Interdisciplinar

y Approach in
Periodontal
Therapy

CONTENTS

Perio-Ortho
Perio-Prostho
Endo-Perio

Orthodontics and Periodontics

Management of periodontal conditions
with orthodontic tooth movement as an
adjunct
AND
Management of periodontal problems
arising during and after orthodontic tooth
movement

Role of orthodontics adjunct

to periodontal therapy

Benefits Of Orthodontics For A

Periodontal Patient
Reducing plaque retention

Crowded teeth
Tipped teeth
Malposed teeth
Teeth in linguoversion

Vertical tooth positioning improves certain types of

osseous defects.
Facilitating prosthetic replacements
Implant
placement
Improving esthetics allows open gingival embrasures
regain lost papilla

Orthodontic tooth movement in adults

with periodontal tissue breakdown.
Inflammation
+
Orthodontic forces
+
Occlusal trauma
=
Rapid destruction
(Kessler 1976)

Study by Artun & Urbye (1988)

Bone level measurements on radiographs indicated
that the majority of sites showed little or no
additional loss of bone support.
(Nelson & Arun 1997, Ree et al 2000)

Pretreatment evidence of periodontal tissue

destruction is no contraindication for orthodontics.
Orthodontic therapy improves the possibilities of
saving and restoring a deteriorated dentition.
The risk of recurrence of an active disease process
is not increased during appliance therapy.

Orthodontic Treatment Considerations

Eliminate/reduce

Plaque accumulation
Gingival inflammation

Fixed appliances

Design of the appliance

Need to facilitate oral hygiene

Bonded ceramic brackets

Appliances & mechanics simple
Avoid hooks, elastomeric rings, excess bonding resin
Steel ligatures preferred over elastomeric rings ( Forsberg
et al 1991)
Bonds preferable to bands
Periodic professional tooth cleaning at 3 months interval

Possibilities and limitations

Each individual treatment plan may depend on a variety of
factors and can be limited by biomechanical considerations
(force systems, limited anchorage), by periodontal risk factors
(tooth/alveolar bone topography, sinus recesses, activity and
prognosis of the periodontitis), and by limited patient motivation
and poor oral hygiene co-operation.

Single case reports have documented successful periodontalorthodontic treatment with ( LAP) after conventional
periodontal therapy. However, until more evidence is
accumulated, it may seem wise to avoid orthodontic treatment in
patients with particularly ( GAP) forms of periodontal disease.

Orthodontic Treatment Of Osseous Defects

Pre-Orthodontic Osseous Surgery

Osseous Craters
Lesion

eliminated

reshaping & PD
Need for surgery

Initial RP
PDL resistance
Location of defect

by

Three-Wall Intrabony Defects

Regenerative
therapy
Results stable 36 months

Hemiseptal Defects
Hemiseptal defects
Tipped tooth
Supraerrupted tooth
After completion of
orthodontic tt. stabilization
for 6 months followed by pdl
reassessment.

It would be injudicious to perform preorthodontic osseous

corrective surgery in such lesions if orthodontics is part of the

 In some patients, a discrepancy may exist between both the

marginal ridges and the bony levels between two teeth. discrepancies may not be of equal magnitude.

In these patients, orthodontic leveling of the bone may still

leave a discrepancy in the marginal ridges.

In these situations, the crowns of the teeth should not be used

as a guide for completing orthodontic therapy. The bone should
be leveled orthodontically and any remaining discrepancies
between the marginal ridges should be equilibrated. This
method produces the best occlusal result and improves the
periodontal health.

Advanced Horizontal Bone Loss

Outcome of orthodontic therapy

Location of bands and brackets on

teeth

Health- Determined by anatomy of

tooth
Bone level should act as a guide to bracket placement

Molar Uprighting
Tipped molars- a causative/aggravating factor future periodontal
tissue breakdown
Indications-functionally disturbing interferences, paralleling or space
problems associated with prosthetic rehabilitation, or traumatic
occlusion.
It causes a shallowing-out of the angular defect, with new bone
forming at the mesial alveolar crest
When there is a definite osseous defect caused by periodontitis on the
mesial surface of the inclined molar, uprighting the tooth and tipping
it distally will widen the osseous defect.

