Case Report

Ortho‑perio integrated approach in

periodontally compromised patients
C. S. Ramachandra, Pradeep Chandra Shetty, Sanyukta Rege1, Chitrang Shah

Department of Abstract:
Orthodontics It is an undisputed fact that sound and strong periodontal health is a must in patients seeking orthodontic
and Dentofacial treatment. Does this mean that we are going to deny orthodontic treatment for those adults whose number is rising,
Orthopaedics, more often secondary to periodontal deterioration and pathological migration of teeth resulting in aesthetic and
1
Department of functional problems? Need of the hour is to have an integrated approach where in periodontal treatment precedes
Periodontics, AECS orthodontic treatment to restore periodontal health. Orthodontic treatment should be performed under strict plaque
control measures to place the teeth in a structurally balanced and functionally efficient position. Aim of this article
Maaruti College of is to familiarize the practicing clinicians both in the field of orthodontics and periodontics with current thoughts
Dental Science and and successful clinical techniques used in the field of periodontology to regenerate lost periodontal structures.
Research Centre, Furthermore, it aims to integrate such techniques into the orthodontic treatment of patients with severe bone loss.
Bangalore, India Key words:
Intrusion, multidisciplinary approach, orthodontic intervention, regeneration

INTRODUCTION microbial plaque. Inadequate maintenance

of oral hygiene during orthodontic treatment

M ultidisciplinary approach is often necessary

to treat complex dental problems in our
patients and there cannot be a better example
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than ortho perio interaction. Orthodontic
Website: treatment is based on the principle that if
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prolonged pressure is applied to a tooth, it will
DOI: move as the surrounding bone remodels. Bone
10.4103/0972-124X.92583
is selectively removed in some areas and added
Quick Response Code: in others. In essence, the tooth moves through
the bone carrying its attachment apparatus
with it, as the socket of the tooth migrates. Since
this response is mediated by the periodontal
ligament, tooth movement is primarily a
periodontal ligament phenomenon.[1]
This being the situation, it is mandatory to see
that good periodontal health prevails before,
during, and after orthodontic treatment. It could
be an oral prophylactic procedure in adolescent
patients or advanced periodontal treatment
in adults so as to eliminate the presence
of inflammation in the presence of which
carrying out orthodontic treatment will have
Address for deleterious effect. The orthodontic literature
correspondence: has presented different treatment modalities for
Dr. Sanyukta Rege, the management of adult orthodontic patients
Department of with mild to moderate bone loss. However,
Periodontics, AECS the management of adult orthodontic patients
Maaruti College of Dental with severe bone loss continues to present a
Science and Research challenge. All the experienced clinicians would
Centre, Bangalore, India.
agree that a well aligned dentition may be
E‑mail: sanyukta.rege@
gmail.com more conducive to periodontal health than a
crowded dentition. The most important factor
Submission: 07-01-2011 in the initiation, progression, and recurrence
Accepted: 18‑11‑2011 of periodontal problems is the presence of
414 Journal of Indian Society of Periodontology - Vol 15, Issue 4, Oct-Dec 2011
increases the risk of developing gingival
inflammation. There is evidence of increase in
the lactobacillus count in saliva after appliance
placement.[2]
Many adult patients seek orthodontic treatment for
aesthetic improvement due to the mal‑alignment
of the anterior teeth secondary to periodontal
breakdown. But the aesthetics may not be the only
concern for the clinician as malocclusion more
often than not leads to trauma from occlusion,
which would aggravate the deterioration of the
dentition.
In a follow‑up study on 22 patients with up
righted mandibular molars after an average of
3.5 years, it was reported that pockets on the
mesial surfaces were shallower on the up righted
teeth than on the control teeth.[3] Some case
reports have reported that a reduction of probing
depths in bony defects following tooth extrusion
can also be achieved. [4] The combination of
orthodontic intrusion and periodontal treatment
has also been shown to improve periodontal
conditions in animals provided oral hygiene is
maintained and tissues are healthy.[5]
Intrusion of incisors in adult patients with
marginal bone loss and deep overbite has been
reported to cause root resorption varying from
one to three mm. It is suggested that intrusion is
best performed with low forces (5‑15 g/tooth)
to minimize root resorption. [6] Studies have
also shown that moving teeth into adjacent
osseous defects, orthodontic extrusion with
 Ramachandra, et al.: Ortho–perio integrated
or without fiberotomy, and labial tipping of anterior teeth
can be successfully accomplished without jeopardizing the
periodontal support in the presence of adequate plaque
control.[7]
