Adjunctive role of Orthodontic Therapy in Periodontology
ADJUNCTIVE ROLE OF
ORTHODONTIC THERAPY IN
Orthodontic treatment is based on the principles that if prolonged
pressure is applied to a tooth, tooth movement will occur as the
bone around the tooth remodels.
Orthodontic tooth movement may be a substantial benefit to
the adult periorestorative patient. Many adults who seek
routine restorative dentistry have problems with tooth
malposition that compromise their ability to clean and
maintain their dentitions.
If these individuals also are susceptible to periodontal
disease, tooth malposition may be an exacerbating factor
that could cause premature loss of specific teeth.
The loss of periodontal support or teeth may result in
elongation, spacing and proclination of incisors, rotation
and tipping of premolars and molars with collapse of the
posterior occlusion, and decreasing vertical dimension.
PHYSIOLOGICAL RESPONSE TOHEAVY
PRESSURE AGAINST A TOOTH:-
TIME (SECONDS) EVENT
<1 PDL fluid incompressible, alveolar
bone bends, piezoelectric signal
1-2 PDL fluid expressed, tooth moves
within PDL space
3-5 PDL fluid squeezed out, tissues
compressed; immediate pain if
pressure is heavy
Orthodontic tooth movement is made possible by the application of prolonged
forces. In addition, light prolonged forces in the natural environment- forces from the
lips, cheeks, or tongue resting against the teeth- have the same potential as
orthodontic forces to cause the teeth to move to a different location.
The response to sustained force against the teeth is a function of
force magnitude: heavy forces lead to rapidly developing pain,
necrosis of cellular elements within the PDL, and the phenomenon
of “undermining resorption” of alveolar bone near the affected tooth.
Lighter forces are compatible with survival of cells within the PDL
and a remodeling of the tooth socket by a painless “frontal
resorption” of the tooth socket.
In orthodontic practice, the objective is to produce tooth movement
as much as possible by frontal resorption, recognizing that some
areas of PDL necrosis and undermining resorption will probably
occur despite efforts to prevent this.
BIOLOGIC CONTROL OF TOOTH
It is necessary to consider the biologic control mechanism
that leads from the stimulus of sustained force application
to the response of orthodontic tooth movement.
Two control mechanisms have been proposed :
Pressure- tension theory
PRESSURE- TENSION THEORY
Alteration in blood flow associated with pressure within PDL
Formation & release of chemical messengers
Activation of PDL cells & Bone remodeling
Cellular differentiation & activity leads to bone remodeling by: bone resorption (-) on
*Bone deposition (+) on tension side.
EFFECT OF ORTHODONTIC FORCES ON PERIODONTIUM
When a removable appliance is worn less than 4 to 6 hours per day, it
will produce no orthodontic effects, but above this duration threshold,
tooth movement does occur.
Experiments have shown increase levels of PG and IL-1ß in PDL within
short time after pressure application. Also, evidence shows PG release
when cells are mechanically deformed. Other chemical messengers-
cytokines and NO and other regulators of cellular activity also involved.
For tooth movement to occur osteoclasts must be formed to remove
bone from the area adjacent to compressed PDL. Osteoblasts are
needed for formation of bone on tension side and remodel resorbed
areas on pressure side.
PG E stimulates both osteoclastic and osteoblastic activity
In clinical orthodontic it is difficult to avoid pressure that produces at
least some avascular area in the PDL, and it has been suggested
that releasing pressure against a tooth at intervals while maintaining
the pressure for enough hours to produce the biologic response,
could help in maintaining tissue vitality
Interrelationship of orthodontic tooth movement with periodontal health:
1.Loss of periodontal attachment and bone relative to
In patients with active periodontitis (that is, plaque infected deep pockets
evidenced by bleeding on probing), orthodontic tooth movement may
accelerate the disease process, even when good oral hygiene is practiced.
Orthodontic bodily movement into plaque induced infra bony defects can
be successfully performed, provided that the periodontal lesion is
eliminated before tooth movement is began, and excellent oral hygiene is
2. Gingival recession relative to orthodontic therapy
Orthodontic tooth movement per se does not cause gingival
In areas of thin labial tissue, labial orthodontic tooth movement
can result in bony dehiscence, creating an environment in which
plaque / or toothbrush trauma may cause sudden recession.
