ORTHODONTIC-

PERIODONTAL INTERFACE
Preceptor: Dr Payal Sharma
Presented by : Shubhangi Jain
CONTENTS

1. Periodontal microbiology

2. Effects of orthodontics on periodontium

1. Microbiological
2. Clinical
3. Different tooth movements

• Gingival and periodontal maintenance procedures during

different orthodontic procedures
• Mucogingival problems in young
• Chronic periodontitis in adults
• Adjunct to prosthodontic procedure

• periodontally accelerated osteogenic orthodontics

(PAOO)
Why is the knowledge of orthodontic
periodontal interactions needed?

Ortho treatment possible due to the

presence of periodontal ligament.

The age group of the population opting

for orthodontic treatment is expanding

Maintenance of Periodontal health is a m

treatment goal in orthodontics
Normal before abnormal

Biology
Basicofperiodontology
Microbiologytooth movement
of periodontium
• PRESSURE TENSION THEORY

A theory that relies n chemical

rather than electric signals as
cellular differentiation and tooth
movement
• MICROBIOLOGY OF PERIODONTIUM

• Dental plaque is a structurally and

functionally-organized biofilm.

• Plaque forms in an ordered way and has a

diverse microbial composition that, in health,
remains relatively stable over time (microbial
homeostasis)

• Microbial species differ in healthy and diseases

sites
Socransky et al. associated characteristic bacterial
complexes with states of periodontal health and disease,
which were color-coded according to disease association.

IN HEALTH
Streptococcus species

Campylobacter concisus,
gram-positive facultative
Eikenella corrodens
anaerobic rods and cocci
Aggregatibacter
including Actinomyces
actinomycetemcomitans
and Veillonella parvula
type a
• GINGIVITIS, INADEQUATE ORAL HYGIENE
Eubacterium nodatum, Peptostreptococcus,
Fusobacterium, Prevotella, and Campylobacter species

• PERIODONTITIS

Porphyromonas gingivalis, Tannerella forsythia, and

Treponema denticola
 Overview of periodontology

Plaque
accumulation

•slight signs of erythema due to proliferation of capillaries

1 week • bleeding on probing may be evident
• gingival crevicular fluid (GCF) secretion is increased.

•Established gingivitis
2-3 weeks
Periodontitis
• inflammatory destruction becomes irreversible and is
associated with loss of attachment and supporting
bone.

Clinical attachment level (CAL)

• defined as the location of the base of sulcus relative
to the CEJ, is considered the best marker for
periodontal diagnosis and is an absolute sign of
disease.
 Microbial effects of orthodontics
on the periodontium
• Appliances encourage plaque accumulation
and the development of gingivitis.
• IN HEALTHY INDIVIDUALS
BEGINNING OF PLAQUE ACCUMULATION

12 DAYS Greater number of cocci and motile

rods

6 WEEKS Cocci decrease,

Spirochete and motile rods increase

3 MONTHS Bacteria in red and orange complex

IN INDIVIDUALS WITH PREVIOUS PERIODONTAL DISEASE

Investigations on the factors influencing of the subgingival

microflora in chronic periodontitis. A study in adult patients
during fixed appliance therapy.

Investigated changes in the subgingival flora in adults with chronic

periodontitis undergoing orthodontic fixed appliance therapy.

RESULTS:
Reduction in total bacteria
count from subgingival pocket
metal brackets, NiTi archwires and stainless
steel archwires to metal corrosion entailing
the release of primarily nickel ions, which
have a toxic effect on bacteria and thus
enable the regeneration of the physiological
bacterial flora.

Increase in total count of

pathogenic bacteria after end of
treatment
Clinical effects of orthodontics
on the periodontium
• PLAQUE INDEX

• In some studies the plaque index

reduced, This improvement may be
attributed to the increased focus on
oral hygiene instructions by the
dental practitioner, along with an
increased number of dental visits to
reinforce oral hygiene instructions
that occur during orthodontic
therapy.
 GINGIVAL INDEX and
BLEEDING ON PROBING

Seen to increase in most of higher BOP in banded

the studies. sites compared to
The reduction again, may be bracketed sites
attributed to focus on
hygiene instruction
 PERIODONTAL
PROBING DEPTH
In any case, most authors
agree that the deeper
probing depths observed in
orthodontic patients are
most likely attributed to
pseudopockets or deeper
probe penetration into
weakened connective
tissues, as opposed to
attachment loss of the
supporting periodontium.
most of the time, orthodontic therapy does not cause irreversible harm to the
periodontium.

