Periotiorirology 2000, Vol.
9, 1995, 132-149
Pririterl in L)rnmui-k . All rights reserved
Orthodontics and periodontal
therapy
ROBERTL. VANARSDALL
Periodontal care should be directed toward elimin-
ating the bacterial infection and preventing reinfec-
tion. This involves creating an environment more self-
cleaning and less conducive to harboring pathogenic
bacteria. Appropriate therapy for each individual de-
pends on the type, severity and morphology created
by the specific disease, but patient compliance is also
a factor. Areas accessible for plaque removal by one
person may not allow for effective oral hygiene by
a less motivated individual. Regardless, elimination
of as many plaque-retentive areas as possible should
be an objective. Large numbers of teeth are extracted
in an effort to eliminate periodontal defects (defects
that represent bacterial reservoirs) that could be cor-
rected by simple tooth eruption.
Our objectives in therapy must be realistic. Oral
hygiene measures used alone have been ineffective
in removing inflammation in deeper diseased sites of
periodontal pockets. In addition, clinical trials have
shown that regular and short-interval prophylaxis by
a hygienist may prevent disease. Unfortunately, large
groups of patients are not always as compliant with
suggested or recommended maintenance schedules
as the study patient groups that have been reported
(42). Idealistic oral hygiene demands may not be re-
alistic for many patient groups. Less-motivated dis-
eased individuals can be cared for and treated in a
way that would best prevent or minimize the
chances of reinfection as much as possible. Overtre-
atment for one patient might be considered negli-
gent care if not provided for another, depending on
demands, needs and personal circumstances.
Indications for and
contraindications to
tooth movement
Although orthodontic services have not been con-
sidered protective or directly related to the control
132
C o p y r i g h t 0 Munksgaard 1995
PERIODONTOLOGY 2000
ISSN 0906-67i3
of periodontitis (6), one of the most dramatic means
available to improve local environmental factors is
through tooth movement. Tooth movement can be
used to modify the site specificity of the disease pro-
cess and to enhance the potential for long-term
maintenance. Periodontally susceptible patients
who have experienced shifting, migration, extrusion,
flaring and lost teeth can benefit from tooth move-
ment to correct local etiological factors, predisposing
malpositions and certain bony and periodontal
pockets. Solutions to occlusal problems may require
repositioning teeth to establish buccolingual land-
marks, eliminate interferences, re-establish incisal
guidance and correct loss of vertical dimension.
Clearly delineated treatment objectives should be es-
tablished before any appliances are placed. The
most common indications and contraindications in-
volving adjunctive tooth movement are listed in
Table 1.
For patients with advanced disease and large
numbers of deep pockets, surgery (ostectomy) may
be contraindicated. Eruption of individual teeth can
reduce pocket depth, provide physiological gingival
and osseous topography, preserve the maximum
amount of attachment apparatus and prepare a pa-
tient for long-term maintenance.
Prior to irreversible tooth replacement and re-
storative dentistry procedures, tooth movement can
allow for proper tooth preparation and parallel abut-
ments, create pontic spaces, improve crown-to-root
ratios, correct mucogingival and osseous defects, es-
tablish occlusal landmark relationships, provide
proper embrasure spaces and achieve the most
favorable distribution of teeth (34). Furcation-
involved abutments for restorative dentistry are con-
sidered to have a guarded or poor prognosis. Abnor-
mal tooth position for the highly periodontally sus-
ceptible patient needing restorative care may create
inaccessible areas, poor gingival contour and other
adverse local etiological factors. Distobuccal root
contacts with adjacent teeth can be repositioned for