Many researchers and clinicians agree that this thin labial tissue
should be augmented before labial orthodontic tooth movement is
begun. It is interesting to note that in areas of a labially positioned
tooth with dehiscence, bone may reform and gingival thickness
may increase when the tooth is moves lingually
In regard to relationship between rapid maxillary expansion
procedures and gingival recession Grabe r and Vanarsdall stated that
if the maxillary expansion is performed after the mid palatine suture
begin to fuse (after approximately 14-16years of age), there is a
greater risk of recession of the buccal gingival tissue of the maxillary
premolars and molars later in life.
Periodontal evaluation of a potential adult orthodontic patient must
include not only the response to periodontal probing but also level
and condition of attached gingiva.
We nnstro m e t al (1 9 8 7 ) found no relationship between initial width of
keratinized gingiva and tendency for development of gingival
recession during orthodontic tooth movement in monkeys.
Instead it is the buccolingual thickness which maybe the determining
factor for development of gingival recession and attachment loss at
sites with gingivitis during orthodontic treatment.
ORTHODONTIC TOOTHMOVEMENT IN ADULTS WITHPERIODONTAL TISSUE
With properly performed treatment, extensive orthodontic tooth movement
can be made in adults with a reduced but healthy periodontium without
further periodontal deterioration.
More recent studies on much larger groups (350-400 patients) of
consecutively treated adult patients from different practice s (Ne lso n
& Artun 1 9 9 7 , Re e t al. 20 0 0 ) have confirmed that
(1) pretreatment evidence of periodontal tissue destruction is no
contraindication for orthodontics,
(2) orthodontic therapy improves the possibilities of saving and
restoring a deteriorated dentition, &
(3) the risk of recurrence of an active disease process is not
increased during appliance therapy
Esthetic finishing of treatment results
The presence of papillae between the maxillary incisors is a key esthetic
factor after orthodontic treatment.
Normally, when a long-standing crowding with incisor overlap is corrected
orthodontically in adults, it is generally not possible to have an intact papilla.
This is because the contact point becomes located too far incisally on the
triangular crowns that have not had a normal interdental wear pattern.
Similarly, in patients with advanced periodontal disease and destruction of
the crestal bone between the incisors, the papillae may be absent.
This produces unaesthetic gaps between the teeth after orthodontics.
The best method of correcting this problem is to recontour the mesiodistal
surfaces of the incisors during the orthodontic finishing stage (Tuverson
When the diastema thus created is closed, the roots of the teeth can come
The contact point is lengthened and moved apically, and the papilla can fill
out the interdental space more easily.
Retention - problems and solutions; long-termfollow-up
According to Pro ffit (1 9 7 8 ), two major primary factors are involved in the
equilibrium which determines the final position of teeth.
These are the resting pressures of lip or cheek and tongue, and forces
produced by metabolic activity within the periodontal membrane.
With an intact periodontium, unbalanced tongue-lip forces are normally
counteracted by forces from the periodontal membrane.
However, when the periodontium breaks down, its stabilizing function no
longer exists and the incisors begin to move.
A consequence of this concept would be that persons with advanced
periodontal disease and tooth migration would need permanent retention
after the orthodontic correction.
SPECIFIC FACTORS ASSOCIATEDWITHORTHODONTIC TOOTH
MOVEMENT IN ADULTS
1. Tooth movement into infrabony pockets
Orthodontic forces pe r se are unlikely to convert gingivitis into
The plaq ue -induce d le sio n in g ing ivitis is co nfine d to the
supra-alve o lar co nne ctive tissue , whe re as tissue re actio ns to
o rtho do ntic fo rce s o ccur in the co nne ctive tissue be twe e n the
ro o t and the alve o lar bo ne .
Infrabony pockets, i.e. angular bony defects with inflamed
connective tissue and epithelium apical to the bone crest,
may develop as a result of destructive periodontitis.
Infrabony pockets may also be created by orthodontic tipping
and/ or intruding movements of teeth harboring plaque
(Ericsson et al. 1977).
The effect of bodily tooth movement into infrabony defects has
been evaluated experimentally in monkeys (Polson et al. 1984)
and in dogs (Wennstrom et al. 1993)
Provided elimination of the subgingival infection was performed
before the orthodontic tooth movement was started, no
detrimental effects on the attachment level were observed.
The angular bony defect was eliminated by the orthodontic
treatment, but no coronal gain of attachment was found and a thin
epithelial lining covered the root surface corresponding to its
It was the re fo re co nclude d that o rtho do ntic to o th m o ve m e nt into
infrabo ny pe rio do ntal de fe cts had no favo rable e ffe cts o n the
le ve lo f co nne ctive tissue attachm e nt.
Ho we ve r, it was po ssible to m o ve te e th with re duce d he althy
pe rio do ntium witho ut additio nalattachm e nt lo ss.
