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| CASE REPORT |
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| Year : 2017 | Volume
: 7
| Issue : 1 | Page : 41-44 |
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Ortho-perio management of malocclusion in an adult patient
Saroj Kumar Rath, SK Datan, Ankit Gupta
CO & Corps Dental Adviser, 9 Corps Dental Unit, Dharamshala, Himachal Pradesh, India
| Date of Web Publication | 29-May-2017 |
Correspondence Address:
Saroj Kumar Rath
9 Corps Dental Unit, Yol Cantt, Dharamshala, Himachal Pradesh
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jid.jid_81_15
 Abstract | | |
In modern clinical practice, successful treatment of a compromised situation demands multidisciplinary approach. Increasing esthetic demand in adult patients may require a close interaction of orthodontist and periodontist and to work together to provide the best treatment possible to the patient. The present case report highlights the team approach for successful management of malocclusion in an adult patient with compromised periodontal condition. Keywords: Esthetics, intrusion, retention
How to cite this article:
Rath SK, Datan S K, Gupta A. Ortho-perio management of malocclusion in an adult patient. J Interdiscip Dentistry 2017;7:41-4 |
| Clinical Relevance to Interdisciplinary Dentistry | |  |
Since Orthodontics and Periodontics (2 Disciplines of dentistry) are being projected in the following article as per as therapeutic considerations is concerned for correction of malocclusion, this manuscript was considered most appropriate for publication in Journal of Interdisciplinary Dentistry
| Introduction | | |
With the increasing awareness among patients toward orthodontic treatment, adult patients seeking orthodontic correction has increased in the recent past.[1] It is an undeniable fact that the incidences of periodontal problems are more among adult patients. Hence, the number of patients with compromised periodontal status attending orthodontic clinics has increased enormously. The patients with poor periodontal health and pathological migration should be co-evaluated by periodontist and orthodontist together to make a treatment plan which is individualized to the patient, keeping the treatment needs, objectives, and patients expectations in mind.[2] The common problems noticed in periodontally compromised patients include increased proclination of maxillary anterior with irregular spacing and extrusion (pathologic migration), traumatic occlusion and rotations. These undesirable changes are a sequel of reduced periodontal support and may hinder the regenerative periodontal procedures by compromising the condition for good oral hygiene and weakened function.[3] The condition may require adjunctive orthodontic treatment therapy to help periodontist to facilitate the good periodontal health for the patient.[4] Orthodontic treatment is required to reduce/eliminate the traumatic occlusion, correction of supra-eruption, rotation or proclination in these patients. The present clinical report describes an interdisciplinary (periodontic, orthodontic) approach for the treatment of a periodontally compromised patient with extrusion of 11 and proclination of upper anterior.
| Case Report | | |
A 36-year-old female reported with chief complaints of forward placed upper front teeth and gaps in between teeth. The patient noticed increasing gap in-between teeth for the past 1 year. She had never consulted any dental surgeon before for any of the complaints. The patient was systemically healthy with an average body built.
Extraoral examination showed well-balanced face with increased fullness in the premaxillary region. Intraoral examination revealed Class I molar relation bilaterally with increased proclination upper and lower anterior, diastema in 12, 13 region and 31, 41 region. Prclination, extrusion, and gingival recession (exposed root surface) 11 was noticed. On palpation 11, 31, 41 had Grade II mobility. There was observable drifting of anterior teeth with marked pathological migration of 11 in both axial and horizontal direction because of compromised periodontal support [Figure 1]. Orthopentomogram revealed generalized horizontal bone loss with vertical bone loss in relation to 11 and 12 region [Figure 2]. Radiovisiograph (RVG) of the local area confirmed the same finding with almost two-third root surface of 11 not covered with alveolar bone [Figure 2]. Vitality test of teeth confirmed it be vital with hot and cold test. The patient was planned for initial periodontal intervention followed by orthodontic correction.
Treatment objectives were (a) periodontal flap surgery to eliminate existing pockets and thus achieve a favorable periodontal environment for good oral hygiene with a regular follow-up. (b) Alignment and leveling of both arches, (c) to achieve optimal facial esthetics and to obtain an optimal over jet-over bite relationship. Periodontal examination and charting were performed including assessment of probing depths (PDs), clinical attachment levels, full mouth bleeding (gingival bleeding index), and plaque scores (plaque control record).
Before starting comprehensive treatment, the patient received Phase I periodontal treatment, comprised of oral hygiene instructions, supragingival and subgingival scaling, and root planning under prophylactic antibiotic regimen [Figure 3]. An occlusal correction was performed in the anterior teeth with selective grinding to eliminate trauma from occlusion.
Full mouth open flap surgery with root planning and debridement was performed. Necessary regenerative methods with the use of alloplastic bioactive glass (PerioGlass) was undertaken to reduce the vertical bone loss in upper anterior region. The patient was motivated for intensive oral hygiene care and recalled periodically for follow-up. When the gingival inflammation was eliminated and the PD reduced for 3 continuous months, radiographic evaluation was carried out, and orthodontic treatment commenced.