Table 1. Adjunctive tooth movement: indications/contraindications
Indications
1. Adverse gingival topography, root proximity, embrasure
space, open contacts, lack of parallelism, poor
distribution of abutments
2. Flared anterior tooth, lip incompetency, lack of incisal
guidance
3. Buccolingual landmark discrepancy preventing selective
grinding for stability and redistribution of force
4. Severe curve of Spee and locked-in occlusal scheme
with occlusal trauma or restorative needs
5. Severely tipped teeth
6. Occlusal trauma with pseudo-Class 111 anterior
crossbite, posterior crossbite, primary contact in
centric relation
7. Improvement in gingival and osseous defects, poor
crown-to-root ratio, unlevel bone between teeth
8. Anterior deep bites and occlusal trauma with gingival
trauma, retrograde wear, locked bites
9. Anterior open bites and occlusal trauma with lack of
incisal guidance
10. Severe occlusal trauma/excessive mobility, muscle
spasm, severe retruded contact position, maximum
intercuspal position discrepancy, need to establish
vertical dimension, need for selective grinding
Contraindications
1. Lack of inflammatory control prior to, or lack of
maintenance of periodontal health during, tooth
movement
2. Lack of occlusal control (occlusal traumatism,
parafunctional habits) for periodontally susceptible
enhanced plaque control and reduced possibility of
furcation caries.
Improved self-maintenance of soft tissue health is
noted in patients following correction of accentu-
ated mesial drift and bite collapse.
Once the teeth have been aligned, the tissue dem-
onstrates less tendency to bleed on gentle probing
and therefore may require less frequent root planing
and curettage to control or prevent further peri-
odontal breakdown. A recent study shows more
plaque accumulation on malposed teeth as com-
pared with contralateral well-aligned teeth (12). An
acceptable level of mechanical plaque control re-
quires an oral environment that enables the patient
to remove plaque.
Uprighting abutment teeth improves osseous and
soft tissue topography (5). Leveling the bone be-
tween individual teeth and correction of osseous de-
fects can be done by active appliances or through
disarticulation, selective grinding, and allowing
natural tooth eruption to reduce or eliminate associ-
Orthodontics and wriodontal therauv
Appliance and tooth movement
Fixed appliance: alignment, tipping, translation
Fixed and removable appliances: retraction, upping, torque
Fixed and removable appliances: tipping, translation
Fixed appliance: leveling occlusal plane
Fixed appliance: uprighting, tipping
Fixed appliance: retraction, tipping
Fixed appliance: eruption, tipping, intrusion
Fixed appliance: intrusion
Fixed and removable appliances: eruption, retraction
Hawley bite plane for occlusal eruption, rest, and reduction of
muscle hyperactivity
3. Short roots or idiopathic root resorption
4. Inability to retain individual teeth followingmovement
or to secure a restorative commitment in cases of
mutilation. severe skeletal dysplasias, or muscular habit
problems
ated aberrant topography. Forced eruption has been
reported to reduce osseous defects and to help in
the management of fractured teeth (13, 14). For peri-
odontal patients with bone loss on individual teeth,
the clinical crown can be reduced with a high-speed
handpiece; and as the tooth is erupted orthodon-
tically (the same amount of bone will remain on the
clinical root), the crown-to-root ratio will become
more favorable. Tooth movement in dogs resulting
in intrusion has been shown to shift a supragingival
plaque into a subgingival position, thereby changing
a crevicular epithelium into a pocket epithelium and
causing loss of attachment (7).However, in spite of
rapid and extreme extrusion in the presence of yeri-
odontal inflammation in dogs, increased crestal
bone levels were found, along with reduced bleeding
on probing, a shallow sulcus depth and less gingival
inflammation (36). This reduction in gingival in-
flammation with orthodontic extrusion is probably
due to a shift from disease-associated microorgan-
isms to the flora found in gingival health (35).
133
Vanarsdall
Moving a tooth into a periodontal defect has been
shown in monkeys to create a long epithelial attach-
ment rather than new attachment (23).
Tooth movement may be necessary to allow for
correction of occlusal problems. Deep bites can
cause trauma to the gingiva (called periodontal
trauma) and excessive force or retrograde wear on
anterior segments. Patients with anterior open bites
or severe Class 11, division I malocclusions have inef-
fective incisal guidance, allowing for cross-tooth in-
terferences and excessive forces. A recent study has
shown that alveolar bone height in 19-year-old men
was reduced in regions where severe malocclusion
(8 mm of overjet) existed compared with corre-
sponding regions in healthy men with near ideal oc-
clusion (4). Correction of discrepancies between re-
truded contact position, and intercuspal position
and lateral interferences may require tooth move-
ment to line up buccolingual landmarks and regain
incisal guidance.
Though clinicians have used tooth movement to
help stabilize the occlusion and selective grinding to
reduce trauma and mobility, not all studies have
been able to relate malocclusion to periodontal dis-
ease (8, 27). Not only have clinical studies been con-
flicting and comparison of results has been difficult,
but clinicians have been reluctant to accept that oc-
clusion has any relationship to the pathogenesis of
periodontal diseases. This may be due to a limited
ability to correct or have corrected certain types of
occlusal etiology. For example, selective grinding
(the most frequently used form of periodontal oc-
clusal therapy) as a definitive technique can best be
used in a Class I skeletal pattern with an intact den-
tition and sufficient enamel present to accomplish
the “take-away” procedure. Very few periodontally
involved patients have these three clinical prerequi-
sites. The child with Class 11, division I malocclusion
who has been corrected orthodontically to a Class I
skeletal and dental relationship can be more suc-
cessfully and conservatively managed occlusally as
an adult if occlusal therapy is required for peri-
odontal reasons. This finding is an important factor
in adult patients who develop significant periodontal
disease and require occlusal therapy.
Complete orthodontic treatment or limited tooth
movement can be an adjunct to prevent or intercept
disease progression and even be therapeutic from a
periodontal standpoint. However, to obtain these
benefits from “properly executed” tooth movement,
the periodontiurn must be properly prepared. Dis-
ease activity should be reduced with thorough root
planing and curettage, as indicated in the following
134
section. Regular intervals for periodontal mainten-
ance should be continued as necessary throughout
orthodontic therapy, and attachment levels and
bleeding on probing should be monitored. Any al-
veolar defect in an extraction site edentulous ridge
should be repaired by bone grafting and guided
tissue regeneration to establish a normal alveolus
before tooth movement.
Identification of environmental
characteristics of high-risk
orthodontic patients
The short- and long-term successful outcome of or-
thodontic treatment is influenced by the patient’s
periodontal status before, during and after active or-
thodontic therapy. The long-term prognosis of a
natural dentition depends significantly on optimal
responses and systemic resistance or predisposition
of the patient to different clinical forms of peri-
odontal diseases. Periodontal pathogenesis is a
multifactorial etiological process, and all members
of the dental team must recognize the clinical forms
of inflammatory periodontal diseases.
An orthodontic patient may be at greater risk of
attachment loss once teeth have become mobile be-
cause of tooth movement. A recent study suggests
that tooth mobility may constitute a risk factor for
periodontal breakdown due to an increased subgin-
gival prevalence of specific periodontopathogens
(11).It has further been shown that even in the pres-
ence of healthy teeth with increased tooth mobility,
there is an increased probing depth that would indi-
cate increased periodontal risk in the patient suscep-
tible to periodontal disease (33). The clinical signs of
inflammation and tooth mobility must be recog-
nized and controlled during treatment to prevent ex-
tensive bone loss. Periodic monitoring of the peri-
odontal status with probing, microbiological assess-
ment by immunological assays, DNA probes and
culturing as well as clinical findings are useful in de-
termining scaling intervals and in detecting poten-
tial sites of increased risk of attachment loss. These
methods may be used to assess the endpoint of the
effectiveness of scaling and root planing before or-
thodontic treatment to ensure that no putative
pathogens remain. Genetic studies offer potential to
identify high-risk individuals, such as family niem-
bers of localized juvenile periodontitis patients with
neutrophil chemotactic abnormalities, who are 10
times more likely to develop periodontal disease
than most family members.