Increased reinforcement of oral hygiene

can reduce this negative effect over the course of orthodontic therapy
Response of periodontium to different
orthodontic tooth movements

INTRUSION
Healthy periodontium Melsen et al in AJO 1986
Alveolar bone height maintained
It is a reliable method provided gingival
inflammation is controlled
Oral hygiene not Supragingival plaque shifted subgingivally and
maintained infrabony pocket formation
Marginal bone loss Melson et al in AJO 1986
Beneficial effect with radiographs showing positive
bone remodeling
Inflamed pockets Contraindicated as causes further periodontal
destruction
TIPPING
• concentration of pressure in limited areas
of PDL.
• nearly always results in the formation of a
hyalinized zone slightly below the alveolar
crest

In young orthodontic patients,

bone resorption result form a
moderate tipping movement
is usually followed by
compensatory bone formation
which occurs in the apical
region.
adult teeth in labial direction
may result in one destruction
of the alveolar crest, with
little compensatory bone
formation.
TORQUE
• During the initial movement of torque
the pressure areas is usually located
close to the middle region of the root.
• the apical surface of the root
gradually begins to compress adjacent
periodontal fibers and a wider
pressure area in established.
• Direct bone resorption was observed
on the pressure side.
• A cell free area of short duration may
be created
Reitan andadjacent to thein
Kvam found middle
experimental study that the tissue
third of the root.
reaction  
caused hyalinization and root resorption in two
• The areas.
force exerted
The firstduring
was inlight
the wire
middle third of the root and the
torque second,
in of thewhich
continuous type. after the first undermining
was formed
resorption has terminated, was all along the apical third of
the root.
• EXTRUSION OR ERUPTION OF A TOOTH OR SEVERAL
TEETH,
study Early effects stabilization

Raymond yukna et al in Early in the extrusion After stabilization,

AJO 1985 process, the teeth approximately 2 mm of
extrusion of single appeared to be avulsed, new bone was seen
rooted teeth with with more than three coronal to the original
advanced periodontal fourths of the root alveolar crest, and the
disease coronal to the alveolar periapical areas had
crest filled in with bone. The
extruded teeth had an
intact attachment
apparatus. 
BODILY MOVEMENT

On pressure side
compressiona dn
Force application Slight tipping formation of hyalnized
zone between marginal
and middle region

Undermining resorption
PDL on pressure side
and elimination of
widened
hyalinized zone

FURTHER MOVEMENT OCCURS

ROTATION

• In rotation of a tooth around its long axis the

force can be distributed over the entire PDL
rather than over a narrow vertical strip,
whereas forces can be applied than in other
tooth movements.

• Most teeth to be rotated create two pressure

sides and two tension sides. Rotation may cause
certain variations in the type of tissue response
observed on the pressure side.
• In the marginal region rotation usually causes marked
displacement of fibrous structure.

• The free gingival fiber groups are arranged obliquely from the
root surface, because these fibers bundles interlace with the
periosteal structure and the whole supraalveolar fibrous
system, rotation also causes displacement of the fibrous tissue
located some distance from the rotated tooth.

• On the tension side of the middle third, new bone spicules are
formed along stretched fiber bundles arranged more or less
obliquely. In addition, the new bone on the tension sides
consists partly of uncalcified bone spicules.
 Differences in response to orthodontic
therapy between adults and children
ADULT CHILDREN REASON

inflammation, LESS more poor oral hygiene correlated

plaque, or inflammation and with significant attachment
attachment supragingival loss
loss. plaque than the
(BOYD et al) adult groups

shift toward Peaked but Changes peaked at Adults are more likely to have
periopathogeni not sustained 6 months and had periodontitis, resulting in
c bacteria sustained attachment loss and, thus,
allowing appliances to be
placed further away from the
existing gingival attachment.
adults are not undergoing
hormonal changes associated
with puberty
• While both adults and children are theoretically susceptible
to periodontitis, orthodontic therapy may confer less risk in
adults due to their ability to exercise better plaque control
in a less hyperinflammatory phenotype.