If, o n the o the r hand, the o rtho do ntic tre atm e nt invo lve d
m o ve m e nt o f te e th into and thro ug h a site with inflam m atio n and
ang ular bo ne lo ss, an e nhance d rate o f pe rio do ntal de structio n
was no te d.
of persisting junctional
epithelium subsequent to
orthodontic tooth movement
(direction of arrow) into an
2. To o th m o ve m e nt into
co m pro m ise d bo ne are as
O rtho do ntic to o th m o ve m e nt m ay so m e tim e s be pe rfo rm e d in adults
with partially e de ntulo us de ntitio ns ( due to ag e ne sis o r pre vio us
e xtractio ns o f te e th) and such patie nts m ay have a m o re o r le ss
co m pro m ise d alve o lar pro ce ss.
Expe rim e ntal re po rts (Lindsko g - Sto kland e t al. 1 9 9 3) and clinical
studie s (Ste po vich 1 9 7 9 , Ho rn & Turle y 1 9 8 4, Go ldbe rg & Turle y
1 9 8 9 , Thilande r 1 9 9 6 ) have sho wn that a re ductio n in ve rtical bo ne
he ig ht is no t a co ntraindicatio n fo r o rtho do ntic to o th m o ve m e nt
to wards, o r into , the co nstricte d are a.
Mandibular se co nd m o lars can be m o ve d m e sially thro ug h re m o de le d
e de ntulo us first m o lar are as in adults with o nly a lim ite d re ductio n in
ve rticalbo ne he ig ht, ave rag ing -1 . 3 m m (Ho rn & Turle y 1 9 8 4).
Space clo sure is po ssible also in e de ntulo us m axillary first m o lar
are as, altho ug h ve rtical bo ne lo ss and so m e space re -o pe ning can be
a co m plicatio n.
Histo lo g ic o bse rvatio ns in anim al e xpe rim e nts have co nfirm e d that
whe n lig ht fo rce s we re applie d to m o ve te e th bo dily into an are a with
re duce d bo ne he ig ht, a thin bo ne plate was re cre ate d ahe ad o f the
m o ving to o th.
The ke y to m o ving te e th with bo ne is dire ct re so rptio n in the
dire ctio n o f to o th m o ve m e nt, and avo iding hyalinizatio n. Te e th can
be m o ve d with bo ne into the m axillary sinus also (Me lse n 1 9 9 1 ).
Note radiographic visualization of the
thin bone spicule on the mesial side of
the second molar (arrow in d). Although
the molar is moved to contact the
second premolar, a marked gingival
invagination is present in the area
(arrow in c).
Altho ug h the re sults o f clinical e xpe rim e nts and fo llo w- ups are
e nco urag ing , pro vide d lig ht fo rce s are use d and e xce lle nt o ral
hyg ie ne is m aintaine d, it is pro bably wise no t to stre tch the
indicatio ns fo r to o th m o ve m e nt into co nstricte d bo ne are as to o
Marke d g ing ivalinvag inatio ns are so m e tim e s se e n in such are as.
3. To o th m o ve m e nt thro ug h co rticalbo ne
Expe rim e ntal studie s in anim als have de m o nstrate d that whe n a to o th
is m o ve d bo dily in a labial dire ctio n to wards and thro ug h the co rtical
plate o f the alve o lar bo ne , no bo ne fo rm atio n will take place in fro nt o f
the to o th (Ste ine r e t al. 1 9 8 1 , Karring e t al. 1 9 8 2).
Afte r initial thinning o f the bo ne plate , a labial bo ne de hisce nce is
the re fo re cre ate d.
Fo r e xam ple
(1 ) in the m andibular ante rio r re g io n due to fro ntal e xpansio n o f
inciso rs (We hrbe in e t al. 1 9 9 4),
(2) in the m axillary po ste rio r re g io n during late ral e xpansio n o f cro ss-
bite s (Gre e nbaum & Zachrisso n 1 9 8 2),
(3) ling ually in the m axilla asso ciate d with re tractio n and ling ual ro o t
to rq ue o f m axillary inciso rs in patie nts with larg e o ve rje ts (Te n Ho e ve
& Mulie 1 9 7 6 ), and
(4) by pro no unce d traum atic jig g ling o f te e th (Nym an e t al. 1 9 8 2).
