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Revista Facultad de Odontología Universidad de Antioquia

Print version ISSN 0121-246X

Rev Fac Odontol Univ Antioq vol.26 no.1 Medellín July/Dec. 2014

 

CASE REPORT

 

COMBINED ORTHODONTIC-PERIODONTAL TREATMENT IN PATIENTS WITH TREATED AND CONTROLLED AGGRESSIVE PERIODONTITIS

 

 

Juan Fernando Aristizábal1; Rosana Martínez Smit2

 

1 Professor and head of the Or thodontics Graduate Program. Universidad del Valle, Cali, Colombia. E-mail addresses: juanferaristi@hotmail.com, rosana29@gmail.com
2 Professor, Or thodontics Graduate Program. Universidad CES, Medellín, Colombia

 

SUBMITTED: OCTOBER 8/2013-ACCEPTED: APRIL 1/2014

 

Aristizábal JF, Martínez R. Combined orthodontic-periodontal treatment in patients with treated and controlled aggressive periodontitis. Rev Fac Odontol Univ Antioq 2014; 26(1): 180-204.

 

 


ABSTRACT

Accurate diagnosis of aggressive periodontitis (AP) requires taking into account information obtained from the interview with the patient and from clinical periodontal examination, radiographic evaluation, and laboratory tests when needed. AP treatment is aimed at reducing or eliminating triggering agents, managing risk factors, and correcting effects on periodontal tissues. Before starting orthodontic treatment in an AP patient, it is necessary to perform a detailed evaluation by both specialties. This article describes a combined periodontal-orthodontic therapy in four young patients with localized aggressive periodontitis (LAP) and generalized aggressive periodontitis (GAP). A complete periodontal treatment was first conducted. After completely reducing inflammation and stabilizing the periodontium, the clinicians started the orthodontic treatment by using moderate forces along with periodontal monitoring, thus reaching the aesthetic and functional objectives set when treatment started.

Key words: orthodontics, periodontics, aggressive periodontitis.


 

 

INTRODUCTION

Aggressive periodontitis was formerly known as juvenile periodontitis or localized early-onset periodontitis. This disease is characterized by destruction of the periodontal tissue in specific areas of the dental arch during early ages.1

The sites most commonly reported as presenting insertion loss are the area of the first molars and the incisors; in addition, it is still considered that this disease appears in a variety of forms, making it difficult to differentiate from other types of periodontitis.2

Periodontal inflammation increases the hydrostatic and hydrodynamic forces surrounding veins and tissues, resulting in dental displacement3 and malpositions such as extrusion and labial displacement of incisors, which produce aesthetic and functional difficulties in patients.4, 5

Maintaining a healthy periodontium is considered a challenge during and after orthodontic treatment.6-10

The orthodontic forces used in adolescents are considered adequate in adults with a healthy periodontium also. These forces are being currently used in patients with reduced periodontal support.6, 11-13

Histological evaluations have shown that such forces do not produce permanent damage in periodontal structures. However, it is widely accepted that moderate forces should be used in these patients to prevent unwanted effects, such as root resorption and additional damage to periodontal ligament, which can produce excessive tooth mobility.12-14

The prognosis of teeth with periodontal compromise was considered to be bad in the past, so treatments tended to concentrate on tooth extraction before starting orthodontic treatment, which was exclusively focused on closing subsequent edentulous gaps.15, 16

Current mechanical therapies with or without surgery, controlling plaque and local or systemic antimicrobial agents, coupled with interdisciplinary management, have significantly improved the prognosis of these patients to the extent that it is now possible to manage these cases in a comprehensive manner, preserving the integrity of affected teeth and correcting potential aesthetic and/or functional problems by means of restorations or orthodontic treatment, thus maintaining the affected teeth.17

This case report describes the interdisciplinary management of four controlled aggressive periodontitis cases that were treated in a conservative manner. Such management was possible by combining periodontal therapy, antimicrobial treatment, and moderate orthodontic treatment, in order to maintain dental integrity and to restore aesthetic and functional conditions without compromising initial periodontal status, as proven by the clinical, radiographic and microbiological monitoring.

 

CASE REPORT

All the patients were treated in private practice and were aware of possible treatment risks; therefore, they signed an informed consent authorizing both intervention and publication of their clinical records.

PERIODONTAL TREATMENT

PROTOCOL

Periodontal probing was performed in all patients followed by scaling with an ultrasonic device (Cavitron Jet Plus, Dentsply, York, PA, USA®) and root planing with local anesthesia if needed. Oral hygiene instructions were given and patients were prescribed 500 mg amoxicillin and 250 mg metronidazole 3 times a day (every 8 hours) for 7 days.

