L10 Perio-Ortho Relationship

Factors that may 1. Anatomy of alveolar bone

influence the 2. Pressure exerted by soft tissues
extent of 3. Periodontal tissue attachment levels
orthodontic 4. Neuromuscular forces
movement 5. Lip-tooth relationships
Orthodontic Limits of tooth are defined by strict physiologic & anatomic boundaries
treatment Violation may lead to ↓ periodontal & alveolar bone support
Unclear about the distance that the boundaries can be pushed before health of
surrounding tissues become adversely affected
Importance of With FA → ↑ risk of enamel demineralization
OH during ortho • Mean caries index score ↑ with ↑ plaque index & gingival index
treatment FA do not ↑ risk of caries in pt with good OH
With FA
→ For those with health periodontal, have significant increase gingival inflammation
& % of teeth with recession ↑
→ For those with periodontally susceptible (Periodontitis), may have gingival
inflammation, ↑ pocket depth, alveolar bone loss, mobility
Tissue response • Application of ortho forces to teeth generates compressive & tensile strength
to ortho • Area under tension – Site of bone apposition
treatment • Area under compression – Site of bone
resorption
• Net effect of remodelling process =
Movement of teeth along direction of
applied force & into space created by
resorbed bone
• Distribution of compressive & tensile strains
in periodontal tissue is more complex
 • Tooth moving ‘through’ bone or ‘with’ bone

Through bone
• Undermining resorption rather than frontal resorption
• Heavy ortho forces → Cause constriction of microvasculature & localized
necrotic areas within PDL (Hyalinization)
• Removed by tartrate-resistant acid phosphatase-positive macrophages &
multinucleated giant cells migrating from adjacent bone marrow sites
• Delay in tooth movement as no bone apposition can occur on tension side until
necrotic tissue on compression side has been removed

Light orthodontic forces

• Does not prevent hyalinization of PDL in initial stage
• Does not influence rate of tooth movement
• Prevent further hyalinization from occurring after initial period of tooth
movement
Ortho To re-establish aesthetic & functional dentition
considerations Only when periodontal status stable
following perio Involves multi-disciplinary management (Perio-Ortho-Resto)
therapy
Adverse outcomes
1. Gingival recession
2. Black triangles
3. Traumatic occlusion
Response of Poor OH
infrabony pocket • With bodily movement of mand teeth
to ortho • ↑ Pocket depth, Loss of CT attachment especially when teeth were moved
movement towards infrabony defects)
• Apical displacement of adjacent supragingival plaque into subgingival areas
Good OH
• Healing of infrabony defects
• Complete resolution of defects in presence of reduced, but healthy periodontal
tissues
• Outcome of studies high variability due to difference in regenerative capacity of
periodontal tissues following movement of teeth into osseous defects
Effects of ortho 1. Recessions (10-12%) → Mucogingival surgery & Gingival grafts
treatment on 2. Gingival overgrowth
perio tissue & 3. Bone dehiscence
management 4. Gingivitis or periodontitis → Periodontal therapy
Tissue response 5. Orthodontic space closure
to ortho forces 6. Orthodontic intrusion
7. Orthodontic extrusion

Orthodontic Space Closure

1. Large edentulous spaces with severely resorbed alveolar ridges
• Due to loss molars
• Effect of missing teeth
a. Progressive tipping
b. Rotation
c. Lingual rolling of adjacent teeth
d. Scissors bites
e. Non-working side interference
f. Poor gingival contours
g. Deepening of bite
h. Over-eruption of opposing teeth
i. Pseudopockets (Tipped tooth)
• Treatment for missing permanent molars
a. Uprighting
o Results in apical migration of gingival margin
o ↓ pocket depth
b. Space closure
o Establish occlusal contact
o Prepare space for prosthetic restoration
 2. Long-standing edentulous spaces with narrow ridges
• During space closure, width of alveolar ridge increased (Better outcome in
young growing individuals than older pt)
• Risks
a. Gingival dehiscence
b. Poor root parallelism
c. Incomplete space closure
d. Increased treatment duration
e. Relapse
3. Risk of bone loss at alveolar bone crest
• Due to excessive tipping movements
• Higher in adults
• Not advisable for tooth with vertical/infrabony defect
• Bodily movement reduces risk
• Strain levels in range of 1500 – 3000 microstrains favour bone remodelling,
is associated with bone deposition
4. Skeletal anchorage
• Useful in reduced periodontal support
• With missing molar teeth
• But lack of high quality evidence
5. Application of perio regeneration therapies during ortho treatment
• Clinically, ↑ CT attachment levels
• But lack of high quality evidence
6. Use of bone substitutes to treat perio defects & augment atrophied alveolar ridges
• No adverse effect on ortho tooth movement
• Evidence from animal study

Orthodontic Intrusion
1. Flared & elongated teeth
• Benefits
o Improve smile aesthetics & reduction in soft tissue trauma
• Risks
o Root resorption
o Shortening of root
• Effects on periodontal tissue
o Bone deposists along stretched PDL fibres in middle & coronal
thirds of root
o Ligh forces reduces stresses in marginal part of PDL
 o Forces directed through long axis of tooth favour bodily intrision,
limit extent of hyalinization
o Forces magnitude affects reaction of tissue in apical region
o Heavy intrusive forces are assocaited with higher degree of root
resorption
o Light & continuous forces → Pure intrusion with loss of marginal
bone, greater attachement level (Based on animal study)
• Good OH
o Shallower pockets
o Stable marginal bone level
o Bone deposits on labial surface, palatal surface, near root apex
(Increased buccolingual width of alveolar process)
• Poor OH
o Loss of marginal bone (Osteoclastic activity observed)

Orthodontic Extrusion
• Method to manage one- & two-wall infrabony defects with regular
periodontal maintenance
• Favourable clinical outcomes
o Reduction of pocket depth
o Increased zone of attached gingiva
o Crestal bone apposition