• Aggressive periodontitis typically manifests in young

patients and has propensity for inducing rapid periodontal
destruction. In patients diagnosed with aggressive
periodontitis, orthodontic therapy has been conducted
successfully, although treatment modifications are
recommended, including initiating therapy only after
periodontal stability is achieved
Treatment modifications that affect clinical and microbiological
periodontal parameters during orthodontic therapy

• Maintaining excellent oral hygiene most

effective way
• More frequent dental visits, allowing regular
reinforcement of oral hygiene
Manual
Electric
brushes and proxibrush
toothbrushes
floss

Bands vs
Chemical
bonded
means
brackets
 faster increases in PD,
BOP, and GCF flow in
bonded sites
wires hindering Increased BOP and deeper
interproximal cleaning. pockets around bands
Post-treatment clinical and microbial changes

All effect are largely reversible, with

no long term increased risk for
periodontitis

bacterial profile shifts back to

pretreatment levels, although slight,
clinically insignificant changes in
periodontal clinical parameters such
as probing depth and attachment loss
remain.

Resolution of gingival inflammation

and enlargement in 30 days
Resolution of microbial changes
resolves in 3 months of removal
Mucogingival approaches in
young orthodontic patients

• In ideal tooth eruption preserves gingival

tissue on both facial and lingual surfaces.
Thinning of the cortical bone plate
Tooth mayof a dehiscence/ fenestration a
potential formation
break
high incidence Gingiva
of gingival recessions
Ectopic through
entrapped
eruption existing Destruction
between
gingiva near of entrapped
Facially or permanent
mucogingival gingiva
lingually and primary
jn or within
tooth
alveolar
mucosa
OTHER CONDITIONS WITH SIMILAR CONCERNS:

TOOTH IMPACTION

TRANSPOSITION

The goals of therapy are

• to correct the alignment of these teeth in the arch

• achieve an adequate width of keratinized tissue

• prevent the development of gingival recession

• avoid permanent impaction or extraction.

• The most appropriate treatment should be able to simulate the

physiological eruption pattern that occurs at the center of the alveolar
ridge with the tooth surrounded by adequate and healthy periodontal
tissues
 MUCOGINGIVA
L SURGERY ON
ORTHO

preventive Interceptive reconstructive

 Preventive surgery
• Based in depth of impaction
• Buccolingual position of tooth

Treatment of superficially impacted

teeth

tooth is often visible below the gingiva or

the mucosa.

The purpose of the treatment is to

preserve the existing gingiva by
transposing the tissue apically to the tooth
(apically positioned flap), thus avoiding
the subsequent periodontal damage due to
the ectopic eruption
ADVANTAGES OF OPEN APPROACH
• ability of the orthodontist to visually observe and follow the
movement of the impacted tooth

DISADVANTAGES OF OPEN APPROACH

• Excessive intraoperative bleeding,
• difficulty in the placement of the bonded attachment,
• excessive removal of bone and soft tissues when the tooth
position is not accurately identified.
• subsequent periodontal concerns, including recession, bone loss
• decreased width of keratinized tissue,
• delayed periodontal healing, and gingival inflammation
 TREATMENT OF DEEP INTRAOSSEOUS
IMPACTED TEETH

Identification of the impacted tooth

position and depth

Repositioned flap more appropriate

surgical choice

delicate elevation of the flap

re-positioned flap approach maintains the

entire amount of the keratinized tissue
and reduces discomfort during healing

most appropriate treatment of impacted

teeth should be able to simulate the
physiologic eruption pattern that occurs at
the center of the alveolar ridge
Crescini et al’s periodontal orthodontic technique
Specifically for maxillary and mandibular canines