Patients were seen by the periodontist every 3 months, and pockets measuring > 4 mm were treated with additional mechanical therapy if needed. Biofilm was removed and oral hygiene instructions were reinforced each time patients were seen.

To confirm periodontitis diagnosis, all the patients were taken a bacterial culture, which proved the presence of Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis and Tannerella forsythia.

 

CASE I

19-year-old female patient (figure 1) diagnosed with localized AP, confirmed with radiographs (figure 2).

Orthodontically, this patient's diagnosis was considered as a case requiring orthodontic and orthognathic surgery (figures 1 and 2); however, the treatment focused on improving upper incisors inclination, which was the initial reason for consultation.

We used single Tweed 0.01" x 0.025" brackets (C&C Dental Products, Vedbaek, Denmark®) provided with biomechanical properties that favor the use of lighter forces, minimum tooth displacement, and shorter treatment time (figure 3) .

The moderate orthodontic treatment protocol included a sequence of 40°C Cooper NiTi archwires (0.014", 0.018", 0.017" x 0.025") followed by Beta Titanium archwires (0.016" x 0.022") for finalization and functional adaptation. The intermittent forces of Cooper NiTi archwires allowed not only to produce very mild forces due to their flat load-deflection curves but also to guarantee the appropriate hysteresis to protect the reducing periodontium.

This case evolved with significant improvement of periodontal lesions (figure 4), showing the benefit of periodontal therapy in combination with orthodontics.

Tooth 46 was endodontically treated because it presented a periodontal lesion, and this improved periodontal stability. The mechanical therapy coupled with orthodontic improvement achieved a final positive result.

The fixed appliances were removed 20 months later since treatment goals had been achieved: malocclusion was corrected and incisors were moved towards labial (figure 5).

Hawley retainers with continuous archwires were used during the retention phase.

 

CASE 2

26 year-old female patient diagnosed with generalized AP (figure 6).

This patient consulted because she was experiencing tooth spacing in the incisors area (figure 7). She was orthodontically treated in order to close the spaces, using OrthosTM 0.022" x 0.028" brackets (Ormco Corp., Orange, CA, USA®) provided with biomechanical properties based on light forces, thus maintaining the teeth group periodontally affected (figures 7 and 8).

The mechanical protocol of this case included austenitic Nickel Titanium archwires with quaternary copper alloy, which provides it with thermoelastic characteristics, seeking optimal force levels (Cooper NiTi 0.014" -0.018" and 0.016" x 0.22"). Space consolidation was achieved with low-friction Beta Titanium archwires (0.016" x 0.022").

The orthodontic goals were achieved 27 months later and the fixed appliances were removed (figures 9, 10 and 11).

Considerable stability of the achieved results was observed after 2 years of retention (figure 12).

Upper and lower canine-to-canine fixed retainers and Essix retainers were used during the retention phase.

 

CASE 3

41 year-old female patient diagnosed with generalized AP (figures 13 and 14), confirmed with radiographs (figure 15).

Orthodontically, she was diagnosed with dento- alveolar biprotrusion (figures 14 and 15). Due to poor prognosis, the first left upper molar and the first contralateral premolar were extracted. On the other hand, in the lower arch, pontics in the lower front teeth were used to distribute space and to retract.

Quick 0.022" x 0.028" brackets (Forestadent, Pforzheim, Germany®) were used since they allow achieving light forces. In addition, the upper incisor group was mechanically intruded and then extruded (figure 16) seeking additional insertion.

The evolution of this case showed that although additional insertion was not achieved, it was possible to keep it the way it was before starting orthodontic treatment (figure 17).

The mechanical sequence for this case was conducted with 0.014" Biostarter archwires (Forestadent, Pforzheim, Germany®) to achieve alignment, releasing controlled forces, and rectangular super-elastic austenitic termoactive NiTi archwires were later used.

The space closing phase involved sliding mechanics with 0.017" x 0.02" stainless steel archwires, closing with NiTi springs, allowing some controlled inclination—which was one of the therapeutic goals.

The mechanics of intrusion-extrusion of the anterior segment was conducted with a statically- set system, using a Beta Titanium alloy attached to an anterior-base arch (figure 16).

The fixed appliances were removed 30 months later since the orthodontic and periodontal treatment goals had been achieved (figures 18, 19 and 20). In addition, the patient's aesthetic expectations were achieved with the help of prosthetic restorations (figures 18 and 19).

A fixed retainer and an Essix plate were used in the upper arch during the retention phase, as well as a Hawley retainer with a continuous archwire in the lower arch.

 

RECOMMENDATIONS

41 year-old male patient diagnosed with localized AP (figure 21), radiographically confirmed (figure 22).

Due to poor endodontic and periodontal prognosis, the first left upper premolar was extracted (figures 23 and 24), nd then restored with an osseointegrated implant.