Guided tissue regeneration (GTR), demineralized freeze‑dried
bone allograft, or a combination of these are considered to be
the most predictable regenerative procedures for achieving
favorable treatment outcomes. These findings were further
supported by several researchers who established a large
body of clinical evidence that clearly indicated periodontal
bone grafts consistently led to better bone fill of the defect than
the non grafted controls. Histological analyses of cementum
regeneration in experimental animals have conclusively
demonstrated that regenerative treatment with bone grafting
leads to some degree of regenerated bone, cementum, and
periodontal ligament.[8]
General factors, such as the morphology of the defect,
plaque control, and patient compliance can directly affect the
predictability of periodontal regeneration. Defect selection
is critical to achieve a successful outcome. Deep and narrow
defects show the most predictable positive response to
regenerative procedures where as shallow defects show poor
results. In such a scenario, orthodontic intrusion can change
a horizontal bone defect into a deep and narrow defect that is
more favorable for regeneration of the periodontium through
grafting procedures[8] [Figure 1].
Therefore, the field of orthodontics should consider the
combined regenerative and periodontal surgical treatments
an invaluable addition to the armamentarium available for
the orthodontic treatment of adult patients with severe loss
of periodontal tissues. Similarly, the field of periodontics
should recognize the importance of orthodontic intervention
in achieving results unattainable with periodontal treatment
alone.
The treatment consideration
Patients with advanced periodontal disease may experience
tooth migration involving single or multiple teeth. The most
common symptoms include tipping and extrusion of one or
more incisors and the development of spaces between the
anterior teeth. The management of such cases requires judicious
interdisciplinary treatment planning by the periodontist and
the orthodontist. In the present article, the critical role of the
orthodontist in changing the topography of a bony defect to a
more favorable shape is highlighted (i.e., a horizontal defect to
a vertical, narrow, and deep defect) followed by regenerative
procedure by the periodontist to restore the vertical defects
towards favorable clinical outcome.
CASE REPORT
A patient aged 19 years reported to the department of
Orthodontics and Dentofacial Orthopedics at AECS Maaruti
Dental College, Bangalore, with forwardly placed front teeth.
On examination, on the class 1 skeletal base, she had proclined
maxillary and mandibular anterior teeth with spacing, deep
bite, crowding in the posterior segment with scissor bite.
On soft tissue examination, she had inflamed gingiva with
deep periodontal pockets. The patient was referred to the
Journal of Indian Society of Periodontology - Vol 15, Issue 4, Oct-Dec 2011 415
Figure 1: (a) Severe bone loss, spacing and extrusion of incisors. Horizontal defect
(H) around maxillary left central incisor. (b) Orthodontic intrusion changes the
topography of the defect into a vertical (V) defect and narrow defect.
(c) Orthodontic intrusion in the presented case changing the topography of the
original horizontal defect. (d) One wall defect in relation to right central incisor prior
to periodontal regenerative surgery
department of periodontics for further investigation and
opinion. They diagnosed her to be having chronic localized
periodontitis compounded with trauma from occlusion.
On clinical examination, grade III mobility of maxillary
anterior teeth was seen [Figure 2].
After inter departmental discussion on the treatment plan, it
was decided to proceed with following steps in this case:
1. Phase I therapy comprising of scaling and root planing
before orthodontic treatment.
2. Alignment of the teeth with light forces using copper NITI
wires after extraction of 15, 24, 34, and 44.
3. Continuous monitoring of periodontal health with periodic
scaling and root planing and administration of GengigelTM§
(0.8% hyaluronic acid) to improve the attachment was
coordinated by the periodontist.
After evaluation, regenerative periodontal therapy comprising
of GTR and bone graft for the osseous defect.
After the initial prophylactic treatment, we started with the
orthodontic treatment. 022 slot PEA was used in this case.
Special attention was taken in using light forces to achieve
leveling and aligning. For the next phase of retraction and
space closure in the mandibular arch, we used 19×25 SS wires
and the same was achieved [Figure 3].
Continuous periodontal follow‑up comprising of scaling
and root planing with interventional GengigelTM application
in the anterior region was performed with favorable results
[Figure 4, Table 1].
The challenge was in the maxillary arch where we had to
achieve retraction and intrusion. We used 17×25 NITI arch
wire with RCS design and light elastic chain to simultaneously
intrude and retract the anterior teeth. At this juncture,
we decided to do intentional root canal treatment for
maxillary anterior teeth to avoid any endo‑perio cross infection
[Figure 5].
 Ramachandra, et al.: Ortho–perio integrated