The patient was planned for orthodontic management of extruded 11 and to reduce the proclination and for the closure of diastema. 0.018” Roth preadjusted edgewise appliance (PEA) was bonded in both maxillary and mandibular arch. Being an adjunctive therapy in a periodontal compromised situation, molar bands were not used for this patient. Initially, leveling and alignment of upper and lower arch was achieved using nickel titanium (NiTi) wires (0.014,” 0.016,” and 0.016” × 0.022”) except for 11 (bracket was not bonded initially) [Figure 4]a. Finally, a 0.016” × 0.022” stainless steel (SS) wire was secured in upper and lower arch. Spaces were consolidated in lower arch using elastomeric chain. Now, 11 was bonded with a PEA bracket, and a piggyback 0.012” NiTi wire was placed to apply light intrusive force (5–15 g) with a heavy base arch wire (0.016” × 0.022” SS) to distribute the reactionary force [Figure 4]b. Gradually, 11 was intruded and brought to the occlusal plane [Figure 4]c and [Figure 4]d. Spaces were consolidated on steel wire with the help of closed coil springs using light retraction force. Second periodontal surgical intervention was carried out for evaluating the bone formation, and essential debridement of the granulation tissue from the local site was performed [Figure 5]. The patient was kept with fixed appliance in retentive phase after space consolidation to stabilize the teeth in new position. A permanent retention was given in upper and lower anterior. The patient is followed periodically in retention phase. | Figure 4: (a)- Leveling and alignment of upper and lower arch using NiTi wires except 11, (b) 11 bonded with a PEA bracke, (c and d) 11 was intruded and brought to the occlusal plane
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 | Figure 5: Postoperative view of aligned teeth with the second periodontal surgical intervention
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| Discussion | | |
Adult patients who are susceptible to periodontal disease and have experienced advanced levels of bone loss and sometimes loss of dental units may be defined as “periodontally compromised” and are the subject of this article. The reasons for considering these patients separately are that; (1) they are more prone to further bone loss, (2) the reduced periodontium cannot sustain further loss without the potential loss of teeth, (3) there is frequently an acquired malocclusion unique to this group, and (4) the reduced periodontal support dictates altered treatment design, mechanics, and retention.
The biological and biomechanical conditions are different in periodontally compromised patients as compared to a patient with good periodontal health, as the periodontal ligament surface area is reduced; crown-root length ratio is increased, and the center of resistance is moved apically thus resulting in greater moments during force application.[5]
Pathologic tooth migration (PTM) is a common complication of moderate to severe periodontitis. In early stages of PTM, spontaneous correction of migrated teeth sometimes occurs after periodontal therapy. Light intrusive forces are used successfully to treat extrusion and flaring forms of PTM.[6]
Adult patients with compromised periodontal condition often present with drifting teeth leading to the development or worsening of a malocclusion. Many orthodontists are often reluctant to provide fixed appliance therapy. There is good evidence that provided high-quality periodontal intervention is carried out, and the patient can maintain adequate hygiene procedures to control the disease, even in the presence of previous alveolar bone loss, then fixed appliance treatment can be carried out safely and satisfactorily. The primary aim before orthodontic intervention is to stabilize the periodontal condition.[7] In the present case, extensive and successful periodontal intervention was carried out before orthodontic consideration.
The possible orthodontic tooth movements include alignment, space redistribution, and intrusion.[2] Bone loss alters the position of the center of resistance to teeth and force required to achieve movement, but the orthodontist can use reduced or increased force moments as indicated to avoid excessive alveolar bone loss.[8] Permanent retention in such cases is always necessary by fixed or removable retainers and long-term maintenance, and regular screening is mandatory in such adult cases. Intrusion in patients with compromised periodontal health has promising results; it can improve the level of attachment, reduction in the level of recession.[9] The orthodontic forces application in these patients requires close monitoring depending on the amount of bone present and crown root ratio, which is often increased in these patients. Light orthodontic forces are required (5–15 g/tooth) for effective tooth movement and to reduce the chances of root resorption. A good plaque control and reduced inflammation is the key to success in these patients [Figure 6].[10]
| Conclusion | | |
Comprehensive knowledge of different specialties along with multidisciplinary approach and customized treatment planning has widened the spectrum of available treatment options for adult patients. Clinical experience of the orthodontic treatment of patients who have been successful in controlled their chronic periodontal disease is now good and such patients should not be denied orthodontic treatment.
The decision regarding the time of intervention and the sequence of periodontal and orthodontic procedures is sometimes inevitably based on clinical experience, published case reports or case series and subsequent arbitrary assumptions. Therefore, there is a strong need for further research in certain directions through well-designed studies to provide patients with evidence-based treatment.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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| 8. | Khorsand A, Paknejad M, Yaghobee S, Ghahroudi AA, Bashizadefakhar H, Khatami M, et al. Periodontal parameters following orthodontic treatment in patients with aggressive periodontitis: A before-after clinical study. Dent Res J (Isfahan) 2013;10:744-51. |
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| 10. | Rao S C. Management of periodontally compromised patient by orthodontic treatment: Does it help esthetically and biologically? Contemp Clin Dent 2012;3:215-8. [ PUBMED] [Full text] |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
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