International Orthodontics 2022; 20: 100598

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Case Report
Ortho-Perio Risk Assessment and timing
flowchart for lingual orthodontics in an
interdisciplinary adult ortho-perio patient:
A case report of "Perio-Guided" Orthodontic
treatment

Roberto Kaitsas 1, Francesco Kaitsas 2, Gaetano Paolone 1, Maria Giacinta Paolone 1

Available online: 1 December 2021 1. Private Practice, Roma, Italy

2. Medical Student, Catholic University of the Sacred Heart, School of Medicine and
Surgery, Roma, Italy

Correspondence:
Roberto Kaitsas, Viale dei Quattro Venti, 233 00152 Roma, Italy.
robkaitsas@gmail.com

Keywords Summary
Adult orthodontics
Ortho-perio treatment Introduction > The treatment of ortho-perio patients is a challenge for the interdisciplinary team.
Tooth Movement Not only are adult patients with overt perio pathology involved, but any ortho patient, even young
Techniques ones, can be a perio patient and vice versa. Diagnosis and risk assessment of every ortho-perio
Lingual appliance patient is essential to establish a correct treatment plan, schedule and prognosis. Orthodontics
Miniscrew becomes a "Perio-Guided" Orthodontic Treatment and Periodontics a "Ortho-Guided Periodontal
Implant Treatment".
Material and methods > This case report presents a man with a very compromised dentition asking
for a complete interdisciplinary rehabilitation treated with a combined ortho-perio treatment in
lingual mechanics. The periodontal evaluation confirmed the possibility of performing orthodontic
treatment after active periodontal treatment. Treatment objectives were the resolution of the
crowding, the correction of the levels of the gingival margin, the bone levelling, the preparation
for restorative spaces; the objectives of the latter prior to implant placement were: redistribution of
space, optimization of the position of adjacent teeth and their parallelism, exploitation of
edentulous sites to correct dental class II and placement of the least number of implants possible.
After integrating the conventional perio risk assessment with a new Ortho-Perio Risk Assessment
(OPRA), a lingual fixed appliance was applied with the help of miniscrews to correct class II division
2 by substituting the upper right first premolar into a canine and retracting the entire upper arch,
while correcting the deep bite and optimising the occlusion.
Results > At the end of the treatment, the patient had molar relationships of class II on the right
and class I on the left with a class I canine and the 14 in the position of 13. Incisal relationships
were corrected, the position of the incisors was optimized, the spaces in the upper arch were fully
resolved by orthodontics. During the treatment, orthodontics corrected the uneven gingival margin
of the anterior teeth and levelled the bone.

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https://doi.org/10.1016/j.ortho.2021.10.006
© 2021 CEO. Published by Elsevier Masson SAS. All rights reserved.
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Case Report
Conclusions > Correct ortho-perio risk assessment (OPRA) is necessary to plan the risk of expression
of the periodontal phenotype in ortho-patient. OPRA and the lingual mechanics allowed an
orthodontic resolution of the malocclusion and an enhancement of the perio-implant-restorative
contributions. OPRA followed by periodontal therapy and lingual mechanics resolved the maloc-
clusion by improving the restorative peri-implant conditions. Orthodontists and periodontists
should be aware of the characteristics of the individual expression of the periodontal phenotype
at the beginning of treatment and involve patients in the outcome, sequencing of combined
treatments, ortho-perio retention and stability.