Extrusio n and intrusio n o f sing le te e th - e ffe cts o n pe rio do ntium ,
clinicalcro wn le ng th and e sthe tics
O rtho do ntic e xtrusio n o f te e th, o r so -calle d "fo rce d e ruptio n", m ay be
indicate d fo r
(1 ) shallo wing o ut intrao sse o us de fe cts
(2) fo r incre asing clinicalcro wn le ng th o f sing le te e th.
The fo rce d e ruptio n te chniq ue was o rig inally de scribe d by Ing be r (1 9 7 4)
fo r tre atm e nt o f o ne -walland two -wallbo ny po cke ts that we re difficult to
handle by co nve ntio nalthe rapy alo ne .
The e xtrusive to o th m o ve m e nt le ads to a co ro nalpo sitio ning o f intact
co nne ctive tissue attachm e nt, and the bo ny de fe ct is shallo we d o ut.
This was co nfirm e d in anim ale xpe rim e nts (van Ve nro y & Yukna 1 9 8 5)
Be cause o f the o rtho do ntic e xtrusio n, the to o th willbe in suprao cclusio n.
He nce , the cro wn o f the to o th willne e d to be sho rte ne d, in so m e case s
fo llo we d by e ndo do ntic tre atm e nt.
During the e lim inatio n o f an intrao sse o us po cke t by m e ans o f
o rtho do ntic e xtrusio n, the re latio nship be twe e n the CEJ and the bo ne
cre st is m aintaine d.
This m e ans that the bo ne fo llo ws the to o th during the e xtrusive
m o ve m e nt. This m ay o r m ay no t be be ne ficial de pe nding o n the clinical
In o the r wo rds, it is so m e tim e s de sirable to have the pe rio do ntium
fo llo w the to o th and in o the r situatio ns it is de sirable to m o ve a to o th o ut
o f the pe rio do ntalsuppo rt.
O rtho do ntic e xtrusio n o f a sing le to o th that ne e ds to be e xtracte d is an
e xce lle nt m e tho d fo r im pro ve m e nt o f the m arg inalbo ne le ve lbe fo re the
surg ical place m e nt o f sing le im plants. No t o nly the bo ne , but also the
so ft suppo rting tissue s will m o ve ve rtically with the te e th during
o rtho do ntic e xtrusio n.
Regenerative procedures and orthodontic tooth movement
The development of barrier membranes to prevent cells of the epithelium
and gingival connective tissue from colonizing the decontaminated root
surface, as well as the use of Emdogain, would appear to provide a
distinct improvement in orthodontic therapy in the periodontally
New supracrestal and periodontal ligament collagen fibers may be gained
on the tension side, which can transfer the orthodontic force stimulus to
the alveolar bone (Diedrich 1996).
The regenerative techniques would be advantageous associated with
both extrusion and intrusion of teeth with infrabony defects, and for
uprighting of tipped molars with mesial angular lesions.
Severe intraosseous defect between the right central and lateral incisors (b). Three months after
GTR treatment (GoreTex membrane) partial reossification is evident (c), possibly with new
attachment. Orthodontic leveling (d) with controlled space closure and intrusion of the lateral
MINOR SURGERY ASSOCIATED WITH ORTHODONTIC THERAPY
The problem of relapse of orthodontically treated teeth in general, and
rotated teeth in particular, has been well recognized for years.
Methods, to reduce the occurrence of rotational relapse may include
(1) Complete correction, or overcorrection, of rotated teeth,
(2) Long-term retention with bonded lingual retainers, and
(3) The use of fiberotomy.
Two soft-tissue periodontal entities may influence the stability:
The principal fibers of the periodontal ligament, and the supra-alveolar
Whereas the fibers of the periodontal ligament and transseptal groups
remodel efficiently and histologically completely in only 2 to 3 months after
orthodontic rotation of teeth, the supra-alveolar fibers are apparently more
stable, with a slow turnover.
The supracrestal gingival tissues seemingly do contribute to rotational
relapse, as evidenced by the effect of the circumferential supracrestal
fiberotomy (CSF) technique. First developed by Edwards (1970)
Basically this technique consists of inserting a scalpel into the gingival
sulcus and severing the epithelial attachment surrounding the involved teeth.
The blade also transects the transseptal fibers by interdentally entering the
periodontal ligament space.
Adult male patient with
median diastema, small
teeth, and low attaching
frenum (a,b), in whom
different types of minor
performed (d) in order to
improve and stabilize
result (c). Gingivectomy
over four incisors
increased crown length.
Note healing with intact
stippling 2 months
later (e,f). The surgical
and fiberotomies with
interdental vertical cuts
Bergstrom et al (1973) stated that the probability for diastema in the long run
is the same whether or not frenectomy is preformed. Earlier frenectomy
extending into palatal surface was advocated. But this leads to loss of inter
dental papilla between upper central incisors.