Prevalence of recession
% gingival recession.
0Expanston ond edgewise
E Z 3 Edgewise only
40
6o
20
I
I 20
6
n
1 2
Fig. 1. Wenty percent (11 of 55) of the expanded cases
exhibited gingival recession, as compared with only 6%in
the edgewise-only treatment group. The hypothesis that
recession is evenly distributed across expanded and edge-
wise groups was rejected (P=0.0025).
Tronsverse skeletal dimension
(MX-MX)
I Recession
U No recession
50
1 2 3 necessarily be causative in nature. In this regard, the
Time
Fig. 2. From the histogram, note that all of the 55 ex-
panded patients at TI had a maxillary (MX to MX) trans-
palatal dimension of approximately60 mm (deficient)and
were expanded at the bony base 4 to 5 mm at T, and at T3
(final time period). The basal skeletal increase remained
stable and only increased with time 0.33 mm. There was
little difference in the maxillary skeletal dimension of the
(1 1 [dark screen]) patients who experienced gingival re-
cession and the patients (44 [lighter screen]) that did not
experience recession. The relationship between maxillary
and mandibular widths was critical to evaluate, and this
proportional evaluation identified the 11 individuals with
gingival problems.
Clinically identifiable high-risk factors
Individual patients must be assessed to determine
whether periodontal factors exist that may place the
patient at greater risk than normal for developing
periodontal disease during orthodontic therapy. The
clinician must identify the susceptible patient and
Orthodontics and periodontal therapy
develop strategies to prevent loss of attachment and
Significant past dental history could be unsuccess-
ful orthodontic treatment at an earlier age. In ad-
dition, the patient who has had a history of previous
periodontitis is more susceptible to the disease pro-
cess. Although it is difficult to predict which sites may
progress from gingival inflammation to periodontitis,
the group with previous disease is more vulnerable to
further bone loss. In fact, it has been reported that, for
individuals who have shown a history of previous
bone loss, gingivitis may be a greater threat to further
bone loss (18).No one should begin orthodontics with
active destructive sites, and a person who has had
periodontal disease previously should be more
closely monitored to prevent development of new
bursts of active sites that may result in rapid bone loss.
A small percentage of adolescents (10%) and a much
larger group of susceptible adults (50%) must be
treated differently. Other risk factors include gingival
bleeding upon probing, tooth mobility and thin, fri-
able gingival tissue. In addition, tobacco use and dia-
betes have been shown to be risk factors for a higher
prevalence of periodontal disease (2,9).
Skeletal relationships and gingival recession
A risk marker would be a characteristic that would
identify patients who are likely to have periodontal
disease, even though this characteristic may not
transverse skeletal pattern may be the most critical
evaluation when assessing the potential for facial
gingival recession. In a study on patients from two
private orthodontic practices conducted at the Uni-
versity of Pennsylvania, 55 patients (ages 8 to 13 at
the time of treatment with a Haas expander) were
recalled 8 to 10 years after rapid palatal expansion
(consisting of 10 to 10.5 mm of expansion over a 3-
week period) and compared with 30 control patients
(matched for age) from the same practices, who were
evaluated for stability and clinical crown height after
edgewise nonexpansion (32). The patients were as-
sessed from models, Kodachrome slides, posterior/
anterior cephalograms before treatment and at the
end of orthodontic treatment; they were recalled 10
years later for examination and new records. The re-
sults indicated that of the expanded cases, although
extremely stable, 20% exhibited unusual facial gingi-
val recession on one or more teeth as opposed to
only 6% gingival recession in the nonexpanded con-
trol patients (Fig. 1). Skeletally, 9 of the 11 patients
who had undergone expansion and experienced fa-
135
Vanarsdall
Fig. 3. A, B. Pre-orthodontic buccal views of a 9-year-old,
Class 11, Div 1, girl with a 9 mm narrow maxilla and an
excessive (wide) mandible in the transverse dimension
without posterior cross-bite. C, D. Note normal gingival
tissue in buccal segments after completion of orthodontic
cia1 gingival recession had maxilla transverse de-
ficiency along with mandibular transverse excess
and the other 2 patients had excessively large man-
dibles (Fig. 2). Therefore, in the adolescent patient
who has a small maxilla and a large mandible, there
is potential to move teeth beyond the envelope of
the alveolar process and predispose a patient to gin-
136
treatment that involved orthopedic expansion.
E, F. Models 10.8 years after completion of orthodontic
treatment. Note the gingival recession in maxillary buccal
segments bilaterally observed years after the patient is not
wearing appliances.
gival recession (Fig. 3 ) . The envelope of discrepancy”
for the transverse dimension is much more critical
from a stability and periodontal standpoint. Un-
treated susceptible adults with significant transverse
skeletal discrepancy exhibit advanced stages of de-
structive periodontal disease (Fig. 4). Hundreds of
adult orthodontic retreatment patients have been