Consists of mucoperiosteal flap asociated with direct orthodontic

traction towards the centre of alveolar ridge

Phase I- initial Phase II – Surgical Phase III- final

orthodontic treatment exposure and orthodontic treatment
orthodontic traction
The deciduous canine Surgical exposure and Erupting tooth aligned
may be preserved during orthodontic traction of within the dental arch
this early orthodontic the impacted tooth and tooth rotations
phase. Sufficient space towards the center of corrected
is created in the the alveolar ridge.
maxillary dental arch to
accommodate the width
of the permanent
impacted canine by
means of the edgewise
technique.
 Surgical technique

mesio-distal incision in the If needed, minimal amount

A full-thickness
middle of the edentulous of cortical bone is gently
mucoperiosteal flap is
ridge and two para- removed to expose the cusp
elevated
marginal incisions tip of the impacted canine

A fine mesh, button or

The flap is then re- bracket is bonded as closely
positioned at its original site as pos- sible to the cusp of
The bonding is tested by a
with interrupted sutures. the impacted tooth. A
traction force of 150g
The chain emerges from the handmade wire chain of rings
applied with a
gingival tissue at the approximately 1.5 mm in
dynamometer.
incision made in the middle diameter is prepared with a
of the alveolar ridge. 0.011 in ligature wire and
fixed to the fine mesh.
 tunnel traction
A modification of this technique,

Indicated
• When the intra-osseous impaction of the permanent canine is
associated with the presence of the deciduous canine in the dental
arch.
• This tunnel serves for the traction of the impacted canine
• The sutures are removed 10 days after the surgery and the traction
phase begins.
a low-speed bur is inserted
into
the empty socket to perforate
Elevate the flap and exposing the deciduous canine is the bone apically and
the cusp of the impacted tooth removed.
create a tunnel connecting the
socket to the crown
of the impacted canine.

the wire chain connects the

Then, the flap is re-positioned
tooth to the center of the
at its original site with inter- ridge directly through
rupted sutures
the tunnel
 Orthodontic traction
aimed at guiding the impacted tooth directly towards
the center of the alveolar ridge.
while a
.
round traction arch is used to
A RECTANGULAR stabilization guide the impacted canine
arch is used to obtain towards the center of the
adequate anchorage and alveolar ridge formed by loops
maintain sufficient space in The chain is tied to an that allow for progressive
the dental arch ELASTIC DEVICE that passes modification of the direction
through the loops of the of the orthodontic traction
traction arch, perpendicular
to the alveolar ridge. The
elastic device is fastened to
the first permanent molar.

In cases of palatal impaction the orthodontic tooth traction is directed

buccally while a buccal impacted canine is guided towards the palatal
side. An orthodontic force of approximately 100g is applied. Patients
are usually re-called every 4 weeks to adjust their appliance, and every
3 months for professional oral hygiene.
Phase 3: Final orthodontic treatment.

• In this phase, the erupting canine is aligned within the dental arch,
and any tooth rotation is corrected.

• At the end of active orthodontic treatment,

• the patients are discharged with Hawley's plates and lingual

retainers, and the periodontal parameters (probing depth and width
of keratinized tissue) are evaluated to assess the health of the
periodontal tissues around the orthodontically guided tooth
Treatment of tooth transposition

TRANSPOSED FULLY ERUPTED orthodontic

TEETH treatment would be
required without
surgical intervention

complete transposition is Tooth extraction is

associated with little or no suggested
space for repositioning the
teeth

superficial or deep surgical approaches to

transposition expose the teeth
before the orthodontic
therapy.
Interceptive mucogingival
surgery

• maintains the entrapped gingiva

and prevents gingival recession
on buccally erupting teeth
during and after the orthodontic
treatment.
 DOUBLE PEDICLE FLAP
indicated when the tip of the cusp of the
permanent tooth erupts in the keratinized tissue
close to the mucogingival junction

An incision parallel to
the long axis of the
Intrasulcular incision is made moved and secured
tooth allows for the
extending to the gingival crevice apically to the
elevation of the
of the adjacent teeth. erupting cusp.
entrapped gingiva as
a full-thickness flap