So, the frenotomy by Edwards (1977) was introduced, which represents a
more gentle operation, with only partial removal of frenum and with the
purpose of relocating the attachment in an apical direction.
If the gingival discrepancy is apparent, however, one of four different techniques may
Intrusion and incisal restoration or porcelain laminate veneer
Extrusion + fiberotomy + porcelain crown
Surgical crown lengthening, by flap procedure and ostectomy/osteoplasty of bone
(Bragger et al 1992)
Clinical and histologic examination demonstrated that it was possible to permanently
increase clinical crown length after orthodontic treatment by making a labial
gingivectomy to the bottom of the clinical pocket.
The healing and regeneration of the gingiva was uneventful, provided excellent oral
hygiene was maintained in the wound area for 2 months.
BENEFITS OF ORTHODONTIC THERAPY
1. Aligning crowded or malposed maxillary or mandibular anterior teeth
permits the adult patient better access to clean all surfaces of their
teeth adequately. This could be a tremendous advantage for patients
who are susceptible to periodontal bone loss or do not have the
dexterity to maintain their oral hygiene.
2. Vertical orthodontic tooth repositioning can improve certain types of
osseous defects in periodontal patients. Often the tooth movement
eliminates the need for resective osseous surgery.
3. Orthodontic treatment can improve the esthetic relationship of the
maxillary gingival margin levels before restorative dentistry. Aligning
the gingival margins orthodontically avoids gingival recontouring,
which could require bone removal and exposure of the roots of the
4. Orthodontic treatment allows open gingival embrasures to be corrected
to regain lost papilla.
ORTHODONTIC TREATMENT OF
Hemiseptal defects are one-or two-wall osseous defects that often
are found around mesially tipped teeth or teeth that have
Usually, these defects can be eliminated with the appropriate
In the case of the tipped tooth, uprighting and eruption of the tooth
levels the bony defect.
If the tooth is supererupted, intrusion and leveling of the adjacent
cementoenamel junctions can help level the osseous defect.
This patient was
missing the mandibular
left second premolar,
and the first molar had
(B) revealed a
osseous defect on the
mesial of the molar. To
eliminate the defect, the
molar was erupted, and
theocclusal surface was
(C). The eruption was
stopped when the
bone defect was
After the completion of orthodontic treatment, these teeth should
be stabilized for at least 6 months and reassessed periodontally.
In the periodontally healthy patient, orthodontic brackets are
positioned on the posterior teeth relative to the marginal ridges
However, some adult patients may have marginal ridge
discrepancies caused by uneven tooth eruption.
When marginal ridge discrepancies are encountered, the decision
as to where to place the bracket or band is not determined by the
anatomy of the tooth.
In these patients, it is important to assess these teeth
radiographically to determine the interproximal bone level.
If the bone is flat and a marginal ridge discrepancy is present, the
orthodontist should not level the marginal ridges orthodontically. In these
situations, it may be necessary to equilibrate the crown of the tooth.
that the interproximal bone
was flat. To avoid creating a
hemiseptal defect, the
occlusal surface of the first
molar was equilibrated and
malocclusion was corrected
Advanced Horizontal Bone Loss
In a patient with advanced horizontal bone loss, the bone level may
have receded several millimeters from the CEJ.
As this occurs, the crown-to-root ratio becomes less favorable. By
aligning the crowns of the teeth, the clinician may perpetuate tooth
mobility by maintaining an unfavorable crown-to-root ratio.
In addition, by aligning the crowns of the teeth and disregarding the
bone level, significant bone discrepancies occur between healthy and
periodontally diseased roots. This could require periodontal surgery to
ameliorate the discrepancies.
Many of these problems can be corrected by using the bone level as a
guide to position the brackets on the teeth.
In these situations the crowns of the teeth may require considerable
equilibration. If the tooth is vital, the equilibration should be performed
gradually to allow the pulp to form secondary dentin and insulate the
tooth during the equilibration process.
The goal of equilibration and creative bracket placement is to
provide a more favorable bony architecture as well as a more
favorable crown-to-root ratio.
In some of these patients, the periodontal defects that were
apparent initially may not require periodontal surgery after
Furcation defects can be classified as incipie nt (class I),
m o de rate (class II), o r advance d (class III).