given excellent stability following surgically assisted
rapid palatal expansion to correct transverse skeletal
discrepancy. Growth in the transverse dimension is
severely slowed by 15 years of age and has been re-
ported to be essentially completed (1, 3). Therefore,
early orthodontic treatment in the deciduous or
early mixed dentition is ideal to correct transverse
skeletal abnormalities orthopedically, while growth
is significantly active and palatal separation is most
effective. It has been well established that expansion
of buccal segments with fixed appliances has limi-
tations and tends to be unstable, regressing toward
pretreatment widths (24). Orthopedic expansion of
the palate has been studied with the use of implants.
This study confirmed 50% dental movement and
50% skeletal movement in young children. In adoles-
cents, however, only 35% of the movement was skel-
etal and 65%was dental (15).
Therefore as the young patient becomes older,
there is greater dental tipping, which places teeth at
higher risk for gingival recession (Fig. 5). Lindhe (16)
has stated that when, “during orthodontic treatment
a tooth is moved through the envelope of the al-
veolar process ... at sites with thin and inflamed gin-
giva”, there is “a risk that gingival recession may oc-
cur” (16). The labial plate of bone in the maxilla is
extremely thin on the facial surfaces of the teeth (Fig.
6). The buccal plate in the mandible is thin in the
coronal thirds from the first molar area, moving
anteriorly and is considerably thinner in the pre-
molar/incisor areas. Facial movement of the teeth
into thin tissues has been tested in monkeys. Exten-
a Proffit’s envelope of discrepancy indicates that there
are limits in millimeters of movement with tooth move-
ment alone (inner circle of each diagram), possible
changes from combined orthopedic and orthodontic
treatment in growing individuals (middle circle) and
limits of change with combined orthodontic and surgi-
cal treatment in three planes of space. The envelopes
for the transverse dimension depicted in the premolar
areas for the maxillary and mandibular arches are much
smaller than incisors in the anteroposterior plane of
space.
Transverse envelope diagram
Maxilla Mandible
Orthodontics and periodontal therapv
sive bodily movement of incisors in a labial direction
through the alveolar bone resulted in small apical
displacement of the gingival margin, which ap-
peared to be thinned by the tooth movement, and
the alveolar bone height was reduced (40).Less tooth
movement and greater orthopedic changes in the
transverse could be obtained by a surgical adjunct,
which has not been shown to create the adverse gin-
gival changes seen with orthopedic expansion in se-
vere skeletal transverse maxillary deficiency prob-
lems. The decision to use a surgical adjunct is based
upon comparing the maxillomandibular proportions
to individual normal variations. Correction of the
transverse skeletal discrepancy is accomplished 1) to
prevent periodontal problems (Fig. 7A-C); 2) for
greater dental and skeletal stability (Fig. 7D, E) found
in adult retreatment cases; and 3) for improved
dentofacial aesthetics by eliminating or improving
lateral negative space, which accompanies maxillary
transverse deficiency.
Tissue response to certain types of tooth
movement
Age-related changes occur in the skeleton and al-
veolar bone with increasing age, and there is an in-
creased lag period or delayed response to mechan-
ical force in adults that is greater than that seen in
younger patients. However, teeth move equally well
in adults as they do in children, and there is no evi-
dence that teeth move at a slower rate for adults.
Regardless of the direction a tooth is moved in a
healthy periodontium, the bone around the tooth re-
models without the supporting tissues experiencing
damage. The bone should follow the tooth in
changes of position, and this principle is used to
create favorable alveolar changes in patients with
periodontal defects. Significant evidence exists that
uprighting of mesially inclined molars reduces
pocket depth and improve altered bony morphology
(5, 43). The bone on the mesial is erupted a the mo-
lar is tipped distally. Every dentist has seen teeth
erupt, and as a tooth moves occlusally, the healthy
alveolar process moves with it. In chronic inflam-
mation as a tooth erupts, the alveolar bone is lost
and the tooth appears to extrude out of the peri-
odontal tissues. In molar uprighting the connective
tissue attachment on the mesial of the molar and to
the crestal bone creates tension and allows for re-
modeling of the bone.
There are clinical ranges of force that are biologic-
ally acceptable to the periodontium. It is helpful to
remember that, because tooth movement is primar-
137
Vatiarsdall
Fig. 4. A. Untreated 54-year-old C-111 (prognathous) male
with advanced periodontal disease exhibiting severe
transverse skeletal discrepancy and bilateral posterior
crossbite. B. Posteroanterior cephalometric tracing re-
veals severe maxilla deficiency (narrow) and mandibular
excess (wide). C, D. Pre-orthodontic 64-year-old C-I skel-
ily a periodontal ligament-induced phenomenon,
identical forces do not place the same stress on the
supporting tissues of different teeth. Root length and
configuration, quantity of bone support, point of
138
eta1 pattern with severe transverse skeletal problem and
advanced periodontitis. E. Maxillary occlusion view before
treatment. F. Nine months after correction of transverse
maxillary deficiency with orthodontics and surgically as-
sisted expansion.
force application and center of rotation come into
play to determine stress areas in the periodontal
ligament. To prevent potential tissue damage, it is
important to consider areas of maximal stress that
 Orthodontics and periodontal therapy

Fig. 5. A. Occlusal view of 12-year-old girl before rapid weeks post-expansion. Note 3 to 4 mm of gingival re-
maxillary expansion. B. Occlusal view several months cession on the first premolar that has been reported as an
after active expansion. C . Observe tissue level on the initial complication with rapid maxillary expansion
maxillary left first premolar before expansion. D. Several therapy.

Fig. 6. A. Skull material (exhibiting disease) exemplifies molar moving anteriorly and the thin labial bone that re-
how extremely thin to nonexistent the buccal bone is in mains especially where the mandibular teeth are lingually
the maxillary arch. In the mandibular alveolar process, compensated. B. Closer view of thin maxillary buccal
observe root exposure in the coronal thirds from the first bone.

139
Varia rsda 11

Fig. 7. A. A 25-year-old woman post-treatment orthodontic case in

which the skeletal pattern was normal in the sagittal and vertical di-
mensions. The severe transverse skeletal discrepancy was camouflaged
(moving teeth so that the occlusion has been corrected but the skeletal
discrepancy has not). The patient is unstable, teeth are mobile and she
exhibits significant gingival recession in buccal segments. B. Gingival
recession on maxillary and mandibular premolars. C. On the postero-
anterior cephalometric tracing, the maxillary width is narrow and the
mandibular width is wide. The maxillary basal distance (58 mm) and
the mandibular basal distance (92 mm) can only be evaluated from
the posterioanterior cephalometric radiograph. D. Adult female after
nonextraction orthodontic treatment and unsuccessful correction of
severe transverse skeletal problem. Note recession in premolar areas
and orthodontic instability. E. Same patient as in D after 4 premolars
had been removed and orthodontic retreatment in which the trans-
verse skeletal discrepancy is camouflaged. Observe recession on sec-
ond premolar and mandibular first molar.

might occur in the periodontal ligament. Bone loss
risk is increased as a result of inflamed connective
tissue located apical to crestal alveolar bone (371,
and certain types of forces may aggravate the pro-
gression of inflammatory periodontal disease (17).
Periodontal disease in the periodontal ligament
under stress has been shown in rats (between M1
and M2) where infectious inflammatory infiltration
spreads from the epithelial aspect into the trans-
septa1 ligament. These animals demonstrated com-