• Apically positioned flap
• When the cusp of the permanent
tooth is erupting in the alveolar
mucosa slightly apically to the
mucogingival junction.
intrasulcular incision is made in
the crevice of the deciduous
tooth
connected with vertical-releasing
incisions at the line angles of the
tooth, extending apically to the
mucogingival junction
full-thickness partial flap,
including the entrapped gingiva
and sutured apically to the
erupting tooth
Free gingival graft
• This procedure is indicated when the permanent tooth
erupts in the alveolar mucosa very apically to the
mucogingival junction.
• The entrapped gingiva is completely harvested and used
as an epithelialized connective tissue graft. Care is taken
to preserve the underlying periosteum at the donor site.
• The recipient area, apical to the erupting tooth, is
prepared by de-epithelialization and elimination of
muscular fibers, if needed. The graft is sutured in the
proper position with sub- periosteal sutures
 ORTHODONTIC-
PERIODONTAL INTERFACE
continued
Reconstructive periodontal
surgery

• When the tooth is fully erupted with a muco-

gingival deformity during or after the active
orthodontic treatment, mucogingival recon-
structive procedures are performed to repair
or to recreate the injured or lost periodontal
tissues.
 Inadequate width and thickness of attached gingiva

thin periodontal
morphotype, reduced
width/thickness, or lack
of attached gingiva

the direction of the

the quality of
orthodontic tooth
lack of attached gingiva or the presence of plaque
frenulum control.
pull is found to
movement
hinder proper oral hygiene measures and plaque control in a patient
undergoing orthodontic treatment, it would be advisable to perform an
augmentation procedure by means of free gingival graft following or in
combination with a frenectomy.
 Gingival hypertrophy/pseudopockets

Pseudopockets,
hereditary gingival fibromatosis or
drug-associated (phenytoin, cyclosporine A, and calcium channel blockers)

generate difficulties both in bonding orthodontic

brackets and in plaque control at the involved teeth

Gingivectomy is often the treatment of choice for restoring adequate tissue

morphology.
After determining the depth of the pseudopockets, the enlarged
keratinized tissue is eliminated in an apicocoronal direction starting from the bottom
of the pseudopocket.
• This “external beveled”
gingivectomy leaves the underlying
deepithelialized connective tissue
to heal by secondary intention.

• Following surgery, a rapid

reepithelialization occurs, which
allows the reestablishment of an
adequate width of the gingiva
associated with a physiological
sulcus depth.

• In cases of shallow pseudopockets,

an “internal beveled” gingivectomy
may be performed.

• A soft tissue laser may also be used

to perform these gingivectomies.
 Aberrant frenulum

ABBERANT FRENULUM
high pulling force on the
gingival margin, especially
when it is associated with
marginal muscle insertions

gingival margin tends to

move away from the tooth
causing a sulcular
The hyperplastic buccal enlargement that favors
maxillary frenulum is plaque accumulation and
often associated with a complicates proper oral
midline diastema. hygiene measures.

frenotomy, a more
conservative approach that

frenectomy relocates the frenulum in an

apical direction can also be
performed without involvement
of the palate side.
Gingival recession
• Recession is defined as “the migration of the gingival margin apical to the CEJ
with loss of gingiva, connective tissue attachment, and crestal bone.”1

• the advancements in surgical techniques and materials tested in numerous

clinical studies provided predictable and esthetic out- comes in cases of single
and multiple recession defects.

• Coronally advanced flap (CAF) alone or in combination with subepithelial

connective tissue graft (CTG) are the most predictable root coverage
procedures for treating gingival recessions

• Acellular dermal matrix allografts and a two-layer xenogenic collagen matrix

have been proposed to treat single and multiple recessions in combination with
advanced flaps.
The timing of recession treatments can modify the sequence of the
combined orthodontic– periodontal management.
.
patients with optimal plaque recession defects
control can be treated, using the most
appropriate mucogingival
technique,
at the completion of the
orthodontic treatment
oral root coverage must be performed
hygiene is poor or the planned before the orthodontic treatment.
orthodontic movement is
unfavorable
(outside the alveolar bone
envelope)
If a recession of the gingival advisable to stop the active
margin movement and perform the root
develops during orthodontic coverage procedure. The
treatment orthodontic
treatment can be resumed once
the healing process is completed
treatment of patients with malocclusion and chronic
periodontitis