Uprighting and leveling of maxillary

and mandibular molars

Furcation Defects
Require special attention..

Bands with tubes & other attachments impede patient's access to

buccal furcation for home care & instrumentation at the time of
recall.

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.

Class III furcation

Orthodontic therapy

If roots need to be moved apart

If roots not to be moved apart

Do hemisection pre Ortho

2 to 3 months recall visits

Place brackets on roots and

coil springs to seperate

Endodontic therapy

Size of eden. space and

occlusion

Eliminate it by hemisection

7-8mm space may be created

 Class III furcations, tooth may have : Short roots

Fused roots
Advanced bone loss, thus preventing hemisection

 Extract the root and place implant

Implant can act as anchor to facilitate prerestorative
orthodontic therapy.
4-6 months after placement
If not acting as an anchor can be placed after orthodontic
therapy

Fractured Teeth/ Forced Eruption

Criteria
Root length crown-root ratio 1:1
Root form broad & non tapering , root canal should not be
more than one third.
Level of fracture
Relative importance of tooth
Esthetics high lip line
Endo-perio prognosis
Orthodontic considerations: Mechanics can vary from elastic traction to banding and
bracketing.
Root may be erupted slowly or rapidly

Orthodontic Treatment Of Gingival

Discrepancies
Abrasion of incisal edges
Gingival margin
discrepancies
Delayed migration of
gingival margins

Can be corrected

Orthodontically

Surgically

 Esthetically visible
Evaluate sulcular depth
Evaluate relationship of CI to LI
Incisal abrasion intrusion best accomplished 6 months
before

appliance removal.

Open Gingival Embrasures

Tooth shape
Root angulation
Periodontal bone loss

Interproximal contact area

consists of two parts..

Evaluating the problem

Papilla

Tooth contact
Evaluate
radiograph

Lack of bone support

due to PDL problems

Reconstruction of
papilla

Divergent roots
brackets , correct
root position

Non divergent roots

triangular tooth shape
Reshape the tooth

Elimination of unesthetic soft tissue gaps

The problems that may arise during or after orthodontic therapy are
grouped as follows :-

Associated with orthodontic bands.

Associated with excessive orthodontic force.
Orthodontic relapse.
Difficulty in tooth movement.

Associated With Orthodontic

Bands

Associated With Excessive Force

ORTHODONTIC RELAPSE

Reorganization of collagen & elastic supracrestal gingival fibers

When teeth are moved to a new position these fibers stretch

and they remodel very slowly.
The pull of these fibers tend to revert the teeth to their old
positions.
If the supracrestal fibers are sectioned (i.e. by circumferential
supracrestal fibrotomy CSF) and allowed to heal while the teeth
are held in the proper position, relapse caused by gingival
elasticity is reduced.

 Reiten (1969) reported that most relapse following

orthodontic tooth movement occurred during the first five
hours after the appliance was removed hence it is advisable
to do the fiberotomy procedure few weeks before the
removal of appliance.

Several clinical and histologic investigations indicate that the

major relapse pull on a rotated tooth appears to be in the
supracrestal fibers.

Difficulties In Orthodontics Tooth Movement

Age is not a contraindication to orthodontic treatment.
With increasing age cellular activity decreases and the tissue
becomes richer in collagens.
In the elderly, the tissue response to orthodontic forces
including both cell mobilization and conversion of collagen
fibers is much slower than in children and teenagers.
In adults, hyalinized zones are formed more easily on the
pressure side of an orthodontically moved tooth and these
zones may temporarily prevent the tooth from moving in the
intended direction.

 Since the growth in adults is completed, it is not possible by

orthodontic measures to influence zone of growth and
therefore treatment in adult individuals is restricted to
different types of tooth alignment.
It is far more difficult for an adult individual to adopt to an
orthodontic appliance than for a child.
Phonetic adjustment to a removable appliance for instance,
generally require more time in an adult.
A fixed appliance is usually better tolerated by adult patient.