140

Fig. 8. From an unpublished thesis at the University of
Pennsylvania.A. Bar diagram indicates that 4 of 7 patients
who underwent molar uprighting over a 12-week period
without scaling and root planning had a percentage of
Bacteroides forsythus present upon initiation of tooth
movement on the mesial of the experimental molar as de-
termined by indirect immunofluorescence detection. Fol-
plete destruction of the transeptal ligament within
28 days (25).
Therefore, in an effort to prevent aggravated loss
of attachment or tissue damage, it is critical to deter-
mine maximal stress areas, which can occur crestally
or in the periodontal ligament. Although most tooth
movement involves combinations of movements,
clinicians tend to view movement more simply in
terms of intrusion, extrusion, tipping, translation
and torque. It is necessary to be very specific when
describing control of inflammation before each type
of tooth movement.
Eruption of teeth. Eruption or extrusion of a tooth
or several teeth along clinical crown height reduction
has been reported to reduce intrabony defects and
decrease pocket depth (13, 36). Single tooth eruption
should be distinguished from overbite correction
and control of vertical dimension during routine or-
thodontic correction. Extrusion of an individual
tooth is used specifically for correction of isolated
periodontal osseous lesions. Studies have shown that
eruption in the presence of gingival inflammation
reduces bleeding on probing, decreases pocket
depth and even produces new bone formation at the
alveolar crest as teeth erupt, with no occlusal factor
present and while controls remained unchanged
(35). Eruption or uprighting of molars without scal-
ing and root planing in human patients has been
shown to reduce pathogenic bacteria (31). During
clinical treatment, however, inflammation should al-
Orthodontics and periodontal therapy
lowing molar uprighting, patients 3, 4 and 5 had no B.
forsythus remaining and patient 7 had a 50% reduction.
B. Bar diagram indicates that patients 4 and 5 had Por-
phyromas gingivalis present before molar uprighting but
after molar uprighting the pathogen was not detectable.
At no control sites did the levels of E! g i n g k l i s decrease
during the experimental period and all sites were positive.
ways be controlled to ensure that the supracrestal
connective tissue remains healthy and that crestal
alveolar bone height remains at its original level.
In the double-blind molar-uprighting study at the
University of Pennsylvania (31), bacterial samples
were taken from the mesial pockets of molars to be
uprighted (experimental tooth) and from the contra-
lateral mesially inclined molar that served as the
control in each subject. Indirect immunofluor-
escence was used to identify Bacteroides forsythus,
Porphyromonas gingivalis, Prevotella intermedia,
and Actinobacillus actinomycetemcomitans. During
the study no scaling, root planing or subgingival in-
flammatory control was used. The study revealed
that, in all experimental sites (mesial to molar) that
exhibited the above microorganisms at the time of
bonding, their numbers decreased significantly at
the end of treatment (Fig. 8). However, Hawley bite
plates were worn by all patients to disarticulate the
molars during molar uprighting. In a similar study
of 10 patients over a 12-week period, assessing the
effects of molar uprighting on the microflora of hu-
man adults using DNA probes, it was found that
“Bacteroides”pathogens exhibited a decrease at the
experimental site with uprighting (22).
Eruption of a tooth is the least hazardous type of
movement to solve osseous morphology defects on
individual teeth created by periodontal disease or
tooth fractures. It is understood that extrusion of an-
terior segments in skeletal open bite patterns with
muscular problems have been shown to exhibit
141
Fig. 9. A. Adult woman with adult periodontitis after initial
periodontal preparation to eliminate i n f l ~ m a t i o nwas
treated orthodontically.B. Appliances were used to intrude
maxillary and mandibular incisors with light forces. C. Pre-
treatment mandibular anterior radiographs exhibit signifi-
cant horizontalbone loss, calculusanduneven incisaledges.
Fig. 10. A 37-year-old man with missing mandibular first
molars bilaterally. A. Lower right preoperative (test side)
view of side with defect in ridge. B. View of edentulous
area with tissue reflected. Note osseous defect mesial to
second molar. C. Preorthodontic periapical radiographs
with evidence of vertical defect mesial to the molar. Note
l l ~Postortho-
mesial attachment level r a ~ o ~ a p h i c aD.
dontic periapical rad~ographobserve evidence of bone
loss on the mesial of the second molar as the molar was
142
U. Posto~hodontic radiographs show evidence of angular
crests and infrabony defects which were created during in-
trusion of anterior segments. The goal of tooth movement
should be to level the alveolar crests between all teeth while
opening the bite. Source: Marks MH, Corn H, ed. Atlas of
adult orthodontics. Philadelphia: Lea & Febiger, 1989.
moved mesially to close the space. E. Lower left preortho-
dontic view of side without a vertical defect in the alveolar
ridge. F. Lingual view of area with tissue reflected (control
side). Note that there is no defect in the osseous ridge.
G. Preor~odonticperiapical radiograph of lower ieft be-
fore space closure. Note mesial attachment on second mo-
lar. H. Periapical r a d i o ~ a p hafter space closure. There is
no radio~aphicevidence of bone loss on the mesial of
the second molar after mesial tooth movement.
Orthodontics and periodontal therapy