• treatment of active periodontal disease is required prior to initiation

of orthodontic tooth movement
• control of plaque levels during orthodontic therapy in periodontally
susceptible patients.

patient's overall
health status periodontal malocclusion
and periodontal diagnosis, classification
susceptibility,

periodontal
periodontal oral hygiene
bone loss
biotype levels.
pattern
 Periodontal conditions

periodontal disease good oral proper orthodontic treatment

hygiene, reduced but healthy caused no significant long-term
periodontium effects on periodontal attachment
levels and bone levels
active periodontal disease (i.e., deep orthodontic tooth movements can
PD, BoP, and presence of subgingival accelerate the disease process, even
plaque in the presence of good oral hygiene
systemic conditions and findings are risk factors for disease
psychosocial stress,tobacco use, progression
systemic immune deficiencies,
diabetes mellitus, osteoporosis,
: autoimmune disorders, and
certain
the presence of putative periodontal
pathogens.
MALOCCLUSION

Teeth more prone to tipping. So, the

moment to force ratio should be
adjusted

Extraction of severely periodontally

involved teeth and tooth move- ment
to treat crowding can yield vast
improvements in oral hygiene.

Teeth that have periodontal bone

rotation can be accomplished fairly
easily, it can be difficult to maintain
due to the slower turnover of the
supra-alveolar periodontal and gingival
fiber bundles as compared to the
periodontal ligament (PDL) fibers
loss have a more apical center of
resistance than those with a healthy
periodontium.
The distance between the center of
resistance and the alveolar bone
crest is smaller than that of a tooth
with a healthy periodontium
 TYPE OF BONE DEFECT

Infrabony pockets,
Tooth movt possible if active disease has been arrested

extrusive tooth movement can be used to yield coronal

positioning of connective tissue attachment and
shallowing of one- and two-walled infrabony defects.

intrusion has been shown to improve the periodontal

condition of healthy reduced periodontal tissues when oral
hygiene and the orthodontic forces are optimal

definitive guided tissue regeneration and/or osseous surgery in areas

with vertical defects may be best treated after orthodontic tooth
movements as these movements may alter the defect dimensions, if
the patient is able to keep such defects plaque-free during active
orthodontic treatment.
PERIODONTAL BIOTYPE

While orthodontic tooth movement is not causative for gingival

recession,

• in patients with thin periodontal biotype, labial tooth movements

can result in bony dehiscences, which, particularly in the presence
of plaque, can cause subsequent gingival recession.

• in patients with a thick periodontal biotype and/or in patients

receiving lingual movements of labially displaced teeth, gingival
recession is less likely to occur, and orthodontic treatment may
even result in a reversal of underlying bony dehiscences and
ORAL HYGIENE LEVELS

Orthodontic brackets and bands, particularly placed in the apical third of

the tooth crown, can serve as a plaque-retentive factor and hinder oral
hygiene in patients undergoing orthodontic tooth movement.

1. Oral hygiene levels, therefore, must be optimal prior to orthodontic

treatment

2. close maintenance and monitoring during orthodontic therapy is

warranted.

3. If periodontal pockets are deep enough to prevent the patient from

maintaining good oral hygiene, surgical intervention prior to
orthodontic therapy for pocket elimination may be warranted.
CLINICAL DECISION MATRIX
Orthodontic Forced eruption

Indications
As an alternative to surgical CLP in several clinical
conditions:
• osseous resection during surgical CLP may
significantly compromise the periodontal attachment
apparatus of neighboring teeth;

• osseous resection during surgical CLP will likely

result in furcation exposure at the involved/adjacent
tooth or teeth;
• Apical positioning of the gingival margins at the involved
and neighboring teeth in surgical CLP will create non
harmonious gingival outlines in highly esthetic areas of the
mouth or expose prosthetic crown margins at adjacent
teeth;
• When the anticipated crown-to-root ratio obtained with
surgical CLP is inadequate.
• When teeth adjacent to the involved tooth require coronal
repositioning because of gingival recessions or malocclusion.
Salama and coworkers were the first to publish a series of
articles using orthodontic extrusion to augment bone and
soft tissue of the recipient dental implant site
Contraindications
•  lack of adequate anchorage to perform orthodontic
extrusion;
• the buccal gingival outline at the involved
tooth/teeth is more coronal to the ideal desired
level;
• narrow root taper. patient's rejection towards
orthodontic therapy.
 Principles of orthodontic
extrusion

• Has potential to be an effective alternative for hard

and/or soft tissue augmentation.