These lesions require special attention in the patient undergoing
orthodontic treatment. Often the molars require bands with tubes
and other attachments that impede the patient’s access to the
buccal furcation for home care and instrumentation at the time of
Furcation lesions require special consideration because they are
the most difficult lesions to maintain and can worsen during
orthodontic therapy. These patients need to be maintained on a
2- to 3-month recall schedule. Detailed instrumentation of these
furcations helps minimize further periodontal breakdown.
If a patient with a class III furcation defect will be undergoing orthodontic
treatment, a possible method for treating the furcation is to eliminate it by
hemisecting the crown and root of the tooth. However, this procedure
requires endodontic, periodontal, and restorative treatment.
If the patient will be undergoing orthodontic treatment, it is advisable to
perform the orthodontic treatment first. This is especially true if the roots
of the teeth will not be moved apart. In these patients the molar to be
hemisected remains intact during orthodontics.
This patient would require 2- or 3-month recall visits to ensure that the
furcation defect does not lose bone during orthodontic treatment.
In some patients requiring hemisection of a mandibular molar with a
class III furcation, pushing the roots apart during orthodontic
treatment may be advantageous. If the hemisected molar will be used
as an abutment for a bridge after orthodontics, moving the roots apart
orthodontically permits a favorable restoration and splinting across
the adjacent edentulous spaces.
In these patients, hemisection, endodontic therapy, and periodontal
surgery must be completed before the start of orthodontic treatment.
After completion of these procedures, bands or brackets can be
placed on the root fragments and coil springs used to separate the
roots. The amount of separation is determined by the size of the
adjacent edentulous spaces and the occlusion in the opposing arch.
About 7 or 8 mm may be created between the roots of the hemisected
In some molars with class III furcation defects, the tooth may have short
roots, advanced bone loss, fused roots, or other problems that prevent
hemisection and crowning of the remaining roots. In these patients,
extracting the root with a furcation defect and placing an implant may be
If this type of plan has been adopted, the timing of the extraction and
placement of the implant can occur at any time relative to the orthodontic
treatment. In some patients the implant can be used as an anchor to
facilitate prerestorative orthodontic treatment.
The implant must remain embedded in bone for 4 to 6 months after
placement before it can be loaded as an orthodontic anchor. It must be
placed precisely so that it not only provides an anchor for tooth
movement, but also may be used an eventual abutment for a crown or
If the implant will not be used as an anchor for orthodontic movement, it
may be placed after the orthodontic treatment has been completed.
This patient was missing several teeth in the mandibular left posterior quadrant (A). The
mandibular left third molar had a class III furcation defect and short roots (B). The third
molar was extracted, and two implants were placed in the mandibular left posterior
quadrant (C). The implants were used as anchors to facilitate orthodontic treatment (D)
and help reestablish the left posterior occlusion (E and F).
When roots of posterior teeth are close together, the ability to maintain
periodontal health and accessibility for restoration of adjacent teeth may
be compromised. However, for the patient undergoing orthodontic
therapy, the roots can be moved apart, and bone will form between the
This opens the embrasure beneath the tooth contact, provides additional
bone support, and enhances the patient’s access to the interproximal
region for hygiene.
This approach generally improves the periodontal health of this area.
Fractured Teeth and Forced
Eruption Occasionally, children and adolescents may fall and injure their anterior
teeth. If the injuries are minor and result in small fractures of enamel,
these can be restored with light-cured composite or porcelain veneers.
In some patients, however, the fracture may extend beneath the level of
the gingival margin and terminate at the level of the alveolar ridge;
restoration of the fractured crown is impossible because the tooth
preparation would extend to the level of the bone.
This over-extension of the crown margin could result in an invasion of
the biologic width of the tooth and cause persistent inflammation of the
marginal gingiva. It may be beneficial in such cases to erupt the
fractured root out of the bone and move the fracture margin coronally so
that it can be properly restored.
However, if the fracture extends too far apically, it may be better to
extract the tooth and replace it with an implant or bridge.
The following six criteria are used to determine whether the tooth should be
forcibly erupted or extracted:
1. Root length: the clinician must know how far to erupt the root. If a tooth
fracture extends to the level of the bone, it must be erupted 4 mm. The first
2.5 mm moves the fracture margin far enough away from the bone to
prevent a biologic width problem. The other 1.5 mm provides the proper
amount of ferrule for adequate resistance form of the crown preparation.
The root/crown ratio should be about 1:1.
2. Root form: The shape of the root should be broad and nontapering rather
than thin and tapered. A thin, tapered root provides a narrower cervical
region after the tooth has been erupted 4 mm. This could compromise the
esthetic appearance of the final restoration.