143
Vanarsdall
shortening of the roots. If teeth have normal bone
support or if bone loss has been horizontal (alveolar
crests and cementoenamel junctions are level), then
movement should involve intrusion or extrusion as
necessary to correct the orthodontic deformity.
Intrusion of teeth. Conflicting evidence has been re-
ported regarding the benefits of intrusion of individ-
ual teeth. One study has reported intrusion of indi-
vidual teeth that did not result in development of
pockets (21). This same investigator reported earlier
that intrusion in monkeys induced increased new
attachment levels following flap operations to excise
pocket epithelium and to place an experimental
notch on the root (20). It is well known in peri-
odontal research that dogs and monkeys exhibit new
attachment during normal healing after surgical flap
procedures without tooth movement, and this has
been described (30). Others have observed that in-
trusion may result in root resorption, pulpal disturb-
ances and incomplete root formation in younger in-
dividuals (28). Clinicians have cautioned that in-
trusion of anterior teeth during leveling of the
occlusal plane to correct deep overbite can deepen
infrabony defects on individual teeth (19) (Fig. 9).
These conflicting reports indicate that intrusion can
be a more hazardous type of movement; since the
force is concentrated at the apex, root resorption has
been a well known sequela and light forces have
been recommended.
Intrusion has been reported to create altered
cementoenamel junction and angular crest relation-
ships along with only epithelial attachment to roots;
the periodontally susceptible patient is therefore at
greater risk for future periodontal breakdown. Tooth
movement, when properly executed, will improve
periodontal conditions and be beneficial to peri-
odontal health; extrusion is much more predictable
than intrusion to accomplish this purpose. Whenever
new connective tissue attachment or periodontal re-
generation to restore lost supporting periodontal
tissues is the treatment objective, the use of guided
tissue regeneration (such as barrier membranes) is
the predictable way to manipulate cells that lead to
new attachment. Guided tissue regeneration pro-
cedures should always precede orthodontic tooth
movement and should be part of initial therapy before
active orthodontic treatment is begun.
Tipping movement
When a single force is applied to the crown of the
tooth, the tooth can rotate around its center of re-
144
sistance (for an incisor, approximately the midpoint
of the root), and there is increased compression
(pressure) at the crest and at the root apex. In this
instance, one half of the periodontal ligament has
the potential to receive high pressure from essenti-
ally light force.
Experiments in the beagle dog demonstrated that,
with tipping and intruding movements, forces were
capable of causing a gingival lesion to be converted
to a lesion associated with attachment loss (7). In
tipping movements the force should be light and the
area kept clean to prevent the formation of angular
bony defects.
Bodily movement into a defect
It has been suggested that movement into infrabony
defects can result in healing and regeneration of the
attachment apparatus (10). In addition, peri-
odontists have believed that, in the presence of a
wide osseous defect adjacent to a tooth, if the tooth
were moved in order to narrow the defect, better
healing potential may be possible. Unfortunately, a
more recent study has shown that if infrabony de-
fects are created in the lower incisor area of rhesus
monkeys (undergoing good plaque control) and if
the tooth then is moved into and through the orig-
inal defect, a long epithelial attachment to the roots
is created, with no new attachment apparent (23).
The results, however, indicated that, even though
movement into infrabony periodontal defects did
not result in regeneration of attachment, no further
loss of connective tissue attachment occurred.
The most recent study performed in four beagle
dogs found that angular bony defects were created
and plaque was allowed to accumulate. Teeth were
translated into inflamed, infrabony pockets, and ad-
ditional attachment loss occurred on the teeth
moved into the infrabony pockets (41). It was there-
fore concluded that bodily tooth movement may in-
crease the rate of destruction of the connective
tissue attachment at teeth with inflamed, infrabony
pockets.
At the University of Pennsylvania, teeth have been
moved into defects with the patients’ contralateral
side serving as the control (Fig. 10). Radiographs re-
vealed that loss of attachment has occurred where a
tooth has been moved into a defect in an edentulous
area (Fig. 10a-d). It is possible to move the tooth
away from a defect and, with sufficient eruption, to
eliminate or reduce a bony defect, and this is usually
the treatment of choice to improve the osseous
architecture.

Fig. 11. A 31-year-old C-I1 Div 2 female with a retroposi-
tioned mandibular dentition. To satisfy facial aesthetics,
it is necessary to advance the lower dentition to establish
incisal guidance. A. Observe lower incisors being moved
labially as dictated by orthodontic demands. B. Later in
treatment, the lower anterior segment has been advanced
and the anterior teeth coupled. Note generalized preg-
nancy gingivitis (patient is 7 months pregnant) even
though patient is motivated and performs good oral hy-
giene. C. A 23-year-old severe C-I1 woman with thin gingi-
val tissue and several mm of recession on the mandibular
right lateral and left central incisor. A free gingival graft
Orthodontics and Deriodontal therasv
was placed in the lower anterior segment before ortho-
dontics. D. After completion of orthodontics, observe root
coverage by creeping attachment. The tissue has migrated
incisally to cover the roots. E. Observe the lower incisors
of a 27-year-old C-111 woman with thin hard and soft
tissue over the incisor area that predisposes to recession.
A free gingival graft was placed before the teeth were re-
tracted since retraction will not cause characteristically
thin tissue to become normal to thick with lingual move-
ments of the segment. E C-111 female after lower incisor
retraction. The thicker gingiva (created by the free graft)
provides a functional band of tissue during movement.
145
 A study involving closing edentulous spaces in the
mandible was performed on a group of 11- to 17-
year-old patients and compared with a group of 12-
to 46-year-old adults (29). The results indicated that
the older adults had more loss of crestal bone and
greater root resorption than the younger patient
group.
Mucogingival considerations
During tooth movement, the periodontal tissues
should maintain a stable relationship around the
cervical area of the tooth. An adequate amount of
attached gingiva is necessary to be compatible with
gingival health and to allow appliances (functional
and orthopedic) to deliver orthodontic treatment
without creating bone loss and gingival recession.
Clinical experience and animal studies have clearly
established that more pronounced, clinically recog-
nizable inflammation occurs in regions where there
is a lack of attached gingiva than in areas with a
wider zone of attached gingiva. Histologically, how-
ever, the teeth lacking gingiva were thinner in the
buccolingual dimension than those with a wide zone
of attached gingiva, but investigators reported that
inflammatory cell infiltrate and its apical extension
(degree of inflammation) were similar (38, 39). Two
studies have indicated that, as teeth are moved la-
bially and as tension is created on the marginal
tissue, the thickness of the gingival tissue on the
pressure side becomes important. With labial bodily
movement, incisors exhibited apical displacement of
the gingival margin, but no loss of connective tissue
attachment was apparent where there were no signs
of inflammation. Where inflammation was present,
loss of connective tissue attachment occurred (40).
If the tooth movement is expected to result in a re-
duced volume of soft tissue thickness and where an
alveolar bone dehiscence may have occurred in the
presence of inflammation, gingival recession is
Fig. 12.9-year-oldboy presented before orthodontics with
minimal gingiva, movable tissue and progressive clinical
crown recession on the mandibular central incisors. A. In
November 1976, a small free gingival graft was placed to
relieve labial frenum tension on the gingival margin and
arrest recession prior to orthodontics. B. Observe the graft
area over the mandibular central incisors after orthodon-
tic treatment 2 years later in November 1978. C, D. On
right and left lateral views, observe the clinical crown
heights 2 years later. E, F. On the right and left lateral
views, note gingival recession and exposed roots in buccal
146
therefore a risk. All orthodontic cases have gingival
inflammation, and bodily facial movement can pre-
dispose to gingival recession; to prevent this a gingi-
val graft can be used (Fig. 11).
The free gingival graft is the most versatile, most
widely used and most predictable procedure for gin-
gival augmentation (26).When it is performed before
recession occurs, it is considered to be less traumatic
and highly predictable and will prevent recession
during orthodontics. However, many periodontists
still feel with younger patients that a wait-and-see
attitude is acceptable because so many predictable
ways of correcting recession have become available.
Root exposure is most likely to be progressive in a
younger patient, since labial bone loss may be im-
possible to correct. It is essential to prevent it. There-
fore, clinical judgment and animal studies support
the need for creating a thicker gingiva that can better
withstand the inflammatory insult during tooth
movement.
The thin, delicate tissue is far more prone to ex-
hibit recession during orthodontics than is normal-
to-thick tissue. If there is a minimal zone of attached
gingiva or thin tissue (Fig. 121, particularly on abut-
ment teeth, a free gingival graft that enhances the
type of tissue around the tooth will help to control
inflammation; this should be done before beginning
orthodontic movement. Differences in alveolar
housing also should be evaluated. It is not necess-
arily true that a thin soft tissue is associated with a
thin labiolingual osseous support. All combinations
are seen, such as thick soft tissue with a thin labial
plate of bone. It is difficult to change the labial oss-
eous thickness (especially the thin type) that is
characteristic for the individual patient; however, it
is not difficult or traumatic to improve the soft tissue
with grafting procedures. The decision concerning
prophylactic periodontal procedures must be made
with consideration for, among other things, growth
and development, tooth position, type and direction
of anticipated tooth movement, oral physiotherapy,
segments but no recession on the lower central incisors.
The patient exhibits a significant transverse skeletal dis-
crepancy that has been camouflaged. G . Observe the lower
incisor area 9 years after the free gingival graft was placed.
H. 19 years later, the central incisors that received the free
gingival graft have not exhibited recession, but the right
lateral incisor that was not covered by the graft now shows
2 mm of labial root exposure. Normally occurring at-
tached gingiva has not prevented recession throughout
the month, but the incisor graft area is well maintained.
Orthodontics and periodontal therapy

