Case Report

Perio‑ortho interdisciplinary approach

in a 50‑year‑old patient: A case report
with 5‑year follow‑up
Swati Agarwal, Krishna Kumar Chaubey, Abhinav Chaubey,1
Raghu Raghav Agarwal

Departments of
Periodontics and
1
Conservative Dentistry
and Endodontics,
Kothiwal Dental College
and Research Centre,
Moradabad,
Uttar Pradesh, India
The work belongs to the
Superspeciality Dental
Clinic, A Multispeciality
Clinic, 173, Awas Vikas
Colony, Moradabad, UP,
244001
Abstract:
Esthetic demands for correction of irregularities of dentition are becoming a prime concern even in patients
above the age of 40 years. Severe periodontitis, being insidious, if present simultaneously, complicates
the situation. Periodontally compromised adult patients requiring the treatment for malaligned teeth are
encountered very frequently in daily practice, and the correction of these requires a combined perio‑ortho
interdisciplinary approach. The present case report deals with a 5‑year follow‑up of a case whose prime
concern was rotated anterior teeth in the maxillary arch. However, along with this, severe periodontitis was
also present. Open flap debridement along with osseous grafting was done wherever required, followed
by fixed adjunctive orthodontic treatment. After the completion of orthodontic treatment, a fixed retainer in
the form of splinting was given and the entire treatment met the esthetic along with functional demands of
the patient. Early 6 months followed by yearly follow‑ups reflected clinical and radiographic improvements
in the dentition.
Key words:
Adjunctive orthodontics, esthetic, open flap debridement, periodontitis, perio‑ortho

Access this article online INTRODUCTION CASE REPORT

Website:

C
www.jisponline.com hronic periodontitis is considered to be the
DOI: disease of adulthood, and is characterized
10.4103/jisp.jisp_651_20 by various problems among which one is the
Quick Response Code: malalignment/pathological migration of the
teeth. This, when occurs in the esthetic region
or in areas interfering with the maintenance and
occlusion, demands correction. Moreover, in the
modern era when everyone is more concerned
with prolonged retention of the natural dentition
and esthetics both, patients demand for it.
This increases the need for management of
periodontal defects and malalignment, and
ultimately adjunctive orthodontics in the
elderly. [1] Hence, such type of cases needs
Address for
correspondence: multidisciplinary management and co‑operation
Dr. Swati Agarwal, among the periodontist, orthodontist, and
Department of endodontist.
Periodontics, Flat No.
AG/1, Campus Kothiwal
The present case report deals with the
Dental College and
Research Centre, Mora multidisciplinary management in a 50‑year‑old
Mustaqueem, Kanth Road, patient who was having severe periodontitis
Moradabad ‑ 244 001, and rotation of the maxillary incisors. The
Uttar Pradesh, India. prime concern of the patient was mobility of
E‑mail: swatibds86@gmail. teeth and esthetics. Hence, proper co‑ordination
com between the three specialties and regular
periodontal monitoring helped in managing the
Submitted: 08-Sep-2020
Revised: 16-Dec-2020 periodontal and orthodontic problems for the
Accepted: 31-Jan-2021 last 5 years. The patient is kept under regular
Published: 01-Nov-2021 follow‑up.
© 2021 Indian Society of Periodontology | Published by Wolters Kluwer - Medknow 549
A 50‑year‑old  patient was initially attended by
a general dentist who provided him primary
treatment as scaling and root planing and
then referred him to our clinic. He had a chief
complaint of pain, mobility in teeth, occasional
bleeding from gums, and crowding of anterior
teeth. Detailed interrogation revealed that
bleeding from gums was mostly while brushing
for more than a year, sensitivity to hot and cold
since the last 6–7 months, progressive mobility
and overlapping of upper front teeth, and
halitosis [Figure 1]. Clinical examination revealed
the presence of probing depths ranging from
2 to 5 mm with multiple Grade 1 mobile teeth
and rotation of anterior teeth with crowding. In
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How to cite this article: Agarwal S, Chaubey KK,
Chaubey A, Agarwal RR. Perio‑ortho interdisciplinary
approach in a 50‑year‑old patient: A case report
with 5‑year follow‑up. J Indian Soc Periodontol
2021;25:549-52.
 Agarwal, et al.: Adult orthodontics post severe periodontitis management

relation to tooth #14, deep pocket ranged from 9 to 11 mm at

its different aspects. This tooth was nonvital on electronic pulp
testing with Grade II mobility. Radiographically, generalized
bone loss could be appreciated and angular defect along with
root resorption could be appreciated in tooth #14 [Figure 2].
Keeping the abovementioned clinical and radiographic features
in mind, and an urge to improve the esthetics by the patient,
an endo‑perio‑ortho multidisciplinary treatment approach
was planned.

Treatment provided
Treatment was started with Phase I therapy comprising oral
hygiene instructions, scaling, root planing, occlusal corrections,
and occlusal splinting of #14 with #15. After this, the patient
was kept on periodontal evaluation, and simultaneously,
a randomized control trial of #14 was also done. Once the
patient started following the oral hygiene instructions
Figure 1: Preoperative
properly, surgical management of tooth #14 was planned.
Full‑thickness flap was raised and complete degranulation was
done [Figure 3] followed by placement of the bone graft in the
visualized defect area [Figure 4]. The flap was then sutured
using Mersilk 4‑0 suture (Ethicon, Johnson & Johnson, Pvt.
Ltd.). He was then discharged with postoperative instructions,
antibiotic therapy for 5 days (amoxicillin 500 mg thrice a
day), analgesic (ibuprofen 400 mg thrice, if there was pain),
and chlorhexidine mouthwash (twice a day). The patient was
recalled after 10 days for suture removal and revaluation. He
was kept on maintenance phase, every 15 days, for the next 3
months. The nonsurgical periodontal therapy in other areas
resulted in clinical improvement and reduction in probing
depth in the range of 2–3 mm.