Introduction lip-chin sulcus at rest. No muscle pain, no TMJ problems, no CR-

The treatment of interdisciplinary patients is a challenge and an
opportunity to improve the synergy of the dental team. The
interaction between orthodontic and periodontal treatment
should always be kept in mind for every patient, regardless
of age. In the new vision of modern epigenetics, more and more
importance is given to external factors and habits that can lead a
patient to develop a disease that was latent and not yet
expressed; on the other hand, orthodontics can be a periodontal
treatment and vice versa. Orthodontic treatment must be diag-
nosed and performed as a "Perio Guided" Orthodontic Treatment
and Periodontal treatment may be reviewed as "Ortho-Guided
Periodontal Treatment". From this perspective, it is important to
evaluate every aspect that can be related to an overall risk
assessment in order to predict future phenotype expressions
[1]. Periodontology has widely reiterated the importance in the
literature in numerous references and enhanced the sensibility
to this feature concerning the importance of global risk assess-
ment including patient, tooth, site multiple levels of diagnosis
and evaluation [2–14]. However, when we consider the patient
not only from a periodontal point of view but also from an
orthodontic one, especially in the interdisciplinary and peri-
odontal orthodontic patient, we need to consider and evaluate
the risk factors not only from a conventional periodontal assess-
ment but also from an interconnected ortho-periodontal assess-
ment and this seems to be true in adult and young patients, with
an individual orthopaedic risk assessment (OPRA) [15].
Case report
This case report was an adult patient who had a very compro-
mised dentition and was treated with a combined ortho-perio
treatment in lingual mechanics.
Diagnosis and aetiology
A 37.4-year-old man was referred by his general dentist for
interdisciplinary treatment. His medical history was good (ASA I)
[16]. The man appeared healthy and had a normal facial appear-
ance with normal lip competence, but his smile was impaired by
crowding.
He had facial symmetry, slightly open naso-labial angle, reduced
neck-chin distance and competent lips with an increased lower
CO discrepancy were observed (figure 1). The opening move-
ments were symmetrical and within normal limits. At the
intraoral examination, the gingiva showed a diffused plaque-
induced gingivitis, calculus deposits and the oral hygiene had to
be improved before starting the treatment paying great atten-
tion to the probing. Intraoral photography shows the absence of
13, 16, 26, 36, 46, 37, 47; 17, 28, 38, 48 required restorative
treatment. The patient had a class II molar and canine relation-
ship, a 3 mm overjet and a 8 mm overbite. The maxillary and
mandibular arches were narrow with reduced space conditions;
the upper arch length discrepancy (A.L.D.) was of 5 mm and
the lower arch A.L.D was of 8 mm) (figure 1). The panoramic
radiograph confirmed the absence or the complete destruction
of the following permanent teeth 13, 16, 26, 36, 37, 46, 47. The
roots of the incisors appeared normal, as did the anatomy of the
condyle, mandibular canals, maxillary sinus and mandibular
margin. The 28 was impacted (figure 2). The cephalometric
morphological assessment showed a normal maxillary and
mandibular prognathism resulting in a normal sagittal jaw rela-
tionship. In the vertical dimension, the upper jaw was normally
inclined, but the mandibular inclination was decreased with a
tendency to hypodivergence. The upper incisors were clearly
retroclined, while the lower incisors had a normal inclination.
The overjet (3 mm) was partly of skeletal origin due to the
mandibular retrognathia but camouflaged by the retroclination
of the upper incisors which also justified the very open inter-
incisal angle. The lower incisors were quite normal in the face.
The deep overbite (8 mm) was of dental origin in an increased
vertical relationship of the jaws (table I). The occlusal plane was
compromised. The aetiology could be related to the functional
imbalance with both the upper incisors retroclination and in
mandibular retrognathia, and aggravated by tooth loss
(figure 2).
The patients had an Angle Class II division 2 of both dentoal-
veolar and skeletal origin with Class II molar relationship, deep
overbite of dental origin, absence or compromised teeth (13, 16,
26, 36, 37, 46, 47).
Treatment objectives
The objectives shared with the patient were:

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Case Report
Figure 1
Initial intraoral extra- and intraoral photos
Reproduced from Kaitsas R, Paolone MG. Orthodontics and Periodontology. Edra 2022 with permission

Figure 2
Initial X-rays: cephalometric, panoramic, full periodontal status and tracing
Reproduced from Kaitsas R, Paolone MG. Orthodontics and Periodontology. Edra 2022 with permission

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Case Report
TABLE I
Cephalometric values.