147
Vanarsdall
Table 2. Diagnostic considerations in case
selection for grafting before orthodontic
treatment
Growth and development
Tooth position
Oral physiotherapy
Type of hard and soft tissue
Inflammation
9 Integrity of the muc
Profile considerations
Mechanotherapy to be use
Patient cooperation
-
Adapted with permission from Graber andvanarsdall. Orthodontics:
ciirrenl principles and techniques. St. Louis: Mosby, 1994.
integrity of the mucogingival junction, tissue type,
inflammation, muscle pull, frenum attachment, mu-
cogingival and osseous defects, anticipated tissue
changes and profile considerations (Table 2).
Critical evaluation of the periodontium before or-
thodontic treatment begins can prevent, minimize
or at least not aggravate an existing periodontal con-
dition.
Conclusion
No attempt has been made in this report to provide a
complete discussion of orthodontic and periodontal
interrelationships. The intent has been to highlight
frequent problem areas with different types of tooth
movement. Research information and documented
periodontal problems (gathered from clinical obser-
vation, clinical trials, animal research and retrospec-
tive analysis) are sufficient to allow the formulation
of clinical guidelines for achievement of orthodontic
objectives in problem cases; the ultimate objective
is that the patient will benefit from the treatment.
Periodontal problems have not been eliminated for
all orthodontic patients, but significant progress has
been made toward the prevention of many adverse
responses.
Clinical evidence remains overwhelming that
changing local environmental factors can improve
periodontal health and maintenance. In the future
one of the most fruitful areas for growth in dentistry
is periodontal and orthodontic interrelationships.
Solutions to advanced periodontal disease with mal-
148
occlusion involve a multidisciplinary approach. The
optimal treatment strategy for an individual can only
be based upon the most complete diagnostic data
base. This chapter has reviewed periodontal indi-
cations for tooth movement, the benefits and haz-
ards of different types of movement and the environ-
mental/clinical factors that may increase the prob-
ability that an individual may develop periodontal
disease during orthodontic treatment. The bacterial
challenge may be different for the orthodontic pa-
tient who must experience tooth mobility for tooth
movement to occur.
Major portions of this chapter are based on the
following texts:
1. Genco RJ, Goldman HM, Cohen DW. Contemporary peri-
odontics. St. Louis: Mosby, 1994. Chapter 43.
2. Graber TM, Vanarsdall RL. Orthodontics: current principles
and techniques. 2nd edn. St. Louis: Mosby, 1994. Chapter
13.
References
1. Baumrind S, Korn EL. Transverse development of human
jaws between the ages of 8.5 and 15.5 years, studied longit-
udinally with use of implants. J Dent Res 1990: 69: 1298-
1306.
2. Bergstrom J, Preber H. Tobacco use as a risk factor. J. Peri-
odontol 1994: 65 (suppl): 545-550.
3. Bjork A. Growth of the maxilla in three dimensions as re-
vealed radiographically by the implant method. Br J Orthod
1975: 4: 53-64.
4. Bjornaas T, Rygh E Boe OE. Severe overjet and overbite re-
duced alveolar bone height in 19-year-old men. Am J Or-
thod Dentofac Orthop 1994: 106: 13945.
5. Brown IS. The effect of orthodontic therapy on certain
types of periodontal defects. I. Clinical findings. J Peri-
odontol 1973: 44: 742-756.
6. Brown LJ, Garci R. Utilization of dental services as a risk
factor for periodontitis. J Periodontol 1994: 65: 551-563.
7. Ericsson I, Thilander B, Lindhe 7, Okamoto H. The effect of
orthodontic tilting movements on the periodontal tissues
of infected and non-infected dentitions in dogs. J Clin Peri-
odontol 1977: 4: 278-293.
8. Geiger AM, Wasserman BH, Thompson RH Jr, Turgeon LR.
Relationships of occlusion and periodontal disease. V. Re-
lation of classification of occlusion to periodontal status
and gingival inflammation. J Periodontol 1972: 43: 554-560.
9. Genco RJ, Loe H. The role of systemic conditions and dis-
orders in periodontal disease. Periodonto12000 1993: 2: 98-
116.
10. Geraci TF. Orthodontic movements of teeth into artificially
produced infrabony defects in the rhesus monkey: a histo-
logical report. J Periodontol 1973: 44:116.
11. Grant DA, Grant DA, Flynn MJ, Slots J. Periodontol micro-
biota of mobile and non-mobile teeth. J Periodontol 1995:
66: 386-390.