Frenum Considerations
Many- frenum prevents mesial migration of maxillary CI.
Others- removal of frenum allows space to be closed
orthodontically
Generally , removal of frenum should be delayed until after
orthodontic therapy, unless tissue becomes painful or
prevents space closure, to change irreversible hyperplastic
tissue to normal gingival form & to enhance post
treatment stability.

The Role Of Implants In Orthodontics

Implants as a source of absolute anchorage
Implants used for anchorage and as abutments for
restorations
Implant site preparation improved by orthodontics
Implants in osteogenic distraction.

Time Relationship between

Orthodontic
& Periodontal Therapy
It is generally recommended that orthodontics be preceded by PDL
therapy based on the belief that orthodontics in the presence of
inflammation can lead to rapid and irreversible breakdown of the
periodontium (Lindhe et al. 1974).
SRP (if necessary, by open flap debridement procedures for access)
& gingival augmentation should be performed as appropriate
before any tooth movement (Glickman 1964, Prichard 1965, Profflt
1993d).
The corrective phase of periodontal therapy, i.e., osseous or pocket
reduction/ elimination surgery ought to be delayed until the end of
orthodontic therapy, because tooth movement may modify gingival
and osseous morphology (Goldman & Cohen 1968).

Periodontal Restorative
Interrelationship

Prep of periodontium for restorative

dentistry

Active pdl disease

Restorative dentistry performed on .
Implant dentistry .

Shrinkage of tissue helps in locating ideal gingival margin ..

Position of teeth altered in PDL disease- injurious tension &

pressure

Impairment of functional demands

Impressions made from inflamed gingiva improper fit

Mobility & pain interferes with

masticaton & function

Aim is not only to eliminate periodontal pockets and restore gingival

health.

Treatment should also create the gingivomucosal environment &

osseous topography necessary for the proper function of prosthesis.

Phase I Therapy
Control of active dental disease
Higher quality

Pocket. Ulceration , edema,

vascularity

Return of healthy state in 2 weeks

Thus plaque control, calculus removal and the removal or
correction of any inadequate dental restorations in the
gingival environment should be initial procedures.

Management of Mucogingival
Problems
It often is necessary to carry out a free soft tissue
autograft in the patient who has a mucogingival defect
and requires a dental restoration in the immediate
environment of the gingiva.

Should be carried out at least 2 months before

placement of the dental restorations - allows time for
mature tissue to form

Augmentation of keratinized gingiva provides stability of

the free gingival margin and surrounding gingival tissues
so that the dental restoration can be placed in an
environment in which gingival health can be maintained.

Techniques to increase the width of

attached gingiva
1.Free gingival autografts
2.Apically positioned flap
3.Free connective tissue autograft
4.Pedicle grafts:
laterally displaced
coronally displaced

Crown Lengthening Procedure

The surgical procedure to expose adequate clinical crown

to prevent the placement of the crown margin into the area
of the biologic width is termed crown-lengthening surgery.

Biological width
Consta
nt
Crestal
bone lost
to
reestabli
sh
Gingiva
l
inflamm
ation

Gingivectomy

Crown lenthening procedure

 It is essential that there be at least 3 mm between the most

apical extension of the restoration margin and the alveolar
bone crest.
This space allows sufficient room for the supracrestal collagen
fibers that are part of the periodontal support mechanism, as
well as providing a gingival crevice of 2 to 3 mm.
If this guideline is used, the margin of the crown is finally
positioned at its correct level, approximately halfway down the
gingival crevice.
Failure to allow sufficient space between the crown margin and
the alveolar crest height means that the finished restoration is
positioned deep in the periodontal tissues and results in
increased inflammation and pocket formation.