Pretreatment Post-treatment Out of retention Mean SD

Sagittal skeletal relations

Maxillary position 818 808 818 828 3.58
S-N-A
Mandibular position 798 788 798 808 3.58
S-N-Pg
Sagittal jaw relation 28 28 28 28 2.58
A-N-Pg
Vertical skeletal relations
Maxillary inclination 108 108 108 88 3.08
S-N/ANS-PNS
Mandibular inclination 318 328 328 338 2.58
S-N/Go-Gn
Vertical jaw relation 218 228 228 258 6.08
ANS-PNS/Go-Gn
Dento-basal relations
Maxillary incisor inclination 958 1068 1088 1108 6.08
1 – ANS-PNS
Mandibular incisor inclination 908 948 948 948 7.08
1 – Go-Gn
Mandibular incisor compensation 5 1 1 2 2.0
1 – A-Pg (mm)
Dental relations
Overjet (mm) 4 2 2 3.5 2.5

Overbite (mm) 8 2 2 2 2.5

Interincisal angle 1508 1398 1398 1328 6.08

1/1

 periodontal treatment phase; Treatment alternative and discussion of treatment

 resolution of crowding, for better access to oral hygiene;
 correction of the gingival margin levels;
 bone levelling and correction of overbite;
 preparation of pre-implant restoration spaces (redistribution of
space, optimization of adjacent teeth position and levelling
prior to prosthetic rehabilitation);
 exploitation of edentulous sites to correct dental class II and
minimize the number of implants;
 transforming 14 into 13.
After integrating the conventional perio risk assessment [11–
13] with a new ortho-perio risk assessment (OPRA) [15], a
lingual fixed appliance was applied with mini-screw auxil-
iaries to correct the class II division 2 and optimising the
occlusion.
plan
In this patient's case, the extreme dentoalveolar discrepancy
obliged to an extractive choice. This choice was dictated by an
obliged pattern due to the absence or compromission of many
teeth such as 13, 16, 26, 36, 37, 46, 47. Class II and occlusal
plane control could have been more easily treated surgically but
the patient refused and in the end the skeletal values were not
that compromised. No vertical control or modification of the
maxillary and mandibular inclination was necessary. The torque
of the upper incisors had to be corrected and maintained during
the class II correction with a correction of the interincisal angle.
The combination of miniscrews and Class II elastics was finally
planned for the correction of the canine Class I (with substitution
of the 14 in place of 13), incisors control and intercuspidation.