• Orthodontic tooth movement affects periodontal

structures by translating forces to produce a
predictable biologic response.

mediates cellular
applying a direct force to tension on the
PDL stretch and changes that lead
the tooth in a specific periodontal
elongate to desired bone
direction ligament fibers
formation
Soft tissue response to orthodontic extrusion

Type 1: Increase of
width of attached gingiva
and overall soft tissue
width
Type 2:
Increase
of
overall
soft
tissue
width
with no
effect on
the
width of
attached
gingiva.
Type 3: Width of attached gingiva and overall
width of soft tissue are unchanged.
BIOMECHANICS

• orthodontic extrusion is complex requiring an

understanding of multiple variables in order to
achieve predictable results.

• when a force is applied at a specified distance

from the center-of- resistance resulting in a
rotational movement known as a “moment”
Current orthodontic brackets
orthodontic extrusion often
designed to optimize
has the intended objective
movement of teeth into an
to move teeth to extreme
idealized position within the
positions, often to the
alveolar bone
point of extraction.

undesirable outcome was most likely

the result of a lack of control of the
forward clockwise moment that was
produced during orthodontic
extrusion.
FENESTRATION
HIGH NEGATIVE TORQUE BRACKETS AND RETANGULAR
WIRE

Provides a palatal root torque

Positions the root favorably
INDIVIDUALLY CONSTRUCTED ARCHWIRES THAT POSSESS WIRE-
SPECIFIC CONFIGURATIONS.

• For instance, the use of vertical “T” loops can be made using a
rec- tangular Beta-Titanium wire to produce a vertical
extrusive force.

• allows greater control in the vertical direction while

simultaneously enabling effective root torque control that is
produced by a rectangular archwire.

• The negative implications of using vertical “T” loops and the

like can be the addi- tional time it takes to construct these
appliances.
APPLYING A FORCE FROM AN ALTERNATIVE POINT ON THE
TOOTH.

aligns the vector of force along the long axis of the

tooth. A tooth-borne provisional restoration offers this
unique requirement.
 Orthodontic extrusion for implant site
development

The above concepts can be used for orthodontic tooth

extrusion for improving vertical bone height and at alveolar
crest for implant placement
Crown lengthening and
orthodontics

• Clinical crown lengthening is defined as a

surgical procedure that aims at exposing sound
tooth structure for restorative purposes via
apical repositioning of the gingival tissue with
or without removal of alveolar bone (AAP
Glossary of Terms 2001)
 SURGICAL TECHNIQUES FOR CROWN LENGTHENING

GINGIVECTOMY APICALLY POSITIONED APICALLY POSITIONED

FLAP WITHOUT OSSEOUS FLAP WITH BONE
RESECTION RESECTION

presence of excess KG If gingivectomy would When the underlying bone

and an underlying bone yield less than 3 mm of crest needs to be
crest at 3 mm or more postoperative KG visualized,
from the level of gingival osseous level is at less
resection. than 3 mm from the level
Performed using of gingival resection
conventional scalpels,
electrosurgery,
radiosurgery, or laser.
 BONE RESECTION