3. Level of the fracture. If the e ntire cro wn is fracture d 2 to 3 m m apical to the
le ve lo f the alveolar bone, it is difficult, if not impossible, to attach to the root
to erupt it.
4. Relative importance of the tooth. If the patie nt is 7 0 ye ars o f ag e and bo th
5. Esthetics: If the patie nt has a hig h lip line and displays 2 to 3 m m o f
g ing iva whe n sm iling , any type of restoration in this area will be
more obvious. Keeping the patient’s own tooth would be much more
esthetic than any type of implant or prosthetic replacement.
6. Endodontic/periodontal prognosis. If the to o th has a sig nificant
pe rio do ntal de fe ct, it m ay not be possible to retain the root. In
addition, if the tooth root has a vertical fracture, the prognosis would
be poor, and extraction of the tooth would be the proper course of
After the tooth root has been erupted, it must be stabilized to
prevent it from intruding back into the alveolus. The reason for
re intrusio n is the o rie ntatio n o f the principalfibe rs o f the
pe rio do ntium . During forced eruption, the periodontal fibers become
oriented obliquely and stretched as the root moves coronally. These
fibers eventually reorient themselves after about 6 months. Before
this occurs, the root can reintrude significantly. Therefore, if this
type of treatment is performed, an adequate period of stabilization
To restore the tooth
avoid impinging on the
fractured root was
extruded 4 mm
Hopeless Teeth Maintained forOrthodontic
Patients with advanced periodontal disease may have specific
teeth diagnosed as hopeless, which would be extracted before
orthodontic therapy. However, these teeth can be useful for
orthodontic anchorage if the periodontal inflammation can be
controlled. In moderate to advanced cases, some periodontal
surgery may be indicated around a hopeless tooth.
Flaps are reflected for debridement of the roots to control inflammation
around the hopeless tooth during the orthodontic process. The important
factor is to maintain the health of the bone around the adjacent teeth.
Periodontal recall is imperative during the process.
After orthodontic treatment, there is a 6-month period of stabilization
before reevaluating the periodontal status. Occasionally the hopeless
tooth may be so improved after orthodontic treatment that it is retained.
right first molar was
of an advanced
class III furcation
second molar was
extracted, but the
first molar was
maintained as an
anchor to help
upright the third
C, and D).
ORTHODONTIC TREATMENT OF GINGIVAL
Uneven Gingival Margins
The relationship of the gingival margins of the six maxillary anterior teeth
plays an important role in the esthetic appearance of the crowns.
The following four factors contribute to ideal gingival form:
1. The gingival margins of the two central incisors should be at the same
2. The gingival margins of the central incisors should be positioned more
apically than the lateral incisors and at the same level as the canines.
3. The contour of the labial gingival margins should mimic the CEJs of the
4. A papilla should exist between each tooth, and the height of the tip of
the papilla is usually halfway between the incisal edge and the labial
gingival height of contour over the center of each anterior tooth.
Therefore the gingival papilla occupies half of the interproximal contact,
and the adjacent teeth form the other half of the contact.
However, some patients may have gingival margin discrepancies between
adjacent teeth. These discrepancies may be caused by abrasion of the
incisal edges or delayed migration of the gingival margins.
When gingival margin discrepancies are present, the proper solution for the
problem must be determined: orthodontic movement to reposition the
gingival margins or surgical correction of gingival margin discrepancies.
To make the correct decision, it is necessary to evaluate four criteria. First,
the relationship between the gingival margin of the maxillary central incisors
and the patient’s lip line should be assessed when the patient smiles. If a
gingival margin discrepancy is present but the discrepancy is not exposed,
it does not require correction.
If a gingival margin discrepancy is apparent, the second step is to evaluate
the labial sulcular depth over the two central incisors. If the shorter tooth
has a deeper sulcus, excisional gingivectomy may be appropriate to move
the gingival margin of the shorter tooth apically. However, if the sulcular
depths of the short and long incisors are equivalent, gingival surgery does
not correct the problem.
The objective was to level
the gingival margins during
Although gingival surgery
was a possibility, the labial
sulcular depth of the
maxillary right central
incisor was only 1 mm, and
the cemento enamel
junction was located at the
bottom of the sulcus.
Therefore the best solution
involved positioning the
orthodontic brackets to
facilitate intrusion of the
right central incisor
The third step is to evaluate the relationship between the shortest
central incisor and the adjacent lateral incisors.