Margins

1.Supragingival
2.Equigingival
3.Sub Gingival

Supra Gingival

Least Impact On Periodontium

Applied In Non Esthetic Areas

Equigingival Margins

Traditionally Not Desirable

Plaque Retentive- Greater Inflammation
Any Minor Recession-unsightly Margin Display
Advantage: Finished Easily

Subgingival Margins
no access for finishing
violates biologic
width when placed
incorrectly.
change of microflora from
health to disease
increased gingival
inflammation

apical migration of junctional

epithelium

2 Different Responses

Supragingival/Subgingival Margins
Guy.M.Newcomb (1974 )The relationship between the location of
subgingival crown margins and gingival inflammation and concluded
that the nearer a subgingival crown margin approaches the base of the
gingival crevice, the more likely its that severe inflammation will occur.
D.A.Orkin and D. Bradshaw (1987) conducted a study on the
Relationship of the positions of crown margins to gingival health and
showed that gingival tissues tend to bleed 2.42 times more frequently
with subgingival margins and have 2.65 times higher chance of gingival
recession
D.A.Felton (1991) Effects of in vivo crown margin discrepancies on the
periodontal health in his study he strongly supported the placement of
supragingival margins for artificial crowns and FPDs.
William.G.Reeves in his review article concluded that more
supragingivally a restorative margin is placed, the less chance that the
margin will contribute to gingival inflammation.

Identification Of Biologic Width

Adequacy
Radiographs
Tissue discomfort
experienced by patient
Periodontal probe
Sounding of bone

In 1994, Vacek et al investigated the biologic width

phenomenon. Although their average width finding of 2 mm
was the same as that previously presented by Gargiulo et
al, they also reported a range of different, patient-specific
biologic widths.
They reported biologic widths as narrow as 0.75 mm in some
individuals, whereas others had biologic widths as tall as
4.3 mm.
Dictates that specific biologic width assessment should be
performed for each patient for restorations to be in
harmony with their gingival tissues.

Biological Width Violations

Gingival Inflammation
Gingival Inflammation

Correction of biologic width violation

Transgingival probing/bone sounding
Measure the distance from gingival crest
to alveolar crest

if less than 3mm

ostectomy with apically

displaced flap (rapid).
orthodontic extrusion.

if more than 5mm

gingivectomy

Tissue Retraction
In this process, the tissue must be protected from abrasion,
which will cause hemorrhage and can adversely affect the
stability of the tissue level around the tooth.
During final impression making , a clean, fluid controlled
environment is desired. Tissue management is achieved
with gingival retraction cords, using the appropriate size to
achieve the displacement required.
Thin, fragile gingival tissues and shallow sulcus - smaller
diameter cords be chosen to achieve the desired tissue
displacement.

 Journal of Prosthodontics, Vol 15, No 2 ( March-April),

2006: pp 108-112

Gingival retraction causes an acute injury that heals clinically

in 2 weeks as is indicated by the GI.
It also provides the first evidence that gingival retraction
results in an elevation of the proinflammatory cytokine,
TNF-, in GCF.

Marginal fit
Marginal fit - producing an inflammatory response in the
periodontium.
It has been shown that the level of gingival inflammation
can increase, corresponding with the level of marginal
opening.
Open margins are capable of harboring large numbers of
bacteria and may be responsible for the inflammatory
response seen.
However, the quality of marginal finish and the margin
location relative to the attachment are far more critical to
the periodontium.

Crown Contour
Restoration contour has been described as extremely
important to the maintenance of periodontal health.
Ideal contour provides access for hygiene and has the
fullness to create the desired gingival form and a pleasing
visual tooth contour in esthetic areas.

Emergence profile mimicking the natural tooth contour should be followed.

 Evidence - a relationship between over contouring &

gingival inflammation.
The most frequent cause of overcontoured restorations is
inadequate tooth preparation by the dentist, which forces
the technician to produce a bulky restoration to provide
room for the restorative material.

Proper contour reduces plaque retention.

Flat emergence profile mirrors natural tooth form and

protects plaque trapping

Over contoured restoration traps plaque

Under contoured restoration - less protection from

Surface finish
The rougher the surface of the restoration, the greater the
plaque accumulation and gingival inflammation.

In clinical research, porcelain highly polished gold, and

highly polished resin all show similar plaque accumulation.

Regardless of the restorative material selected, a smooth

surface is essential on all materials subgingivally.