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Case Report
We planned a molar right therapeutic class II and a left molar
class I with closure of all maxillary spaces and replacement of
mandibular first and second molars with implants.
Treatment progress
Periodontal treatment phase
The patient was referred to a periodontist for a periodontal visit
(figure 3). The patient was diagnosed as periodontitis Stage II
localized Grade B [17,18] with medium-high periodontal risk
assessment (PerioRisk: 10) [11–13] and a medium risk
(value:22) according to the Ortho-Perio Risk Assessment (OPRA)
[15] (figure 4). After the first and the second step of periodontal
therapy [19] and the 3-months re-evaluation (figure 5) the
definitive perio-treatment with a protocol of periodontal sup-
porting care and 16, 36, 37, 46, 47 root extraction was
performed.
A lingual Kurtz 7th appliance was chosen with individual indirect
set-up.
After the initial preparation (levelling and alignment of the
arches), the correction phase followed with control of the torque
of the upper incisors, maxillary retraction 23-24-25-14-15, prep-
aration for anchorage. The archwire sequences consisted of
0.016 CuNiTi archwires, then 0.016 b-titanium archwires and
then a 0.017  0.017 b-titanium archwires with retraction loops
for a segmental torque of 12, using a palatal miniscrew between
25 and 27. Retraction was performed using a variant of conven-
tional lingual mechanics by retracting 14 and 23 first and then
only at a second time the upper incisors. Therefore, at a first
phase, the retraction concerned only the left premolar and Figure 3
canine segments with NiTi springs and TADs anchorage, while Periodontal probing at start of the treatment (Ramseier CA, Wolf
CA, The Online Periodontal Charting Tool, www.
performing the 27 mesialization and retraction of the left upper
periodontalchart-online.com, copyright © 2011, University of
premolars and 17 mesialization. Only in a second time the
Bern, Unitectra
torque of the upper incisors is over-corrected. This torque prep- Technology transfer reference number UB- 12/297)
aration is very important in lingual mechanics before retraction.
Retraction was carried out with a 0.017  0.025 b-titanium
archwire with retraction loops, class II elastics; an uprighting
relationships were corrected. Despite the missing of many
of the third molars is performed at the lower arch with NiTi
teeth, the atypical morphology of the molars, the molar occlu-
springs. In the last 6 months, during the orthodontic finishing,
sion of class II on the right and class I on the left a good
four implants were placed in the lower arch at the level of the
intercuspation is realised. The 38 and 48 should have been
edentulous ridges with a conventional osteotomy (figure 6). For
extracted but the patient refused. 14 was positioned on the
the retention phase, a 3-3 bonded retainer was chosen for
site of 13 and 14 was reconstructed. The upper central and
several years and a Hawley at night for several years.
lateral incisors were reshaped and reconstructed (figure 7). The
Treatment results lip function remained good. No muscle, joint or discrepancy
On extraoral examination, lip closure was normalized, the face problems developed. The panoramic radiograph showed that on
was harmonious and the smile was restored (figure 7). On 12, 14, 17, 27, 45, the second order angulations could have been
intraoral assessment, oral hygiene was quite good and the better controlled. On final periodontal probing, the patient
gingiva was healthy. Implants were placed to replace 36, 37, showed good plaque control (FMBS and FMPS < 20%) (figure 8)
46, 47. Despite periodontal supportive care, the patient's oral and the need to extract 38, 48.
hygiene was not always good throughout the treatment. Intrao- On cephalometric evaluation, the Class II malocclusion was well
ral examination shows a Class II molar occlusion on the right and corrected by dentoalveolar modifications. The position of the
Class I molar on the left and a Class I canine on the right, and on maxilla and of the mandible were stable maintaining a good,
the left if the 14 in 13 position is considered. The incisor sagittal discrepancy. The maxillary incisors inclination was

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R. Kaitsas, F. Kaitsas, G. Paolone, M.G. Paolone
Figure 4
Ortho-Perio Risk Assessment OPRA compiled for the patient
Reproduced from Kaitsas R, Paolone MG. Orthodontics and Periodontology. Edra 2022 with permission
corrected and the mandibular incisors inclination remained
stable. The mandibular incisors maintained a normal position
in the face. The overjet and overbite were normalized. The
interincisal angle was increased as expected. The maxillary
complex showed no rotation and maintained its inclination
throughout treatment. There was good vertical control. During
the two years of treatment, the vertical relationship of the two
jaws did not change, and superimpositions on the stable struc-
tures of the maxilla showed that the molars remained stable,
while the incisors were retracted, straightened and corrected on
their torque (figure 9).
Retention
On retention evaluation, there was good facial harmony with
good chin prognathism and normal lip closure (figure 10). The
nose was fine and the face symmetrical. The smile line was
good. On intraoral examination, the oral hygiene was adequate
and the gingiva healthy. No caries developed during this reten-
tion phase. On intraoral examination, there was a good dental
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Case Report
alignment and the occlusion shows a good class I relationship on
the canines and a class II occlusion on the right molars and class I
on the left molars, the overjet and overbite remain ideal. No TMJ
or muscle problems developed during the retention period. The
opening movement was symmetrical and of normal amplitude.
The OC and RC were identical. The lip function was normal. The
periodontal health was stable with FMBS and FMPS < 20% and
no PD > 3 mm was present.
On evaluation of the panoramic radiograph, root inclination
appeared normal with the exception of 12, 14, 17, 27, 45 which
could have been straightened better. The 38 and 48 should
always be extracted but the patient was reluctant (figure 11).
On the cephalometric radiograph, there was good stability of the
sagittal correction of the maxillary and mandibular incisors
(prognathism and inclination). The inclination of the upper
incisors improved, and the one of the lower incisors did not
change. The overjet, overbite and relationship of the incisors
were stable. In the retention and post-retention period, the
position of the maxillae was stable, the molars and incisors
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Case Report
Figure 5
Periodontal probing at 3-month re-evaluation (Ramseier CA, Wolf CA, The Online Periodontal Charting Tool, www.
periodontalchart-online.com, copyright © 2011, University of Bern, Unitectra
Technology Transfer reference number UB- 12/297)