If the shortest central incisor is still lo ng e r than the late ral inciso rs,
the o the r possibility is to extrude the longer central incisor and
equilibrate the incisal edge. This moves the gingival margin coronally
and eliminates the gingival margin discrepancy. However, if the
shortest central incisor is sho rte r than the late ral inciso rs, this
te chniq ue wo uld pro duce an une sthe tic relationship between the
gingival margins of the central and lateral incisors.
The fourth step is to determine whether the incisal edges have been
abraded. This is best accomplished by evaluating the teeth from an
incisal perspective. If one incisal edge is thicker labiolingually than
the adjacent tooth, this may indicate that it has been abraded and the
tooth has overerupted. In such cases, the best method of correcting
the gingival margin discrepancy is to intrude the short central incisor.
Significant Abrasion and Overeruption
Occasionally, patients have destructive dental habits, such as a protrusive bruxing
habit, that can result in significant wear of the maxillary and mandibular incisors and
compensatory overeruption of these teeth.
One option is extensive crown lengthening by elevating a flap, removing sufficient
bone, and apically positioning the flap to expose adequate tooth length for crown
This type of procedure is contraindicated in the patient with short, tapered roots
because it could adversely affect the final root/crown ratio and potentially open
gingival embrasures between the anterior teeth.
The other option for improving the restorability of these short abraded teeth is to
intrude the teeth orthodontically and move the gingival margins apically.
When abraded teeth are significantly intruded, it is necessary to hold these teeth for
at least 6 months in the intruded position with orthodontic brackets or archwires (or
both), or some type of bonded retainer. The principal fibers of the periodontium must
accommodate to the new intruded position, a process that could take a minimum of
The less destructive option was to intrude the four incisors orthodontically, level the
gingival margins (C and D), and allow the dentist to restore the abraded incisal edges
WILCKODONTICS: also known as accelerated osteogenic orthodontics.
Introduced by two wilko brothers-william (orthodontist) and Thomas
History: Surgical intervention to affect the alveolar housing and speed tooth
movement has been used in various forms for more than a hundred years.
Heinrich Köle’s in 1959 arose the term “bony block” .He believed that it
was the continuity and thickness of the denser layer of cortical bone that
offered the most resistance to tooth movement. He theorized that by
disrupting the continuity of cortical layer of bone using vertical
interradicular corticotomy cuts both facially and lingually and these were
joined 10 mm supra-apically with an osteotomy cut through the entire
thickness of the alveolus..
Periodontally accelerated osteogenic orthodontics (PAOO) Wilcko
et al(2000, 2001, 2003, 2008) : which included the corticotomy
surgery with alveolar grafting referred to as Accelerated Osteogenic
Orthodontics (AOO) and more recently to as Periodontally
Accelerated Osteogenic Orthodontics.
This technique advocated for comprehensive fixed orthodontic
appliances in conjunction with full thickness flaps and labial and
lingual corticotomies around teeth to be moved.
Bone graft consisting of demineralized freeze-dried bone and
bovine bone with clindamycin was applied directly over the bone
cuts and the flap was sutured in place. Tooth movement was
initiated two weeks after the surgery, and every two weeks
thereafter by activation of the orthodontic appliance. With this
technique, treatment time reduce to one-third the time of
Figure 1: Preoperative Figure 2: Maxillary anterior teeth coticotomy
Figure 3: Bone graft placed Figure 4: Bone graft placed in the corticotomy site in the lower
Figure 5: Postoperative
1.Reduced treatment time: this technique will reduce treatment time to
one-third the time of conventional orthodontics
2. Less root resorption due to decreased resistance of cortical bone
3. More bone support due to the addition of bone graft
4. History of relapse reported to be very low
Mildly invasive surgical procedure
Post-surgical crestal bone loss and recession may occur.
Some pain and swelling is expected, and the possibility of infection.
Not applicable to all cases, proper case selection is necessary to attain
a good result.
Orthodontic tooth movement is brought about by prolonged
application of force on the attachment apparatus. One should
consider the fact the two disparate processes occur in the gingiva
that alter the transduction of the orthodontic force. First there is an
injury to the connective tissue manifested by the torn and ripped
collagen fibers, second the genes of both collagen and elastin are
activated where a both collagen and elastin are activated where as
that of tissue collagenase is inhibited. Thus affecting the ECM of
Marked frontal expansion of incisors may lead to gingival
recession, loss of attachment and bony dehiscence. Finally some
forms of minor periodontal surgery were briefly discussed. Using
this information along with a well defined patient management
protocol (and a home care commitment from the patient) the inter-
disciplinary team of periodontist and orthodontist can manage
majority of inter related Ortho – Perio problem with predictably