Restorative Correction of Open

Gingival Embrasures
2 causes of open gingival embrasures.
Either the papilla is inadequate in height due to bone
loss.
Periodontral
OR
therapy
The interproximal contact is located too high coronally.
If a high contact has been diagnosed as the cause of the
problem, there are two potential reasons.
If the root angulations of the teeth diverge, the interproximal
contact is moved coronally, resulting in the open embrasure.

Orthodontic
However if the roots are parallel, the papilla formtherapy
is normal,
and an open embrasure exists, then the problem is probably
related to tooth shape, specifically, an excessively tapered
form.
Restorative

dentistry

Pontic Design

A. Sanitary pontic- 3mm from underlying ridge, convex

undersurface-facilitates
cleansing
concave surfaces, difficult
access for
B. Ridge lap pontic
plaque control
C. Modified ridge lap
D. Ovate pontic-ideal pontic form, flat or convex undersurface,
adapts to the site.

Overhanging Restorations

 Cementation: its very important that all excess cement be

removed from the sulcus after cementation as the retained
cement particles causes gingival inflammation and plaque
accumulation.

Splinting
Mobility of teeth - impairs patient comfort, migration of
teeth, or prosthetics where multiple abutments are
necessary.
Before considering splinting, the etiology of the instability
must be identified.' Excessive occlusal forces from
parafunction or deflective tooth contacts ..
Whenever the occlusion is the cause, occlusal therapy is
always performed first.
The mobility is then evaluated over time to determine
whether it resolves before splinting is considered.
In addition, any inflammation of the periodontal supporting
apparatus must be controlled before making a decision on
splinting because inflammation can produce mobility in the
presence of normal occlusal forces and normal periodontal
support.

 The rigidity of the splint and the number of teeth used

determines how the forces are distributed.
It is critical that adequate crown length on the teeth is
being splinted Also, adequate space is needed between the
connector and the papilla for access with - interproximal
brush ..

Periodontics and
Endodontics
Interrelationship

Potential Routes

Dentinal tubules
Communication pathway
Exposure ..
Developmental defects of
cementum Enamel do not meet,
Palatogingival & apical grooves
Disease
Periodontal procedures

Lateral and accessory

canals

Maybe present anywhere along the root

The prevalence of accessory canals may

vary from 23% to 76%.
DeDeus found that 17% of teeth had
lateral canals in the apical third of the
root, 9% in the middle third, and < 2%
in the coronal third.
C.T, vessels , that connect the circulatory
system of the pulp with that of the
periodontium.

Apical foramen

Most direct route of

communication between the pulp
and periodontium.
Bacterial and inflammatory by
products may exit. periapical
pathosis.
Portal of entry from deep
periodontal pockets.

Communication Through Apex Or

Lateral Canal May Cause Furcation
Involvement

Pathways Of Endodontic Periodontic

Disease
Physiological Developmental
Non Physiological

Pathologic

Empty spaces
on root
Root fractures
Idiopathic
Loss of
cementum

Iatrogenic

Exposed dentinal tubules following SR

Accidental root perforations

 CLASSIFICATION OF
ENDODONTIC PERIODONTIC
LESIONS

Based on etiology - by Simon, (1972)

Type1 - Primary endodontic lesions

Type2 - Primary endodontic lesions with secondary periodontal
involvement
Type 3 - Primary periodontal lesions
Type 4 - Primary periodontal lesions with secondary endodontic
involvement
Type 5 - True combined lesions

Effect Of Pulpal Disease On

Periodontium
As long as the pulp maintains vital .. unlikely
Impact of pulpal necrosis result in bone resorption .

Pdl fistulation
Extraosseous
fistulation

Effect Of Periodontal Disease On

Pulp
A clear cut relationship ..less evident.
Bacterial & inflammatory
products.via accessory canals, apical
foramina or dentinal tubules.
Retrograde pulpitis
Inflammatory changes are noted
adjacent to accessory canals exposed
by .periodontitis rarely produces
significant changes in the dental pulp.
Intact layer of cementum
Intact blood supply via apical
foramina.
Retrograde periodontitisrare

Influence Of Periodontal
Treatment Measures On The Pulp
SRP Cementum & dentin may also be
removed
Microbial colonization of the exposed root
dentin may result in bacterial invasion of the
dentinal tubules.