12. Griffiths GS, Addy M. Effects of nonalignment of teeth in
the anterior segments on plaque accumulation. J Clin Peri-
odontol 1981: 8: 481-490.
13. Ingber J. Forced eruption: a method of treating isolated one
and two wall intrabony osseous defects. J Periodontol 1974:
45: 199-206.
14. Ingber 1. Forced eruptions: a method of treatment of non-
restorable teeth; periodontal and restorative consider-
ations. J Periodontol 1976: 47: 203-216.
15. Kreba A. Midpalatal suture expansion studied by the im-
plant method over a seven year period. Trans Eur Orthod
Soc 1964: 40: 131-143.
16. Lindhe J , ed. Textbook of clinical periodontology. 2nd edn.
Copenhagen: Munksgaard, 1989.
17. Lindhe J, Svanberg G. Influences of trauma from occlusions
on progression of experimental periodontitis in the beagle
dogs. J Clin Periodontol 1974: 1: 3-13.
18. Loe H, Anerud A, Boysen H, Morrison E. Natural history of
periodontal disease in man: rapid, moderate, and no loss
of attachment in Sri Lankan laborers, 14 to 40 years of age.
J Clin Periodontol 1986: 13:431-440.
19. Marks MH, Corn H. Atlas of adult orthodontics. Philadel-
phia: Lea & Febiger, 1989: 134-135.
20. Melsen B. Tissue reaction following application of ex-
trusion and intrusion forces to teeth in adult monkeys. Am
J Orthod Dentofac Orthop 1986: 89: 469-475.
21. Melsen B, Agerback N, Markenston G. Intrusion of incisors
in adult patients with marginal bone loss. Am J Orthod
Dentofac Orthop 1989: 96: 232-241.
22. Morenzi V Assessment of the effects of orthodontic molar
uprighting on the microflora of human adult periodontal
tissues using recombinant DNA technology. Thesis. Phila-
delphia: University of Pennsylvania, 1989.
23. Polson A, Caton J, Polson AE Nyman S, Novak J, Reed B.
Periodontal response after tooth movement into infrabony
defects. J Periodontol 1984: 55: 197-202.
24. Riedel RA. Retention and relapse. J Clin Orthod 1976: 10:
454-472.
25. Rygh P. The periodontal ligament under stress. In: Norton
LA, Burstone CJ, ed. The biology of tooth movement. Boca
Raton, FL: CRC Press,1989: 9-27.
26. Seibert J. In: Robinson P, Guernsey L, ed. Clinical transplan-
tation in dental specialties, St. Louis: Mosby, 1980: 131.
27. Shaw WC, Addy M, Ray C. Dental and social effects of mal-
occlusion and effectiveness of orthodontic treatment.
Community Dent Oral Epidemiol 1980: 8: 36-45.
28. Stenvik A, Mjor I. Pulp and denture reactions to experimen-
tal tooth intrusion. Am 1 Orthod 1986: 57: 370-385.
Orthodontics and periodontal therapy
29. Stepovich ML. A clinical study on closing edentulous
spaces in the mandible. Angle Orthod 1979: 49: 227-233.
30. Vanarsdall RL. La reaction des tissues parodontaux aux
movements orthodontiqic. L'Orthodont Francaise, Ortho-
dontic De L'adulte, S.I.D., Vanves 1986: 57: 421-433.
31. Vanarsdall RL, Hamlin J. The effects of molar uprighting
on the microbiological flora of the periodontium. Thesis.
Philadelphia: University of Pennsylvania, 1987.
32. Vanarsdall RL, Herberger TA. Rapid palatal expansion:
long-term stability and periodontal implications. Thesis.
Philadelphia: University of Pennsylvania, 1987.
33. Vanarsdall R, Lemay 1, Lindhe J. The effect of tooth mobility
in probing depts. Compendium 1988: suppl 12: S533-S437.
34. Vanarsdall RL, Musich DR. Adult orthodontics: diagnosis
and treatment. In: Graber TM, Vanarsdall RL, ed. Ortho-
dontics: current principles and techniques. 2nd edn. St.
Louis: Mosby, 1994: 750-834.
35. Van Venrooy JR, Vanarsdall RL. Tooth eruption: correlation
of histologic and radiographic findings in the animal model
with clinical and radiographic findings in humans. Int J
Adult Orthod Orthognathic Surg 1987: 4: 235-247.
36. Van Venrooy JR, Yukna RA. Orthodontic extrusion of single-
rooted teeth affected with advanced periodontal disease.
Am J Orthod 1985: 87: 67-74.
37. Waerhaug J. The infrabony pocket and its relationship to
trauma from occlusion and subgingival plaque. J Peri-
odontol 1979: 50: 355-365.
38. Wennstrom JL, Lindhe J. Plaque-induced gingival inflani-
mation in the absence of attached gingiva in dogs. J Clin
Periodontol 1983: 10: 266-276.
39. Wennstrom JL, Lindhe J. The role of attached gingiva for
maintenance of periodontal health. Healing following ex-
cisional and grafting procedures in dogs. J Clin Periodontol
1983: 10:206-226.
40. Wennstrom JL, Lindhe J, Sinclair F, Thilander B. Some peri-
odontal tissue reactions to orthodontic movement in
makeup. J Clin Periodontol 1987: 14: 121-129.
41. Wennstrom j, Stokland BL, Nyman S, Thilander B. Peri-
odontal tissue response to orthodontic movement of teeth
with infrabony pockets. Am J Orthod Dentofac Orthop
1993: 103:313-319.
42. Wilson TG, Glover ME, Malik AK, Schoen JA, Dorsett D.
Tooth loss in maintenance patients in a private periodontal
practice. J Periodontol 1987: 58: 231-235.
43. Wise RJ, Kramer GM. Predetermination of osseous changes
associated with uprighting tipped molars by probing. Int J
Periodontics Restorative Dent 1983: 3: 69-81.
149