Figure 6
Intraoral photos, lingual appliance, 017  0.025 b-titanium archwires

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R. Kaitsas, F. Kaitsas, G. Paolone, M.G. Paolone
Figure 7
Final intraoral extra- and intraoral photos
Reproduced from Kaitsas R, Paolone MG. Orthodontics and Periodontology. Edra 2022 with permission
maintained their anteroposterior position in the maxilla and
mandible. The molars and lower incisors did not change position
in relation to the stable structures of the mandible. The upper
and lower incisors were stable (figure 11; table I).
Discussion
The ortho-perio patients must be treated with a particular
attention on risk assessment. The periodontal patients are sub-
jected yet to a conventional perio risk assessment on activity
and prognosis of periodontal disease. It is important to perform
it for each individual patient that is to be subjected to ortho-
dontic therapy [20–23]. This is true not only in adults, but also in
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Case Report
young patients, as modern epigenetics teaches us, where phe-
notype, a term that replaces the old "biotype", is the result of
inflammatory and environmental factors; for example, delete-
rious habits such as smoking, poor brushing, use of piercings can
generate or reveal a phenotype that may be falsely linked to
orthodontics. For these reasons, in this case, we introduce a new
combined risk assessment for the interdisciplinary ortho-perio
patient called OPRA (Ortho-Perio Risk assessment) [15]. The
OPRA is a daily screening aid for the orthodontist that serves
in the early detection and identification of patients at risk. This
diagnostic, prognostic and therapeutic reference is a support in
combined or pure orthodontic treatment, in adults as well as in
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International Orthodontics 2022; 20: 100598
Figure 8
Periodontal probing at the end of treatment (Ramseier CA, Wolf CA, The Online Periodontal Charting Tool, www.periodontalchart-
online.com, copyright © 2011, University of Bern, Unitectra
Technology Transfer reference number UB- 12/297)
growing patients. The OPRA analyses two types of factors: pre-
existing factors and factors related to orthodontic
considerations.
Pre-existing factors integrate the classical periodontal risk
assessment (in our case, the PerioRisk of Trombelli and Farina
[11–13]) and include other issues taking into account both
general and dental factors among which we consider family
history and dental factors such as aetiology and onset of tooth
loss [24], dental lesions and abscesses of deciduous teeth,
quality of hygiene [25], apical root resorption [26], gingival
phenotype [20], number of recessions [27,28], and presence
of dental crowding [29].
On the other hand, as indicated in the literature, pure ortho-
dontic considerations are taken into account: the duration of
orthodontic treatment [30], the reachability of the future contact
point morphology and a proper interproximal bone septum
[31,32]. For what concerns the dental movement we consider:
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Case Report
the variation of the incisor inclination [33–35], the amount of
torque [36,37] and expansion variation [38] in the frontal plane,
the risk of apical contact on the cortical bone plates [39] and the
direction of the movement towards/outside the alveolar "hous-
ing'' [40].
All these factors correspond to a value that finally gives us the
Ortho-Perio Risk Assessment with a similar approach to the
conventional Perio risk assessment: a value between 0 and
10 indicates a low risk factor; a value between 11 and 25 indi-
cates a medium risk; while a value between 26 and 40 shows a
high risk of a phenotypic expression of periodontal disease.
It is important for clinicians to be aware of these potential
patient predispositions, as being aware of them at the outset