As the desired movements were achieved, we shifted to

19×25 stainless steel wire incorporated with curve of spee
design. This helped us to intrude and retract the anterior
segment as well as to convert the horizontal bone defect to
a vertical defect which can receive and retain graft material
[Figure 6].

Table 1: Effect of gengigelTM probing depth and CAL

Tooth no. Probing depth CAL (mm)
(mm)
11 21 12 11 21 12
Initial 9 7 8 8 7 8
Mid treatment (1 month) 8 7 8 8 7 7
After 3 months 6 5 6 6 5 7
Before periodontal surgery 5 5 6 5 5 6
CAL – Clinical attachment level

Figure 2: Preoperative photographs and OPG

Figure 5: Post orthodontic treatment. Root canal therapy done with maxillary incisors

Figure 3: Mid treatment photographs and OPG, retraction and space closure Figure 6: Post orthodontic treatment

Figure 7: (a) Vertical defect wrt 11‑12. (b) Bone graft and guided tissue
regeneration wrt 11‑12 [DuoPackTM]

Figure 4: Effect of GengigelTM (0.8% hyaluronic acid gel) Figure 8: Post Op

416 Journal of Indian Society of Periodontology - Vol 15, Issue 4, Oct-Dec 2011
 Ramachandra, et al.: Ortho–perio integrated
On achieving the short term orthodontic objectives such as
alignment, good contacts, absence of rotations, class I occlusion
with good cusp to fosse relation and good facial balance;
periodontal regenerative surgery was performed for 12–21.
GTR with bone graft [DuoPackTM¥– collagen membrane and
reinforced tri calcium phosphate bone graft] in region of vertical
defect 12‑11 [Figure 7].
Two weeks post surgically, we decided to remove the
orthodontic appliance followed by lingual splinting [Figure 8].
Prognosis
This depends on patient education and maintenance. Periodic
follow‑up after periodontal surgery is essential.
CONCLUSION
Orthodontic procedures in periodontally compromised patients
require extensive periodontal care/consideration to maintain the
periodontium in a healthy condition during and after treatment.
Minor periodontal surgery may be required to prevent relapse
after orthodontic treatment in addition to the lingual bonded
retainers on a long term basis. Inter disciplinary approach
complimented by patient education and continued care of good
oral hygiene will transform patients with unattractive dentition
due to migrated teeth secondary to periodontal breakdown
and inflamed periodontium  into  individuals with attractive
dentition and radiant smile.
Since there is a close relationship between orthodontic treatment
and periodontal health and vice versa, an understanding of the
ortho‑perio relationship will help in bringing the best possible
results in needy patients.
Journal of Indian Society of Periodontology - Vol 15, Issue 4, Oct-Dec 2011 417
Footnotes
§
Ricerfarma, Italy,
¥
Equinox, India,
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How to cite this article: Ramachandra CS, Shetty PC, Rege S,
Shah C. Ortho-perio integrated approach in periodontally
compromised patients. J Indian Soc Periodontol 2011;15:414-7.
Source of Support: Nil, Conflict of Interest: None declared.
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