(Adriaens et al 1988)
Vitality of the pulp is not normally put at risk
( Bergenholtz , lindhe 1978)
Rare occasions, deep scaling
expose lateral canalssymptoms of pulpitis.

Impact Of Endodontic Treatment

Measures On The Periodontium
a) Root filled teeth of poor quality:

Unfilled spaces in root canal

Spread of infectious products
into the periodontium

Contribute to increased
probing
depth.
Retarded or impaired
periodontal
tissue healing subsequent to
Jansson, Ehnevid, Lindskog &
periodontal
Blomlof (1993)
therapy

Pathogenesis Endodontic Lesion

Localized Edema
Increased Intrapulpal Pressure
Inflammatory Exudate
Collapse Of Venous Part Of Local Microvasculature
Cell Death
Hypoxia
Anoxia
Necrosis

Pathogenesis :Pulpo-periodontal
Disease
Plaque-calculus
Destruction Of Connective Tissue,pdl,alveolar Bone
Altered Root Surface
Shallow Resorptive Lesions Of Cementum
Soft Tissue Irritation
If Cementum Not Intact
Retrograde Pulpitis

Diagnosis
History
Clinical examination
Intra oral visual
Swelling
Probing
Mobility
Tests
Percussion & palpation
Cold test
Electric pulp test
Radiographs

LDF
PO
MRI

Test
performed

Pulpal

Periapical

Periodontal

Percussion

Normal

Sensitive

Usually
normal

Periodontal
probing

No defects

Single
defect, may
be in
unusual site

Numerous
defects
throughout
mouth,
subgingival
calculus

Response to
ice

Lingering
response or
reduces pain

No response

Normal

Electric pulp
test

Low, normal,
or high
response

No response

Normal

Radiographic
findings

Shallow
caries,
recent
filings,
occlusal &
physical

Deep caries
or filling,
pulp cap

Alveolar
bone loss,
calculus

Differential diagnosis
CLINICAL

PULPAL

PERIODONTAL

Etiology

Pulp infection

Periodontal
infection

Pulp test

Non - vital

Vital

Restorative

Deep/extensive

Not related

Plaque/Calculus

Not related

Primary cause

Inflammation
Pocket

Acute
Single/ Narrow

Chronic
Multiple/ wide

Treatment decision-making
The main factors to consider are:
Pulp vitality and
Type and extent of the periodontal defect.
Primary endodontic lesions should only be treated by
endodontic therapy and has a good prognosis.
Primary periodontic lesions should only be treated by
periodontal therapy. Prognosis depends on severity of the
periodontal disease and patient response.
Primary endodontic disease with secondary periodontal
involvement should first be treated with endodontic therapy.

 Treatment results should be evaluated in 2 to 3 months and

only then should periodontal treatment be considered.

Prognosis depends primarily on the severity of periodontal

involvement, periodontal treatment and patient response.

Primary periodontal disease with secondary endodontic

involvement and true combined endodontic periodontal
diseases require both endodontic and periodontal therapies.

Coming together is the

beginning
Keeping together is
progress
But working together
is success.

THANK

References
Clinical Periodontology Carranza 9 th edition
Clinical Periodontology and Implant Dentistry 4 th edition - Jan Lindhe
Interrelationships between Periodontics and adult OrthodonticsJ Clin
Periodontol 1998; 25: 271-277
The role of implants in orthodontics Net ref
The endo-perio lesion: a critical appraisal of the disease condition.
Endodontic Topics 2006, 13, 3456
Tylmans Theory and practice of fixed prosthodontics 8th edition.
Paul A. Fugazzotto Preparation of the periodontium for the restorative
dentistry1st edition.

References
Thomas G. Wilson Fundamentals of periodontics
M.Martignoni Precision fixed prosthodontics:Clinical and
labobatory aspects.
Rosenstiel Contemporary fixed prosthodontics 3rd edition
Shillingberg H.T Fundamentals of FPD 3rd edition
Reconstruction of the maxillary midline papilla following a
combined orthodonticperiodontic treatment in adult
periodontal patients. J Clin Periodontol 2004; 31: 7984.