lip. In the same direction, Polo in 2008 (107)
recommended the use of Botox for the neuromuscular
correction of excessive gingival display on smiling
achieving satisfactory, but transitory results. The longterm effect of these approaches needs further testing
before recommending them in clinical practice.

Prevention of relapse
Relapse of orthodontic treatment has been attributed to
increased elasticity of gingival tissues that are compressed towards the direction of tooth movement (108).
Remodelling of supra-alveolar fibres continues to take
place even after a period of 46 months (109). It seems
that after the end of orthodontic treatment, the retention period should exceed 12 months to provide
appropriate time for remodelling of the periodontal
fibres (110).
Certain authors report that the stability attributed to
soft periodontal tissues can be accomplished by the
following factors: (i) orthodontic overcorrection, (ii)
adjunctive periodontal surgery, (iii) combination of the
above (1, 111) and (iv) long-term fixed retention.
Overcorrection is beyond the scope of this article and
thus will not be further discussed.
Minor periodontal surgery could be beneficial in
particular cases. After the orthodontic closure of diastemas subsequent to extractions, there is increased
tendency for relapse and reappearance of diastema
between the approximated teeth. Surgical removal of
the stressed interdental soft tissues after closure of the
diastema seems to prevent relapse (112). In cases of
maxillary midline diastema, it is often advisable to
perform a frenectomy after the orthodontic closure to
alleviate relapse. However, this approach presupposes a
sound diagnosis, as there is a general consensus among
scientists regarding the existence of a causeeffect
relationship between the presence of thick frenum
with high insertion and the maxillary midline diastema
(113). The circumferential fiberotomy of supracrestal
gingival fibres has been proposed for preventing relapse
of teeth that were severely rotated prior to treatment.
This procedure alleviates relapse without harmful longterm effects in periodontal health (111, 114). Incisions
at the labial or lingual side of teeth should be avoided

385

386

N . G K A N T I D I S et al.
when the gingival biotype is thin, because there is risk
of recession. Bisection of the interdental papilla by two
vertical incisions (labially and lingually) extending from
below the tip of the papilla to 12 mm below the level
of the alveolar crest can be a good alternative for these
cases (115). This technique is less invasive and safer for
the periodontal tissues; therefore, it is the best choice
for the anterior aesthetic zone.
The long-term results of interproximal reduction
combined with circumferential fiberotomy in preventing orthodontic treatment relapse were investigated by
Boese in 1980 (111). This retrospective clinical study on
40 patients treated for crowding reported that interproximal reduction and fiberotomy resulted in remarkable long-term stability and healthy periodontal tissues
without the need of additional retention measures.
Every action that intends to prevent relapse should
be performed immediately after the completion of
orthodontic movement. Supportive surgical procedures
of soft periodontal tissues are usually performed at the
final stage of orthodontic treatment, few weeks prior to
appliance removal. It is essential to retain teeth in their
desired position at least for a few weeks during healing,
either using the same orthodontic appliances (passive)
or with a retainer (1).
Permanent retention of the result of orthodontic
treatment is indispensable in patients with significantly
reduced periodontal support (27). Probably, the most
appropriate method for retention is the coaxial multistranded stainless steel wire retainer bonded to the
lingual side of each tooth (Fig. 3c). This retainer is easy
to fabricate, not visible, and it allows teeth to retain
their physiological mobility (116). Despite that certain
clinical studies demonstrate a negative influence of
lingual fixed retainers in periodontal parameters (117,
118), other studies demonstrate that in the long-term
this does not result in clinically significant changes
(117, 119). Removable retainers should be avoided,
because they can exert forces that cause uncontrollable
jiggling to the teeth with unpredictable consequences
on the periodontal tissues (38). In patients with loss of
teeth or occlusal trauma, progressive mobility, migration or pain on function, retention should be accomplished by prosthetic reconstruction. Usually,
conventional partial restorations (120), resin-bonded
fixed partial dentures (30) and splints (30, 120) are
placed. As demonstrated by a recent report, the use of
fibre-reinforced composite resin (121) may be an
equally effective, but much less invasive alternative.

Conclusions
Harmonious cooperation of the general dentist, the
periodontist and the orthodontist offers great possibilities for the treatment of combined orthodonticperiodontal problems. Undoubtedly, application of oral
hygiene measures is difficult during orthodontic treatment. Orthodontic treatment along with patients
compliance and absence of periodontal inflammation
can provide satisfactory results without causing irreversible damage to periodontal tissues. Furthermore,
orthodontic treatment can expand the possibilities of
periodontal therapy in certain patients, contributing to
better control of microbiota, reducing the potentially
hazardous forces applied to teeth and finally improving
the overall prognosis. Participation of the periodontist is
also essential, either in management of orthodontic
periodontal problems or in specific interventions aiming to prevent orthodontic treatments relapse.
Comprehensive knowledge of the fields of periodontology and orthodontics along with close co-operation
among clinicians widen the spectrum of the available
treatment options in many circumstances. Usually, the
interdisciplinary approach leads to an optimal qualitative, functional and aesthetic management, providing
the best treatment plan in complex clinical situations.
Despite the great significance of co-operation between orthodontists and periodontists, in particular
aspects of combined orthodonticperiodontal treatment
analysed in the present review, there is considerable
lack of sound scientific evidence. The decision regarding
the time of intervention and the sequence of periodontal and orthodontic procedures is sometimes inevitably
based on clinical experience, published case reports or
case series and subsequent arbitrary assumptions.
Therefore, there is a strong need for further research
in certain directions through well-designed studies to
provide patients with evidence-based treatment.

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Correspondence: Nikolaos Topouzelis, Ass. Professor, Department of
Orthodontics, School of Dentistry, Aristotle University of Thessaloniki,
GR-54124, Thessaloniki, Greece.
E-mail: ntopouz@dent.auth.gr

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