OSTECTOMY
the removal of supporting bone
attached to the root surface via
OSTEOPLASTY periodontal ligament
to reduce osseous enlargements and first carried out at the site/sites
minimize the risk of postoperative requiring tooth exposure. This is
rebound of soft tissues. followed by ostectomy at the
adjacent mesial and distal sites to
reestablish a positive architecture
INDICATIONS CONTRAINDICATIONS

if it significantly compromises crown-to-root ratio of

the treated and adjacent teeth;
violation of the BW if adequate supporting bone will not remain
postoperatively;
surgical exposure of 1–2 mm of tooth struc- in areas where buccal or interproximal soft tissue
ture in addition to the BW to allow ferrule recession is not a desired outcome, and black
effect; triangles are likely to develop if the postresection
distance between the contact area and the
Inadequate tooth structure for crown interdental bone crest increases;
retention
a small distance (less than4 mm) between furcation
entrance relative to the final restorative margin in
furcated molar teeth
 conventional fixed or removable
orthodontic appliances, magnets, and
mini implants

tooth is erupted slowly, bringing the alveolar

bone and gingival tissue with it

Tooth reaches
intended
position

CLP Supracrestal
performed fibrotomy

Retention of 2
months
Combining orthodontic and periodontal treatments
in cases of APE

• APE combined with malocclusion

• Orthodontic treatment precedes periodontal therapy as
it influences gingival levels
• Final analysis after orthodontic treatment.
• If gingival margin locations have not been achieved,
then surgical crown lengthening to be performed.
CORTICOTOMY FACILITATED ORTHODONTICS

‘Wilckodontics’, also known as Periodontally Accelerated Osteogenic

Orthodontics (PAOO) or Alveolar Osteogenic Orthodontics, is a
relatively new treatment in the dental realm. It is a clinical procedure
that combines selective alveolar corticotomy, particulate bone
grafting and the application of orthodontic forces.

It allows teeth to be moved 2-3 times further in 1/3rd to 1/4th the

time required for traditional orthodontic treatment. This procedure is
theoretically based on the bone healing pattern known as the regional
acceleratory phenomenon (RAP).
Biological Rationale

• Rapid tooth movement was thought to be due to the

movement of bony blocks of bone after decortication. This
was reported by Heinrich Kole in 1959.

• In 2001, Wilcko et al reported that rapid tooth movement

was not the result of movement of bony blocks but is due
to the demineralization and remineralization of the
alveolar bone around the tooth by a normal healing process
known as regional acceleratory phenomenon (RAP).

• Regional acceleratory phenomenon was developed by Frost

and Jee in 1983.
 Flap design

decortication

Bone
grafting

flap closure
 INDICATIONS FOR PAOO

With proper timing and

sequencing, recession defects
When certain malocclusions are
can be simultaneously treated
beyond what can be treated
with PAOO and gingival
with orthodontic camouflage
augmentation as periodontal
but may not be so severe as to
surgery would otherwise be
warrant orthognathic surgery,
required for root coverage and
orthodontic purposes.

correction of fenestration and

dehiscence
 CONTRA INDICATIONS OF PAOO

• Patients with bleeding disorders,

• On long-term bisphosphonate drugs, corticosteroids or NSAID

therapy, as well as immunocompromised patients,

• Additionally, if patient is non cooperative

• Unavailable for frequent visits (every 2-3 weeks)

STABILITY

There is a clear literature consensus that the

mandibular dental arch in the permanent
dentition changes over time as follows:
mandibular incisor crowding increases,
mandibular intercanine width decreases, and
mandibular arch length decreases. These
changes occur in both untreated as well as
orthodontically treated individuals.
Results of some studies about stability of occlusion
following orthodontic treatment, with PAOO, without PAOO
and controls was as follows

(1) mandibular incisor re- crowding is expected in the

retention phase if crowding was present prior to
orthodontic treatment

(2) the intercanine width will decrease over time whether

or not that distance was increased during orthodontic
therapy. Orthodontic treatment is effective, but the
magnitude of changes that occur after therapy may vary
and is virtually impossible to predict

(3) increased stability of the mandibular dental arch

following PAOO therapy.
CONCLUSION

• Orthodontic treatment can be done in periodontally

compromised patients without active periodontal
disease, however adequate oral hygiene measures and
modifications should be done

• Adjunct periodontal procedures are helpful in children

with mucogingival problems

• Hopeless teeth are not useless teeth as they may help

in anchorage, space maintenance or implant site
preparation
• Orthodontic forced eruption may eliminate the
need for crown lengthening procedure

• PAOO may help in resolving periodontal issues

along with reduction in treatment time
THANK YOU