Self-ligating passive Damon Q 0.022" x 0.028" brackets (Ormco, California, USA®) were used as they are provided with biomechanical properties that favor the use of light forces (figure 23).

The mechanical sequence of this case involved Cooper NiTi arches (0.014", 0.014" x 0.0245") and Beta Titanium completion arches (0.017" x 0.025").

The fixed appliances were removed 24 months later since the orthodontic treatment goals had been achieved (figures 23 and 25).

An Essix plate was used during the retention phase and a canine-to-canine fixed retainer was placed in the lower arch plus a Hawley retainer with continuous archwire.

 

DISCUSSION

Orthodontists should be cautious when applying forces on teeth with severe periodontal disease. Patients should receive oral hygiene instructions before, during and after installing orthodontic appliances. Orthodontic appliances usually have a negative effect on oral hygiene; therefore, motivation and careful evaluation are necessary. Follow-up periodontal appointments once every 3 months are recommended during the period of active orthodontic treatment.18

During orthodontic treatment, clinical periodontal evaluation including periodontal probing must be conducted every 6 months. If pathological pockets are found, further radiographic evaluation is required, as well as referral to a periodontist. Orthodontic appliances removal should be considered as a way to improve periodontal results. Orthodontic treatment may be resumed after improvement of periodontal disease; however, in cases of excessive incisor proclination, special attention must be paid during new follow-ups in order to avoid recurrent periodontal disease.18

In addition, the interval of activation of orthodontic forces should be greater in patients with a healthy periodontium, since remodeling periodontal tissues usually takes more time in affected patients.19, 20

All of the patients included in this case report were diagnosed with microbiological presence of Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis and Tannerella forsythia, which have been considered as representative pathogens of AP.21

The clinical and radiographic evolution of case 1 confirms what was reported in 2002 by Re et al, 22 who showed that it is possible to improve bone lesions through orthodontic tooth movement in periodontal patients with supra-bony pockets.

Intrusion and extrusion mechanics were used in case 3 based on the reports by Melsen et al,23, 24 who claim that this can produce new insertion tissue, as well as clinical insertion, if the patient is able to maintain proper oral hygiene.

It has also been reported that re-leveling extruded teeth with infra-bony defects significantly reduces probing depth and allows clinical insertion gain and bone filling, as confirmed by x-rays.25

Incorporating self-ligating appliances opens a special horizon, due to the level of forces that can be achieved with these systems, which become gentler at the time of applying force curves, especially if combined with wires provided with good hysteresis.12

The results achieved in all of the cases reported in this article confirm that it is possible to perform orthodontic movement without causing further damage to bone insertion levels—provided that active treatment begins once inflammation has been controlled—.7 However, failing to give special oral hygiene instructions or performing inadequate periodontal treatment will result in further bone loss.18

This case report shows that conservative management allowed maintaining teeth with high periodontal compromise, under safe conditions. Continuous controls and periodontal management is essential to achieve this goal.

 

CONCLUSIONS

Correcting malocclusions is an important aid in the comprehensive treatment of periodontally compromised patients, even under conditions of extreme pathologies such as aggressive periodontitis, coupled with continuous monitoring and occlusal care to support the results.

These clinical cases show that it is possible to improve the periodontal architecture conditions and to maintain the periodontal health levels achieved after successful mechanical and antimicrobial therapies. Also, the changes show that the aesthetic conditions may be improved with simple mechanics that are not very invasive.

 

ACKNOWLEDGEMENTS

To Dr. Adriana Kabalan for the periodontal management of three cases and to Dr. Wilhelm Bellaiza for the periodontal management of one case.

To Dr. Rafael Murgueitio for the restoring management of one case.

The Dr. Herney Garzón for the restoring management of one case.

 

CONFLICTS OF INTEREST

The authors declare having no conflicts of interest.

 

REFERENCES

1. Armitage GC. Development of a classification system for periodontal diseases and conditions. Ann Periodontol 1999; 4(1): 1-6.         [ Links ]

2. Hart TC, Marazita ML, Schenkein HA, Brooks CN, Gunsolley JG, Diehl SR. No female preponderance in juvenile periodontitis after correction for ascertainment bias. J Periodontol 1991; 62:745-749.         [ Links ]

3. Sutton PR, Graze HR. The blood-vessel thrust theory of tooth eruption and migration. Med Hypotheses 1985; 18(3): 289-295.         [ Links ]

4. Towfighi PP, Brunsvold MA, Storey AT, Arnold RM, Willman DE, McMahan CA. Pathologic migration of anterior teeth in patients with moderate to severe periodontitis. J Periodontol 1997; 68(10): 967-972.         [ Links ]