Three months postoperatively, orthodontic treatment was

started using metallic brackets (MBT.022” slot) and very
mild force [Figure 5]. The orthodontic treatment was started
escaping the bracket on tooth #14. The de‑rotation of the right
maxillary central incisor was brought about in approximately Figure 2: Preoperative radiograph
5 months. However, in order to retain the tooth in its place,
the brackets were kept on for another 6 months. Following
the orthodontic treatment, permanent retention in the form of
splinting was done. The patient was kept on regular 3‑month
follow‑up [Figure 6].

The present case is a report of 5‑year follow‑up [Figures 7‑9]

in which relapse of any kind is not seen, clinically as well as
radiographically. The patient is happy with healthy dentition,
both esthetically and functionally, though at reduced
periodontal support.

DISCUSSION

Adult orthodontics is usually considered as orthodontics

beyond 35 years of age. This happens in a group of people who
could not get orthodontic treatment due to ignorant parents or
have now become financially independent to afford it. Older
adults, usually above 50 years of age having multiple dental
Figure 3: Post debridement of granulation tissue
problems, may require adjunctive orthodontics as a part of
complete treatment. Thus, with the increase in geriatric patients
and their esthetic demands, adult orthodontics is becoming necessary to control disease, restore function, and/or enhance
the need of hour. According to Proffit et  al., “Adjunctive appearance.”[1] In the present case, it was needed for control
orthodontic treatment for adults is, by definition, tooth of periodontal disease in the adult of 50 years of age who
movement carried out to facilitate other dental procedures exhibited generalized loss of attachment, with 9–11 mm of

550 Journal of Indian Society of Periodontology - Volume 25, Issue 6, November-December 2021
 Agarwal, et al.: Adult orthodontics post severe periodontitis management

Figure 5: Post bracket placement

Figure 4: Bone graft placed in the defect site

Figure 7: Five years post treatment

Figure 6: Post treatment completion

Figure 9: Five‑year postoperative radiograph

planned. Three months following the completion of periodontal

treatment, orthodontic treatment was started with the lightest
0.014” nickel–titanium wire, skipping the bracket on #14 with
the intention not to disturb the healing osseous lesion.
Figure 8: Post treatment radiograph

During orthodontic tooth movement, the tooth moves with

pockets in tooth #14 at different sites, and rotation of anterior
teeth. The patient’s prime concern was esthetics in respect to
maxillary anteriors and mobility in some teeth. Thus, it was
an obvious multidisciplinary case requiring approaches from
various dental disciplines. Hence, with the patient’s consent,
a combined perio‑endo‑ortho multidisciplinary approach was
its socket and the movement is possible without jeopardizing
periodontal support in the presence of adequate plaque
control.[2] It has been demonstrated that the compression
in the periodontal ligament for about 4 h causes changes
in the chemical environment producing different patterns
of cellular activities.[3] Focal adhesion kinase appears to be

Journal of Indian Society of Periodontology - Volume 25, Issue 6, November-December 2021 551
 Agarwal, et al.: Adult orthodontics post severe periodontitis management
the mechanoreceptor in periodontal ligament cells, and
their compression leads to release of prostaglandin E2 and
interleukin‑1 beta.[4] Increased concentration of the receptor
activator of nuclear factor-kappa B ligand (RANKL) in gingival
crevicular fluid during orthodontic tooth movement suggests
that periodontal ligament cells under stress may induce
formation of osteoclast cells through upregulation of RANKL.[5]
Studies of cellular kinetics indicate that osteoclasts arrive in two
waves: in the first wave, they may be derived from a local cell
population, while in the larger second wave, they are brought
in from distant areas via blood flow and remove bone in the
frontal resorption and tooth movement begins.[6]
Both the amount of force delivered to a tooth and the area of
periodontal ligament over which that force is distributed are
important in determining the biological effect. The periodontal
response is determined not by force alone, but by force per unit
area. In tipping movement, only a partial area of periodontal
ligament is under pressure. Hence, forces must be kept quite
low not exceeding approximately 50 g.
The aim of adjunctive orthodontics is to provide periodontal
health by eliminating plaque retentive areas and improve the
contour of the periodontium to a self‑maintainable level, as far
as possible. Through continuous periodontal monitoring and
application of advanced periodontal treatment, orthodontic
management is possible even in adult patients. This favorable
physiologic and realistic occlusion has little to do with Angle’s
idealistic occlusion, as is observed in this 54‑year‑old patient
during 5‑year follow‑up. The treatment is possible because of
minutely, and carefully taking care of the periodontal status
at every step.
552 Journal of Indian Society of Periodontology - Volume 25, Issue 6, November-December 2021
To conclude, a better understanding of the tissue behavior
and broader treatment modalities help in discovering cures
for situations which were otherwise deemed to be impossible
before. With the advancement in the interdisciplinary
treatment approaches, esthetics can be improved through
adult orthodontics even in patients with reduced periodontal
support, under strict periodontal invigilation and monitoring.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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1. Proffit WR, Fields HW, Sarver DM. Special Considerations
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2. Melsen B, Agerbaek N, Markenstam G. Intrusion of incisors in
adult patients with marginal bone loss. Am J Orthod Dentofacial
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3. Khouw FE, Goldhaber P. Changes in vasculature of the
periodontium associated with tooth movement in the rhesus
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