of treatment can prevent future problems, as the literature
extensively indicates.
With the control of risk factors in this interdisciplinary patient,
deemed to be of "medium risk level'', lingual orthodontics here
R. Kaitsas, F. Kaitsas, G. Paolone, M.G. Paolone
Figure 9
Final X-rays: cephalometric, panoramic, full periodontal status, tracing and superimpositions
Reproduced from Kaitsas R, Paolone MG. Orthodontics and Periodontology. Edra 2022 with permission
provided vertical and occlusal plane control with a safe peri-
odontal environment. The use of additional anchorage with mini
screws (TADs) integrated with lingual orthodontics, which is by
definition a self-anchoring mechanics, allowed the biomechan-
ics in this periodontal patient.
It is the correct risk assessment that makes the diagnosis
efficient and dictates the timing of the different stages of
treatment: in the pre-orthodontic phase, initial periodontal
treatment, re-evaluation and periodontal surgery, if necessary,
are the pre-requisites; orthodontics can then be started and
performed optimally without inflammation; orthodontic bio-
mechanics should be guided by the level of the periodontal
bone. Implants can be placed during the orthodontic phase,
thus reducing the total treatment time; the subsequent
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Case Report
prosthetic rehabilitation will consolidate the correct occlusion
and provide a function that will encourage stability for a bal-
anced retention; finally, the supportive periodontal care in the
post-orthodontic phase is a crucial part of the treatment and
represents a maintenance that must be continued for life [41–
43] (figure 12).
It is important to point out that orthodontics can help perio
patients not only with conventional tooth levelling but also with
bone levelling [44–47], and soft tissue harmonisation. The chal-
lenge of lingual orthodontics in these interdisciplinary patients
also included anchorage due to the loss of many teeth and the
redistribution of teeth for final occlusion; to this end, mechanics
can be adapted and modified with partial extrusions, torques,
retractions, using TADs as anchorage auxiliaries. It should always
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Case Report
Figure 10
5 years after retention intraoral extra- and intraoral photos
Reproduced from Kaitsas R, Paolone MG. Orthodontics and Periodontology. Edra 2022 with permission

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Case Report
Figure 11
5 years after retention X-rays: cephalometric, panoramic, tracing superpositions
Reproduced from Kaitsas R, Paolone MG. Orthodontics and Periodontology. Edra 2022 with permission

Figure 12
Schematic diagram of the timing in the orthodontic-periodontal treatment with phases. GTR: guided tissue regeneration; SPT:
supportive periodontal therapy
Reproduced from Kaitsas R, Paolone MG. Orthodontics and Periodontology. Edra 2022 with permission

be kept in mind that orthodontic biomechanics in perio patients Conclusions

has its rules: it must respect and accommodate the remaining Perio and an Ortho-Perio Risk Assessment, a correct timing, a
healthy bone and root morphology. Also, we have to remember strict control of anchorage, inflammation and an individualized
that orthodontics must be performed only under conditions of biomechanics allow clinicians to perform orthodontics in inter-
no inflammation, disciplinary cases. Orthodontics itself can modify, enhance,

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International Orthodontics 2022; 20: 100598
increase predictability of perio treatments in adults and young
patients. Under this perspective Orthodontics becomes a "Perio-
Guided" Orthodontic Treatment and Periodontics a "Ortho-
Guided Periodontal Treatment".
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tome 20 > n81 > March 2022