5. Martinez-Canut P, Carrasquer A, Magán R, Lorca A. A study on factors associated with pathologic tooth migration. J Clin Periodontol 1997; 24(7): 492-497.         [ Links ]

6. Ong MA, Wang HL, Smith FN. Interrelationship between periodontics and adult orthodontics. J Clin Periodontol 1998; 25(4): 271-277.         [ Links ]

7. Re S, Corrente G, Abundo R, Cardaropoli D. Orthodontic treatment in periodontally compromised patients: 12 -year report. Int J Periodontics Restorative Dent 2000; 20: 31- 39.         [ Links ]

8. Feng X, Oba T, Oba Y, Moriyama K. An interdisciplinary approach for improved functional and esthetic results in a periodontally compromised adult patient. Angle Orthod 2005; 75(6): 1061-1070.         [ Links ]

9. Gomes SC, Varela CC, da Veiga SL, Rösing CK, Oppermann RV. Periodontal conditions in subjects following orthodontic therapy. A preliminary study. Eur J Orthod 2007; 29(5): 477-481.         [ Links ]

10. Closs LQ, Grehs B, Raveli DB, Rosing CK. Occurrence, extension, and severity of gingival margin alterations after orthodontic treatment. World J Orthod 2008; 9(3): e1-e6.         [ Links ]

11. Braun S, Winzler J, Johnson BE. An analysis of orthodontic force systems applied to the dentition with diminished alveolar support. Eur J Orthod 1993; 15(1): 73-77.         [ Links ]

12. Mavreas D. Self -ligation and the periodontally compromised patient: A different perspective. Semin Orthod 2008; 14: 36-45.         [ Links ]

13. Fukunaga T, Kuroda S, Kurosaka H, Takano-Yamamoto T. Skeletal anchorage for orthodontic correction of maxillary protrusion with adult periodontitis. Angle Orthod 2006; 76 (1): 148-155.         [ Links ]

14. Cardaropoli D, Gaveglio L. The influence of orthodontic movement on periodontal tissues level. Semin Orthod 2007; 13(4): 234-245.         [ Links ]

15. McLain JB, Proffit WR, Davenport RH. Adjunctive orthodontic therapy in the treatment of juvenile periodontitis: report of a case and review of the literature. Am J Orthod 1983; 83(4): 290-298.         [ Links ]

16. Compton DW, Claiborne WJ, Hutchens LH Jr. Combined periodontal, orthodontic and fixed prosthetic treatment of juvenile periodontitis: a case report. Int J Periodontics Restorative Dent 1983; 3(4): 20-33.         [ Links ]

17. Castellanos L, Machuca G, Mendoza A, Iglesias A, Soto L, Solano E. Integrated periodontal, orthodontic and prosthodontics treatment in a case of severe aggressive periodontitis. Quintessence Int 2013; 44(7): 481-485.         [ Links ]

18. Levin L, Einy S, Zigdon H, Aixenbud D, Machtei EE. Guidelines for periodontal care and follow-up during orthodontic treatment in adolescents and young adults. J Appl. Oral Sci 2012; 20(4): 399-403.         [ Links ]

19. Mathews DP, Kokich VG. Managing treatment for the orthodontic patient with periodontal problems. Semin Orthod 1997; 3(1): 21-38.         [ Links ]

20. Boyd RL, Leggott PJ, Quinn RS, Eakle WS, Chambers D. Periodontal implications of orthodontic treatment in adults with reduced or normal periodontal tissues versus those of adolescents. Am J Orthod Dentofacial Orthop 1989; 96(3): 191-198.         [ Links ]

21. Tomita S, Komiyaito A, Imamura K, Kita D, Ota K, Takayama S et al. Prevalence of Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis and Tannerella forsythia in Japanese patients with generalized chronic and aggressive periodontitis. Microb Pathog 2013; 61-62: 11-15.         [ Links ]

22. Re S, Corrente G, Abundo R, Cardaropoli D. Orthodontic movement into bone defects augmented with bovine bone mineral and fibrin sealer: a reentry case report. Int J Periodontics Restorative Dent 2002; 22(2): 138-145.         [ Links ]

23. Melsen B, Agerbaek N, Eriksen J, Terp S. New attachment through periodontal treatment and orthodontic intrusion. Am J Orthod Dentofacial Orthop 1988; 94(2): 104-116.         [ Links ]

24. Melsen B, Agerbaek N, Markenstam G. Intrusion of incisors in adult patients with marginal bone loss. Am J Orthod Dentofacial Orthop 1989; 96(3): 232-241.         [ Links ]

25. Corrente G, Abundo R, Re S, Cardaropoli D, Cardaropoli G. Orthodontic movement into infrabony defects in patients with advanced periodontal disease: a clinical and radiological study. J Periodontol 2003; 74(8): 1104-1109.         [ Links ]